Cardiovascular health metrics in low and middle-income countries: A scoping review.

BACKGROUND: In 2010 the American Heart Association defined the concept of ideal cardiovascular health to renew the focus on primordial prevention for cardiovascular disease. Evidence primarily from high-income countries suggests ideal CVH prevalence is low and decreases with age, with vulnerable populations differentially affected. We aimed to identify and characterize the evidence relevant to CVH metrics in low- and middle-income countries (LMICs). METHODS: We followed the Joanna Briggs Institute guideline for the conduct of this scoping review. We searched MEDLINE, Embase, LILACS and study registers from inception to 14 March 2022. We included cross-sectional and cohort studies in populations representing a geographically-defined unit (urban or rural) in LMICs, and with data on CVH metrics i.e. all health or clinical factors (cholesterol, blood pressure, glycemia and body mass index) and at least one health behavior (smoking, diet or physical activity). We report findings following the PRISMA-Scr extension for scoping reviews. RESULTS: We included 251 studies; 85% were cross-sectional. Most studies (70.9%) came from just ten countries. Only 6.8% included children younger than 12 years old. Only 34.7% reported seven metrics; 25.1%, six. Health behaviors were mostly self-reported; 45.0% of studies assessed diet, 58.6% physical activity, and 90.0% smoking status. CONCLUSIONS: We identified a substantial and heterogeneous body of research presenting CVH metrics in LMICs. Few studies assessed all components of CVH, especially in children and in low-income settings. This review will facilitate the design of future studies to bridge the evidence gap. This scoping review protocol was previously registered on OSF: https://osf.io/sajnh.

Experiences and influences of online health information-seeking about statin use in patients with high cardiovascular risk: a qualitative study.

OBJECTIVES: Online health information (OHI) has been shown to influence patients' health decisions and behaviours. OHI about statins has created confusion among healthcare professionals and the public. This study explored the views and experiences of patients with high cardiovascular risk on OHI-seeking about statins and how OHI influenced their decision. DESIGN: This was a qualitative study using semi-structured in-depth interviews. An interpretive description approach with thematic analysis was used for data analysis. SETTING: An urban primary care clinic in Kuala Lumpur, Malaysia. PARTICIPANTS: Patients aged 18 years and above who had high cardiovascular risk and sought OHI on statins were recruited. RESULTS: A total of 20 participants were interviewed. The age of the participants ranged from 38 to 74 years. Twelve (60%) participants took statins for primary cardiovascular disease prevention. The duration of statin use ranged from 2 weeks to 30 years. Six themes emerged from the data analysis: (i) seeking OHI throughout the disease trajectory, (ii) active and passive approaches to seeking OHI, (iii) types of OHI, (iv) views about statin-related OHI, (v) influence of OHI on patients' health decisions, and (vi) patient-doctor communication about OHI. CONCLUSION: This study highlights the changing information needs throughout patient journeys, suggesting the opportunity to provide needs-oriented OHI to patients. Unintentional passive exposure to OHI appears to have an influence on patients' adherence to statins. The quality of patient-doctor communication in relation to OHI-seeking behaviour remains a critical factor in patient decision-making.

Factors influencing healthcare seeking in patients with dengue: Systematic review.

OBJECTIVE: Delays in seeking healthcare for dengue are associated with poor health outcomes. Despite this, the factors influencing such delays remain unclear, rendering interventions to improve healthcare seeking for dengue ineffective. This systematic review aimed to synthesise the factors influencing healthcare seeking of patients with dengue and form a comprehensive framework. METHODS: This review included both qualitative and quantitative studies. Studies were obtained by searching five databases, contacting field experts and performing backward reference searches. The best-fit meta-synthesis approach was used during data synthesis, where extracted data were fitted into the social-ecological model. Sub-analyses were conducted to identify the commonly reported factors and their level of statistical significance. RESULTS: Twenty studies were selected for meta-synthesis. Eighteen factors influencing healthcare seeking in dengue were identified and categorised under four domains: individual (11 factors), interpersonal (one factor), organisational (four factors) and community (two factors). The most reported factors were knowledge of dengue, access to healthcare, quality of health service and resource availability. Overall, more barriers to dengue health seeking than facilitators were found. History of dengue infection and having knowledge of dengue were found to be ambiguous as they both facilitated and hindered dengue healthcare seeking. Contrary to common belief, women were less likely to seek help for dengue than men. CONCLUSIONS: The factors affecting dengue healthcare-seeking behaviour are diverse, can be ambiguous and are found across multiple social-ecological levels. Understanding these complexities is essential for the development of effective interventions to improve dengue healthcare-seeking behaviour.

