Fadhlina Abd Majid

Understanding the modifiable health systems barriers to hypertension management in Malaysia: a multi-method health systems appraisal approach

BackgroundThe growing burden of non-communicable diseases in middle-income countries demands models of care that are appropriate to local contexts and acceptable to patients in order to be effective. We describe a multi-method health system appraisal to inform the design of an intervention that will be used in a cluster randomized controlled trial to improve hypertension control in Malaysia.MethodsA health systems appraisal was undertaken in the capital, Kuala Lumpur, and poorer-resourced rural sites in Peninsular Malaysia and Sabah. Building on two systematic reviews of barriers to hypertension control, a conceptual framework was developed that guided analysis of survey data, documentary review and semi-structured interviews with key informants, health professionals and patients. The analysis followed the patients as they move through the health system, exploring the main modifiable system-level barriers to effective hypertension management, and seeking to explain obstacles to improved access and health outcomes.ResultsThe study highlighted the need for the proposed intervention to take account of how Malaysian patients seek treatment in both the public and private sectors, and from western and various traditional practitioners, with many patients choosing to seek care across different services. Patients typically choose private care if they can afford to, while others attend heavily subsidised public clinics. Public hypertension clinics are often overwhelmed by numbers of patients attending, so health workers have little time to engage effectively with patients. Treatment adherence is poor, with a widespread belief, stemming from concepts of traditional medicine, that hypertension is a transient disturbance rather than a permanent asymptomatic condition. Drug supplies can be erratic in rural areas. Hypertension awareness and education material are limited, and what exist are poorly developed and ineffective.ConclusionDespite having a relatively well funded health system offering good access to care, Malaysias health system still has significant barriers to effective hypertension management.DiscussionThe study uncovered major patient-related barriers to the detection and control of hypertension which will have an impact on the design and implementation of any hypertension intervention. Appropriate models of care must take account of the patient modifiable health systems barriers if they are to have any realistic chance of success; these findings are relevant to many countries seeking to effectively control hypertension despite resource constraints.

Rare Copy Number Variants Identified Suggest the Regulating Pathways in Hypertension-Related Left Ventricular Hypertrophy

Left ventricular hypertrophy (LVH) is an independent risk factor for cardiovascular morbidity and mortality, and a powerful predictor of adverse cardiovascular outcomes in the hypertensive patients. It has complex multifactorial and polygenic basis for its pathogenesis. We hypothesized that rare copy number variants (CNVs) contribute to the LVH pathogenesis in hypertensive patients. Copy number variants (CNV) were identified in 258 hypertensive patients, 95 of whom had LVH, after genotyping with a high resolution SNP array. Following stringent filtering criteria, we identified 208 rare, or private CNVs that were only present in our patients with hypertension related LVH. Preliminary findings from Gene Ontology and pathway analysis of this study confirmed the involvement of the genes known to be functionally involved in cardiac development and phenotypes, in line with previously reported transcriptomic studies. Network enrichment analyses suggested that the gene-set was, directly or indirectly, involved in the transcription factors regulating the “foetal cardiac gene programme” which triggered the hypertrophic cascade, confirming previous reports. These findings suggest that multiple, individually rare copy number variants altering genes may contribute to the pathogenesis of hypertension-related LVH. In summary, we have provided further supporting evidence that rare CNV could potentially impact this common and complex disease susceptibility with lower heritability.

Development, Testing, and Implementation of a Training Curriculum for Nonphysician Health Workers to Reduce Cardiovascular Disease

Background Cardiovascular disease (CVD) is the leading cause of death worldwide. The need to address CVD is greatest in low- and middle-income countries where there is a shortage of trained health workers in CVD detection, prevention, and control. Objectives Based on the growing evidence that many elements of chronic disease management can be shifted to nonphysician health care workers (NPHW), the HOPE-4 (Heart Outcomes Prevention and Evaluation Program) aimed to develop, test, and implement a training curriculum on CVD prevention and control in Colombia, Malaysia, and low-resource settings in Canada. Methods Curriculum development followed an iterative and phased approach where evidence-based guidelines, revised blood pressure treatment algorithms, and culturally relevant risk factor counseling were incorporated. Through a pilot-training process with high school students in Canada, the curriculum was further refined. Implementation of the curriculum in Colombia, Malaysia, and Canada occurred through partner organizations as the HOPE-4 team coordinated the program from Hamilton, Ontario, Canada. In addition to content on the burden of disease, cardiovascular system pathophysiology, and CVD risk factors, the curriculum also included evaluations such as module tests, in-class exercises, and observed structured clinical examinations, which were administered by the local partner organizations. These evaluations served as indicators of adequate uptake of curriculum content as well as readiness to work as an NPHW in the field. Results Overall, 51 NPHW successfully completed the training curriculum with an average score of 93.19% on module tests and 84.76% on the observed structured clinical examinations. Since implementation, the curriculum has also been adapted to the World Health Organizations HEARTS Technical Package, which was launched in 2016 to improve management of CVD in primary health care. Conclusions The robust curriculum development, testing, and implementation process described affirm that NPHW in diverse settings can be trained in implementing measures for CVD prevention and control.