Online health information-seeking behaviour of patients attending a primary care clinic in Malaysia: a cross-sectional study.

BACKGROUND: The internet has become a common source of health information; however, little is known about online health information-seeking behaviour (HISB) among patients in low- and middle-income countries (LMICs). OBJECTIVES: This study aimed to determine the prevalence of online health information-seeking and its associated factors among patients in primary care in Malaysia. We also examined the reasons for, and the sources of, online health information-seeking, patients' level of trust in the information found and what the information was used for. METHODS: A cross-sectional study using a self-administered questionnaire was conducted on patients who attended a primary care clinic. The questionnaire included the use of the internet to seek health information, sources and types of health information, eHealth literacy, patients' trust in online information, and how patients appraise and use online health information. RESULTS: Out of 381 patients in this study, 54.7% (n = 208) used the internet to search for health information. Patients mainly sought information via Google (96.2%) and the most common websites that they visited were Wikipedia (45.2%) and MyHEALTH (37.5%). Higher levels of education, longer duration of internet use, and higher eHealth literacy were significantly associated with online HISB. Patients' trust in websites (45.6%) and social media (20.7%) was low when compared to trust in healthcare professionals (87.9%). Only 12.9% (n = 22) of patients had discussed online health information with their doctors. CONCLUSION: Online HISB was common among primary care patients; however, their eHealth literacy was low, with suboptimal appraisal skills to evaluate the accuracy of online health information.

Exosomal microRNAs in the development of essential hypertension and its potential as biomarkers.

MicroRNAs (miRNAs) are small regulatory molecules that are involved in posttranscriptional modifications. These noncoding RNAs are usually ferried by extracellular carriers such as exosomes or other protein and lipid carriers inside a range of body fluids including plasma and urine. Due to their ability to withstand harsh external conditions, exosomal miRNAs possess enormous potential as noninvasive disease biomarkers for, notably hypertension, whereby exosomal miRNAs have been implicated in its pathophysiological processes. More importantly, alterations in the microenvironment as a result of disease progression can induce active and selective loading of miRNAs into exosomes. In this paper, we first review the mechanisms of miRNA loading into exosomes, followed by the roles of exosomal miRNAs in the development of hypertension, and the potentials of exosomal miRNAs as biomarkers in comparison with other free circulating miRNAs. Finally, challenges and future research surrounding exosomal miRNAs will also be discussed. This review will aid in the understanding of noninvasive biomarkers for the early diagnosis of hypertension and for probing therapeutic efficacy.

mHealth adoption among primary care physicians in Malaysia and its associated factors: a cross-sectional study.

BACKGROUND: mHealth apps potentially improve health care delivery and patient outcomes, but the uptake of mHealth in primary care is challenging, especially in low-middle-income countries. OBJECTIVE: To measure factors associated with mHealth adoption among primary care physicians (PCPs) in Malaysia. METHODS: A cross-sectional study using a self-administered questionnaire was conducted among PCPs. The usage of mHealth apps by the PCPs has divided into the use of mHealth apps to support PCPs' clinical work and recommendation of mHealth apps for patient's use. Factors associated with mHealth adoption were analysed using multivariable logistic regression. RESULTS: Among 217 PCPs in the study, 77.0% used mHealth apps frequently for medical references, 78.3% medical calculation and 30.9% interacting with electronic health records (EHRs). Only 22.1% of PCPs frequently recommended mHealth apps to patients for tracking health information, 22.1% patient education and 14.3% use as a medical device. Performance expectancy and facilitating conditions were associated with mHealth use for medical references. Family medicine trainees, working in a government practice and performance expectancy were the facilitators for the use of mHealth apps for medical calculation. Internet connectivity, performance expectancy and use by colleagues were associated with the use of mHealth with EHR. Performance expectancy was associated with mHealth apps' recommendation to patients to track health information and provide patient education. CONCLUSIONS: PCPs often used mHealth apps to support their clinical work but seldom recommended mHealth apps to their patients. Training for PCPs is needed on the appraisal and knowledge of the mHealth apps for patient use.

Implementation Strategies for Web-Based Apps for Screening: Scoping Review.

BACKGROUND: Screening is an effective primary prevention strategy in health care, as it enables the early detection of diseases. However, the uptake of such screening remains low. Different delivery methods for screening have been developed and found to be effective in increasing the uptake of screening, including the use of web-based apps. Studies have shown that web-based apps for screening are effective in increasing the uptake of health screening among the general population. However, not much is known about the effective implementation of such web-based apps in the real-world setting. Implementation strategies are theory-based methods or techniques used to enhance the adoption, implementation, and sustainability of evidence-based interventions. Implementation strategies are important, as they allow us to understand how to implement an evidence-based intervention. Therefore, a scoping review to identify the various implementation strategies for web-based apps for screening is warranted. OBJECTIVE: This scoping review aims to identify (1) strategies used to implement web-based apps for health screening, (2) frameworks used for implementing web-based apps for health screening, (3) outcome measures of implementation strategies, and (4) effective implementation strategies. METHODS: This scoping review was conducted based on Arksey and O'Malley's framework. After identifying the review question, two researchers independently screened and selected relevant literature from PubMed, Embase, Cochrane, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, International Standard Randomised Controlled Trial Number Registry, OpenGrey, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Web of Science. This was followed by charting the data using a standardized form. Finally, we collated, summarized, and reported the results quantitatively and qualitatively based on the review objectives. RESULTS: A total of 16,476 studies were retrieved, of which 5669 were duplicates. From a total of 10,807 studies, 10,784 studies were excluded based on their titles and abstracts. There were 23 full-text articles reviewed, and 4 articles were included in the final analysis. Many studies were excluded because they focused on the effectiveness and not on the implementation of web-based apps. Facilitation was the most cited implementation strategy used, followed by reminders, clinical champions, and educational meetings and materials. Only 2 studies used implementation frameworks to guide the evaluation of their studies. Common outcome measures for implementation strategies were feasibility, fidelity, and penetration. Implementation strategies reported to be effective were quality improvement meetings, facilitation, educational meetings, and clinical champions. CONCLUSIONS: There is a dearth of literature on the implementation of web-based apps for health screening. Implementation strategies were developed without any reported use of implementation theories or frameworks in most studies. More research on the development and evaluation of web-based screening app implementations is needed.

Knowledge on the action to be taken and recognition of symptoms of stroke in a community: findings from the May Measurement Month 2017 blood pressure screening Programme in Malaysia.

BACKGROUND: Information regarding the knowledge on the action to be taken during stroke and good recognition of stroke symptoms is mandatory in helping to plan out educational strategies to deliver health education to the community. METHODS: This is a cross-sectional study of adults aged 18 and above attending a blood pressure screening program in community in conjunction with May Measurement Month 2017 in Malaysia. A structured self-administered questionnaire was given to the participants who gave verbal consent. Data analysis was done using SPSS v. 23 and multiple logistic regression was used to identify the determinants of knowledge on actions to be taken during stroke and recognition of stroke symptoms. RESULTS: Out of 4096 respondents, 82.9-92.1% of them able to recognise the common stroke symptoms. and 74.2% of the study respondents will go to hospital within 4.5 h of stroke onset. According to binomial logistic regression analyses, adults aged 45 years old and above (OR 1.39 95%CI 1.01-1.92), being Malay (OR 1.74, 95% CI 1.27-2.40), being non-smokers (OR = 2.491, 95% CI: 1.64-3.78), hypertensives (OR: 1.57, 95% CI: 1.02-2.42)and diabetics (OR: 2.54, 95% CI:1.38-4.69) are determinants of right actions to be taken during stroke. Meanwhile, respondents aged 45 years old and older (OR = 1.68, 95% CI: 1.39-2.03), being Malay (OR = 1.49, 95% CI: 1.24-1.79), hypertensive (OR = 1.32, 95% CI: 1.04-1.66) and those who had a previous history of stroke (OR = 2.25, 95% CI: 1.01-5.00) are determinants of good recognition of stroke symptoms. CONCLUSIONS: The overall knowledge of stroke in our study population was good. Older age, being Malay, non-smokers, hypertensives and diabetics are determinants of right actions to be taken during stroke. Meanwhile, older age, being Malay, hypertensive and those who had a previous history of stroke are determinants of good recognition of stroke symptoms.