674 CARDIOVASCULAR RISK FACTORS ASSOCIATED WITH PREHYPERTENSION IN MALAYSIAN ADULTS

Background & Objectives: Malaysia is facing an epidemic of cardiovascular diseases (CVD) withhypertension asa major driver. Given that cardiovascular risk factors (CVRFs) occur in clusters, the aim of the study is to determine the prevalence of CVRFs among Malaysian adults with Prehypertension (PreHT). Methods: This community-based, cross sectional study involving 11,288 adults aged ≥ 30 years was carried out in urban and rural areas in Malaysia between 2007 and 2010. An average of 3 readings of the brachial blood pressures (BP) was recordedwith semi-automated, validated Omron HEM 757 sphygmomanometers. Anthropometric measurements and fasting venous blood for lipid and glucose assays were obtained. Multiple logistic regression analysis was used to determine the factors associated with PreHT. Results: The prevalence of PreHT was 34% (35.4% in males and 33.0% in females). Males (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.43–2.17), rural dwellers (OR 1.29 CI 1.04–1.61), overweight (OR 1.92, CI 1.25–2.95), obesity (OR 2.58, CI 1.60–4.16), increased waist circumference (OR 1.29, CI 1.01–1.65), hypertriglyceridaemia (OR 1.23 CI 1.01–1.49) and family history of hypertension (OR 1.31 CI 1.08–1.58) were more likely to be associatedwith PreHT. Interestingly, waist-hip ratio, total cholesterol, HDL-cholesterol and diabetes mellitus were not associated with PreHT Conclusion: Prevalence of PreHT is overwhelming in Malaysian adults and is associated with multiple CVRFs. Concerted effort must be undertaken aggressively to manage CVRFs in the community and to prevent progression of PreHT to hypertension.

Responsive and Equitable Health Systems—Partnership on Non-Communicable Diseases (RESPOND) study: a mixed-methods, longitudinal, observational study on treatment seeking for hypertension in Malaysia and the Philippines

Introduction Hypertension is a leading contributor to the global burden of disease. While safe and effective treatment exists, blood pressure control is poor in many countries, often reflecting barriers at the levels of health systems and services as well as at the broader level of patients’ sociocultural contexts. This study examines how these interact to facilitate or hinder hypertension control, taking into account characteristics of service provision components and social contexts. Methods and analysis The study, set in Malaysia and the Philippines, builds on two systematic reviews of barriers to effective hypertension management. People with hypertension (pre-existing and newly diagnosed) will be identified in poor households in 24–30 communities per country. Quantitative and qualitative methods will be used to examine their experiences of and pathways into seeking and obtaining care. These include two waves of household surveys of 20–25 participants per community 12–18 months apart, microcosting exercises to assess the cost of illness (including costs due to health seeking activities and inability to work (5 per community)), preliminary and follow-up in-depth interviews and digital diaries with hypertensive adults over the course of a year (40 per country, employing an innovative mobile phone technology), focus group discussions with study participants and structured assessments of health facilities (including formal and informal providers). Ethics and dissemination Ethical approval has been granted by the Observational Research Ethics Committee at the London School of Hygiene and Tropical Medicine and the Research Ethics Boards at the Universiti Putra Malaysia and the University of the Philippines Manila. The project team will disseminate findings and engage with a wide range of stakeholders to promote uptake and impact. Alongside publications in high-impact journals, dissemination activities include a comprehensive stakeholder analysis, engagement with traditional and social media and ‘digital stories’ coproduced with research participants.

Rationale and design of a cluster randomized trial of a multifaceted intervention in people with hypertension: The Heart Outcomes Prevention and Evaluation 4 (HOPE-4) Study