Validation of the pooled cohort risk score in an Asian population - a retrospective cohort study.

BACKGROUND: The Pooled Cohort Risk Equation was introduced by the American College of Cardiology (ACC) and American Heart Association (AHA) 2013 in their Blood Cholesterol Guideline to estimate the 10-year atherosclerotic cardiovascular disease (ASCVD) risk. However, absence of Asian ethnicity in the contemporary cohorts and limited studies to examine the use of the risk score limit the applicability of the equation in an Asian population. This study examines the validity of the pooled cohort risk score in a primary care setting and compares the cardiovascular risk using both the pooled cohort risk score and the Framingham General Cardiovascular Disease (CVD) risk score. METHODS: This is a 10-year retrospective cohort study of randomly selected patients aged 40-79 years. Baseline demographic data, co-morbidities and cardiovascular (CV) risk parameters were captured from patient records in 1998. Pooled cohort risk score and Framingham General CVD risk score for each patient were computed. All ASCVD events (nonfatal myocardial infarction, coronary heart disease (CHD) death, fatal and nonfatal stroke) occurring from 1998-2007 were recorded. RESULTS: A total of 922 patients were studied. In 1998, mean age was 57.5 ± 8.8 years with 66.7% female. There were 47% diabetic patients and 59.9% patients receiving anti-hypertensive treatment. More than 98% of patients with pooled cohort risk score ≥7.5% had FRS >10%. A total of 45 CVD events occurred, 22 (7.2%) in males and 23 (3.7%) in females. The median pooled cohort risk score for the population was 10.1 (IQR 4.7-20.6) while the actual ASCVD events that occurred was 4.9% (45/922). Our study showed moderate discrimination with AUC of 0.63. There was good calibration with Hosmer-Lemeshow test χ2 = 12.6, P = 0.12. CONCLUSIONS: The pooled cohort risk score appears to overestimate CV risk but this apparent over-prediction could be a result of treatment. In the absence of a validated score in an untreated population, the pooled cohort risk score appears to be appropriate for use in a primary care setting.

Does use of pooled cohort risk score overestimate the use of statin?: a retrospective cohort study in a primary care setting.

BACKGROUND: Initiation of statin therapy as primary prevention particularly in those with mildly elevated cardiovascular disease risk factors is still being debated. The 2013 ACC/AHA blood cholesterol guideline recommends initiation of statin by estimating the 10-year atherosclerotic cardiovascular disease (ASCVD) risk using the new pooled cohort risk score. This paper examines the use of the pooled cohort risk score and compares it to actual use of statins in daily clinical practice in a primary care setting. METHODS: We examined the use of statins in a randomly selected sample of patients in a primary care clinic. The demographic data and cardiovascular risk parameters were captured from patient records in 1998. The pooled cohort risk score was calculated based on the parameters in 1998. The use of statins in 1998 and 2007, a 10-year interval, was recorded. RESULTS: A total of 847 patients were entered into the analysis. Mean age of the patients was 57.2 ± 8.4 years and 33.1% were male. The use of statins in 1998 was only 10.2% (n = 86) as compared to 67.5% (n = 572) in 2007. For patients with LDL 70-189 mg/dl and estimated 10-year ASCVD risk ≥7.5% (n = 190), 60% (n = 114) of patients were on statin therapy by 2007. There were 124 patients in whom statin therapy was not recommended according to ACC/AHA guideline but were actually receiving statin therapy. CONCLUSIONS: An extra 40% of patients need to be treated with statin if the 2013 ACC/AHA blood cholesterol guideline is used. However the absolute number of patients who needed to be treated based on the ACC/AHA guideline is lower than the number of patients actually receiving it in a daily clinical practice. The pooled cohort risk score does not increase the absolute number of patients who are actually treated with statins. However these findings and the use of the pooled cohort risk score need to be validated further.

Online health information behaviour and its association with statin adherence in patients with high cardiovascular risk: A prospective cohort study.

Objective: Statins are effective for preventing cardiovascular disease. However, many patients decide not to take statins because of negative influences, such as online misinformation. Online health information may affect decisions on medication adherence, but measuring it is challenging. This study aimed to examine the associations between online health information behaviour and statin adherence in patients with high cardiovascular risk. Methods: A prospective cohort study involving 233 patients with high cardiovascular risk was conducted at a primary care clinic in Malaysia. Participants used a digital information diary tool to record online health information they encountered for 2 months and completed a questionnaire about statin necessity, concerns and adherence at the end of the observation period. Data were analysed using structural equation modelling. Results: The results showed that 55.8% (130 of 233 patients) encountered online health information. Patients who actively sought online health information (91 of 233 patients) had higher concerns about statin use (ß = 0.323, p = 0.023). Participants with higher concern about statin use were also more likely to be non-adherent (ß = -0.337, p < 0.001). Patients who actively sought online health information were more likely to have lower statin adherence, mediated by higher concerns about statin use (indirect effect, ß = -0.109, p = 0.048). Conclusions: Our results suggest that patients with higher levels of concern about statins may be actively seeking online information about statins, and their concerns might influence how they search, what they find, and the potential to encounter misinformation. Our study highlights the importance of addressing patients' concerns about medications to improve adherence.

How do patients with high cardiovascular risk evaluate online health information? A qualitative study.

BACKGROUND: People are exposed to variable health information from the Internet, potentially influencing their health decision-making and behaviour. It remains a challenge for people to discern between good- and poor-quality online health information (OHI). This study explored how patients evaluate and determine trust in statin-related OHI in patients with high cardiovascular risk. METHODS: This qualitative study used vignettes and think-aloud methods. We recruited patients from a primary care clinic who were at least 18 years old, had high cardiovascular risk and had previously sought OHI. Participants were given two statin-related vignettes: Vignette 1 (low-quality information) and Vignette 2 (high-quality information). Participants voiced their thoughts aloud when reading the vignettes and determined the trust level for each vignette using a 5-point Likert scale. This was followed by a semi-structured interview which was audio-recorded and transcribed verbatim. The transcripts were coded and analysed using thematic analysis. RESULTS: A total of 20 participants were recruited, with age ranging from 38-74 years. Among all the high cardiovascular-risk participants, eight had pre-existing cardiovascular diseases. For Vignette 1 (low-quality information), five participants trusted it while nine participants were unsure of their trust. 17 participants (85%) trusted Vignette 2 (high-quality information). Five themes emerged from the analysis of how patients evaluated OHI: (1) logical content, (2) neutral stance and tone of OHI content, (3) credibility of the information source, (4) consistent with prior knowledge and experience, and (5) corroboration with information from other sources. CONCLUSION: Patients with high cardiovascular risks focused on the content, source credibility and information consistency when evaluating and determining their trust in statin-related OHI. Doctors should adopt a more personalised approach when discussing statin-related online misinformation with patients by considering their prior knowledge, beliefs and experience of statin use.

Utility and usability evaluation of an information diary tool to measure health information access and exposure among patients with high cardiovascular risk.

Background: Online health misinformation about statins potentially affects health decision-making on statin use and adherence. We developed an information diary platform (IDP) to measure topic-specific health information exposure where participants record what information they encounter. We evaluated the utility and usability of the smartphone diary from the participants' perspective. Methods: We used a mixed-method design to evaluate how participants used the smartphone diary tool and their perspectives on usability. Participants were high cardiovascular-risk patients recruited from a primary care clinic and used the tool for a week. We measured usability with the System Usability Scale (SUS) questionnaire and interviewed participants to explore utility and usability issues. Results: The information diary was available in three languages and tested with 24 participants. The mean SUS score was 69.8 ± 12.9. Five themes related to utility were: IDP functions as a health information diary; supporting discussion of health information with doctors; wanting a feedback function about credible information; increasing awareness of the need to appraise information; and wanting to compare levels of trust with other participants or experts. Four themes related to usability were: ease of learning and use; confusion about selecting the category of information source; capturing offline information by uploading photos; and recording their level of trust. Conclusion: We found that the smartphone diary can be used as a research instrument to record relevant examples of information exposure. It potentially modifies how people seek and appraise topic-specific health information.