BACKGROUND Cardiovascular disease is the leading cause of death throughout the world, with the majority of deaths occurring in low- and middle-income countries. Despite clear evidence for the benefits of blood pressure reduction and availability of safe and low-cost medications, most individuals are either unaware of their condition or not adequately treated. OBJECTIVE The primary objective of this study is to evaluate whether a community-based, multifaceted intervention package primarily provided by nonphysician health workers can improve long-term cardiovascular risk in people with hypertension by addressing identified barriers at the patient, health care provider, and health system levels. METHODS/DESIGN HOPE-4 is a community-based, parallel-group, cluster randomized controlled trial involving 30 communities (1,376 participants) in Colombia and Malaysia. Participants ≥50 years old and with newly diagnosed or poorly controlled hypertension were included. Communities were randomized to usual care or to a multifaceted intervention package that entails (1) detection, treatment, and control of cardiovascular risk factors by nonphysician health workers in the community, who use tablet-based simplified management algorithms, decision support, and counseling programs; (2) free dispensation of combination antihypertensive and cholesterol-lowering medications, supervised by local physicians; and (3) support from a participant-nominated treatment supporter (either a friend or family member). The primary outcome is the change in Framingham Risk Score after 12 months between the intervention and control communities. Secondary outcomes including change in blood pressure, lipid levels, and Interheart Risk Score will be evaluated. SIGNIFICANCE If successful, the study could serve as a model to develop low-cost, effective, and scalable strategies to reduce cardiovascular risk in people with hypertension.

682 PREVALENCE OF METABOLIC SYNDROME AMONG MALAYSIAN ADULTS AGED ≥ 30 YEARS ACCORDING TO THE NCEP-ATP III, IDF AND JIS DEFINITIONS

Objective: The objective of this study is to compare the prevalence of Metabolic Syndrome (MetS) as defined by the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP-ATP III)1, International Diabetes Federation (IDF) world-wide definition2 and the ‘harmonised’ definition by the Joint Interim Statement (JIS)3. Methods: A community based cross-sectional study involving 11,288 adults aged ≥ 30 years was conducted in urban and rural areas of Malaysia between 2007 and 2010. Demographic data, waist circumference (WC), blood pressure readings; and fasting venous blood for lipid and glucose assays were obtained. Data was analysed using STATA version 11. Results: Out of the11,288 subjects, 8836 had complete data on all the MetS components and were therefore included in the analysis. Mean age was 53.2 years (SD ± 10.6). The table shows the overall and age-adjusted prevalence of MetS according to the NCEP-ATP III, IDF and JIS definitions by location, gender, ethnicity and education attainment. Table. No title available. Conclusions: The JIS definition gave the highest overall prevalence of MetS among Malaysian adults, as well as the age-adjusted prevalence by location, gender, ethnicity and education attainment. The NCEP-ATP III gave the lowest prevalence due to the higher WC cut points. Prevalence was significantly lower in Chinese and Indigenous groups regardless of the criteria used. There was no significant difference in the prevalence between urban and rural population using IDF and JIS definitions. ReferencesNational Cholesterol Education Program (NCEP)Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143–421.Alberti KG, Zimmet P, Shaw J, International Diabetes Federation (IDF) Epidemiology Task Force Consensus Group. The metabolic syndrome: a new world- wide definition. Lancet 2005; 366: 1059–62.Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the metabolic syndrome. A Joint Interim Statement (JIS) of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009; 120: 1640–5.

220 OVERWEIGHT AND OBESITY IN MALAYSIA: AN EPIDEMIOLOGY SURVEY

Background and Objective: In Malaysia, the prevalence of overweight and obesity (>18 years old) is escalating with 16.6% and 4.4% in 1996, 29.1% and 14.0% in 2006, and 33.6% and 19.5% in 2008 (1-3). This study aim at continue monitoring the prevalence and its associations as it is strongly related to cardiovascular death (4). Design and Method: A community-based cross sectional study, was carried out in Malaysia between 2007 and 2010, using cut-off points body mass index (BMI) of 23 and 27.5 kg/m2 for overweight and obese (5). Data was analysed using STATA version 11. Results: A total of 10,963 subjects with complete BMI readings, out of 11,572 adult (>18 years old) subjects’ (mean age 51.2±11.0) data were analysed. The age-adjusted prevalence of overweight and obese were 38.3% (95% CI: 37.7- 39.1) and 34.0% (95% CI: 33.0-34.8), with female was significantly more obese (36.7%, CI; 35.4-37.8) than male (30.4%, CI; 29.1-31.7) (p<0.001) and urban population was significantly more obese (36.9%, CI; 35.6-38.1) than rural population (30.9%, CI; 29.6-32.1) (p<0.001). Highest prevalence of obesity were in Malays (38.9%, CI; 37.8-39.9), followed by Indians (35.8%, CI; 30.7-41.2) and lowest in Chinese (17.4%, CI; 15.2-19.5). Obese subjects were 1.8 (CI; 1.44-2.33), 1.7 (CI; 1.04-2.81), 2.38 (CI; 1.34-4.23) and 2.4 (CI; 1.91-3.01) more likely to have dyslipidaemia, impaired fasting glucose (IFG), newly diagnosed diabetes and hypertension, when compared to normal BMI, respectively. Conclusion: This study highlights the serious rise in obesity prevalent which deem the health system into action strategy at national level, as suggested by WHO (6) in fighting globesity. References:Khambalia AZ, Seen LS. Trends in overweight and obese adults in Malaysia (1996–2009): a systematic review. Obesity Reviews. 2010;11(6):403-12.Kee CC, Jamaiyah H, Noor Safiza MN, Geeta A, Khor GL, Suzana S, et al. Abdominal obesity in Malaysian adults: National Health and Morbidity Survey III (NHMS III, 2006). Malaysian Journal of Nutrition. 2008;14(2):125-35.Mohamud WN, Musa KI, Khir AS-M, Ismail AA-S, Ismail IS, Kadir KA, et al. Prevalence of overweight and obesity among adult Malaysians: an update. Asia Pacific Journal Of Clinical Nutrition. 2011;20(1):35-41.Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing Epidemic of Coronary Heart Disease in Low- and Middle-Income Countries. Current Problems in Cardiology. 2010;35(2):72-115.MOH. Clinical Practice Guideline on the Management of Obesity 2004. 2004.