Measurement accuracy and reliability of self-reported versus measured weight and height among adults in Malaysia: Findings from a nationwide blood pressure screening programme.

Most studies reporting prevalence of obesity use actual weight and height measurements. Self-reported weight and height have been used in epidemiological studies as they have been shown to be reliable, convenient, and inexpensive alternatives to actual measurements. However, the accuracy of self-reported weight and height might vary in different regions because of the difference in health awareness and social influences. This study aims to determine the accuracy and reliability of self-reported weight and height compared to actual measured weight and height among adults in Malaysia. This was a cross-sectional study conducted at the community level during blood pressure screening campaigns. Participants self-reported their weight and height in a questionnaire survey. Their weight and height were validated using measurements by researchers on the same setting. Body mass index (BMI) was defined as underweight (<18.5kg/m2), normal (18.5-22.9 kg/m2), overweight (23-27.4 kg/m2) and obesity (≥27.5 kg/m2). Bland-Altman analysis, intraclass correlation coefficients and weighted Kappa statistics were used to assess the degree of agreement between self-reported and measured weight and height. A total of 2781 participants were recruited in this study. The difference between the mean self-reported and measured weight and height were 0.4 kg and 0.4 cm respectively. Weighted Kappa statistics analysis showed that there was a substantial agreement between the BMI classifications derived from self-reported and actual measurement (Ò¡ = 0.920, p<0.001). There was no marked difference in the sensitivity and specificity of self-reported BMI among Malaysian adults by gender. We observed substantial agreement between self-reported and measured body weight and height within a sample of Malaysian adults. While self-reported body weight showed weaker agreement with actual measurements particularly for obese and overweight individuals, BMI values derived from self-reported weight and height were accurate for 88.53% of the participants. We thus conclude that self-reported height and weight measures may be useful for tracking and estimating population trends amongst Malaysian adults.

Association between online health information-seeking and medication adherence: A systematic review and meta-analysis.

Background: The evidence of the impact of online health information-seeking (OHIS) on health outcomes has been conflicting. OHIS is increasingly recognised as a factor influencing health behaviour but the impact of OHIS on medication adherence remains unclear. Objectives: We conducted a systematic review and meta-analysis to examine the associations between OHIS and medication adherence. Methods: We searched Medline, Embase, Web of Science, Scopus, CINAHL and Psychology and Behavioural Science Collection for studies published up to December 2020. The inclusion criteria were studies that reported the associations of OHIS and medication adherence, quantitative design, reported primary data only, related to any health condition where medications are used and conducted on patients either in clinical or community settings. A meta-analysis was used to examine the association between OHIS and medication adherence. Results: A total of 17 studies involving 24,890 patients were included in this review. The study designs and results were mixed. In the meta-analysis, there was no significant association (n = 7, OR 1.356, 95% CI 0.793-2.322, p = 0.265), or correlation (n = 4, r = -0.085, 95% CI -0.572-0.446, p = 0.768) between OHIS and medication adherence. In the sub-group analysis of people living with HIV/AIDS, OHIS was associated with better medication adherence (OR 1.612, 95% CI 1.266-2.054, p < 0.001). Conclusions: The current evidence of an association between OHIS and medication adherence is inconclusive. This review highlights methodological issues on how to measure OHIS objectively and calls for in-depth exploration of how OHIS affects health decisions and behaviour.

Health motivations and perceived barriers are determinants of self-care behaviour for the prevention of hypertension in a Malaysian community.