360 STOKING THE FIRE- LOW SECONDARY PREVENTION MEDICATIONS AMONG HIGH RISK PATIENTS IN MALAYSIA

Background and Objective: Beta-blockers, antiplatelets, ACE inhibitors / Angiotensin Receptor Blockers (ACE-i/ARB) and statins are well established secondary prevention drugs for high risk patients, especially those with coronary heart disease (CHD) or stroke. However, often these are not widely used. The objective of this study is to determine their use in Malaysia. Methodology: The Prospective Urban Rural Epidemiology (PURE) study is a community-based world-wide research collaboration involving 154,000 adults (15,617 from Malaysia) to evaluate the impact of urbanization on cardiovascular disease. Demographic, anthropometric, blood pressure and fasting glucose and lipids were obtained using validated questionnaires and standard laboratory methods. Results: PURE involves 6891 rural and 8726 urban dwellers with a mean age 51.13+9.9 years; 55.9% are females. Hypertension, diabetes, overweight (BMI 25-30), obesity (BMI>30), and smokers make up 44.1%, 15.7%, 38.2%, 21.3% and 23.1% respectively. Beta-blockers, antiplatelets, ACE-i/ARB and statins are used in 2.9%, 1.3%, 2.5% and 2.5% respectively. Among CHD or stroke participants, their use is 11.1%, 13.6%, 10.9% and 13.9% respectively; urban dwellers using more Beta-blockers and antiplatelets (14.0% vs 13.4% and 12.9% vs 9.9% respectively) and rural dwellers using more ACEi/ARB and statins (11.5% vs 10.1% and 14.1% vs 13.5% respectively) and their use is more in males than females. Conclusion: Although the Malaysian public health system provides these drugs free, their actual use is abysmally low even among high risk individuals. Improving patient awareness, health education, professional commitment and health delivery system may alter the scenario.

679 PREVALENCE OF DIABETES MELLITUS AMONG URBAN AND RURAL POPULATION IN MALAYSIA: IS THERE A DIFFERENCE?

Background & Objectives: Diabetes mellitus (DM) is one of the major cardiovascular risk factors. Its prevalence in Malaysia has showed an increased trend in the past three decades. The 3rd Malaysian National Health and Morbidity Survey 2006 reported that 14.9% of adults aged ≥ 30 years had DM. The aim of this study is to determine the prevalence, awareness, treatment and control of DM among the urban and rural population in Malaysia. Methods: This was a cross-sectional community-based study involving 11,288 adults aged ≥ 30 years conducted between 2007 and 2010. Demographic data, anthropometric measurements and venous blood glucose were obtained. Data was analysed using STATA version 11. Results: The prevalence of DM was 15.9 % (CI: 15.2 – 16.5), awareness rate was 76.3% (CI: 74.3 – 78.3), treatment rate was 56.1% (CI: 53.7 – 58.4) and control rate was 57.4% (CI: 55.0 – 59.7). The age, gender and ethnicity adjusted prevalence was significantly higher in the urban than rural population (15.8 % vs 14.5 %, p = 0.002). Similar trend was found for the treatment rate (57.4% vs 45.3%, p = 0.001). However, a reverse trend was seen for the control rate (47.7% vs 53.6%, p = 0.001). There was no significant difference in the adjusted awareness rate observed between urban and rural population (73.8% vs 66.7%, p = 0.356). Conclusions: The prevalence of DM in the urban population is higher in Malaysia. This might reflect the effect of urbanization. However, the control rate was lower for the urban population in spite of having higher treatment rate.