INTRODUCTION: Self-care behaviour is fundamental in preventing hypertension in the general population. According to the Health Belief Model, health beliefs and perceptions influence the success in adopting disease prevention strategies. While factors influencing hypertension self-care behaviour have been examined previously in patient populations, they have not been assessed in the general community. METHODS: This was a cross-sectional study conducted between 12 June 2020 to 26 July 2021. An online survey was administered via email and social media to Malaysians in the Selangor and Kuala Lumpur communities. Respondents were over 18 years old, without a formal diagnosis of hypertension. The survey evaluated hypertension knowledge, Health Belief Model constructs, self-care behaviour frequency, and motivators and barriers to self-care behaviour. Multiple linear regression was performed to determine the main predictors of self-care behaviour, and descriptive statistics were used to characterise motivators and barriers of each self-care behaviour. RESULTS: Only health motivations (ß = 0.217, p < 0.001) and perceived barriers (ß = 0.571, p < 0.001) significantly influenced self-care behaviour. Maintaining a healthy diet, regular physical activity and blood pressure checks need to be improved in the community, particularly in reducing salt and calorie intake. Lack of time, limited choices and laziness are the biggest challenges that need to be tackled in adopting a healthy diet and an active lifestyle in the community. Many are ignorant towards their health status, therefore, do not prioritize blood pressure screenings, suggesting a need to enhance community blood pressure checks for early diagnosis of hypertension. CONCLUSION AND IMPLICATIONS: Motivations and barriers were the main determinants of self-care behaviour in the Selangor and Kuala Lumpur community. Targeting these aspects of self-care behaviour should be considered when developing interventions and education programmes tailored to local cultural, environmental and personal factors, to more effectively reduce the hypertension prevalence and burden.

Prevalence and determinants of medications non-adherence among patients with uncontrolled hypertension in primary care setting in Sarawak, Malaysia: A cross-sectional study.

Introduction: Non-adherence to antihypertensive medications is a leading cause of uncontrolled hypertension and its complications. However, data on the factors associated with non-adherence to antihypertensive medications in the communities of Sarawak, Malaysia, are limited. This study aimed to examine the prevalence and determinants of medication non-adherence among patients with uncontrolled hypertension. Method: A cross-sectional study was conducted using the systematic sampling method in four government primary healthcare clinics in Sarawak. A self-administered questionnaire was used to obtain socio-demographic data and evaluate non-adherence. Blood pressure was measured, and relevant clinical variables were collected from medical records. Multivariate logistic regression was used to determine the determinants of medication non-adherence. Results: A total of 488 patients with uncontrolled hypertension were enrolled in this study. The prevalence of medication non-adherence was 39.3%. There were four predictors of medication non-adherence among the patients with uncontrolled hypertension: tertiary educational level (odds ratio [OR]=4.21, 95% confidence interval [CI] = 1.67-10.61, P=0.010), complementary alternative medication (0R=2.03, 95% CI=1.12-3.69, P=0.020), non-usage of calcium channel blockers (0R=1.57, 95% CI=1.02-2.41, P=0.039) and 1 mmHg increase in the systolic blood pressure (0R=1.03, 95% CI=1.00-1.05, P=0.006). Conclusion: Because of the high prevalence of medication non-adherence among patients with uncontrolled hypertension, primary care physicians should be more vigilant in identifying those at risk of being non-adherent. Early intervention should be conducted to address non-adherence for blood pressure control.

eHealth literacy of patients attending a primary care clinic in Malaysia and its associated factors: A cross-sectional study.

Background: People are overloaded with online health information (OHI) of variable quality. eHealth literacy is important for people to acquire and appraise reliable information to make health-related decisions. While eHealth literacy is widely studied in developed countries, few studies have been conducted among patients in low- and middle-income countries (LMICs). Objective: We aimed to determine the level of eHealth literacy in patients attending a primary care clinic in Malaysia and its associated factors. Methods: A cross-sectional study using a self-administered questionnaire was conducted in an urban primary care clinic. We used a systematic random sampling method to select patients aged 18 years and above who attended the clinic. The eHealth literacy scale (eHEALS) was used to measure eHealth literacy. Results: A total of 381 participants were included. The mean eHEALS was 24.4 ± 7.6. The eHEALS statements related to skills in appraising OHI were scored lower than statements related to looking for online resources. Higher education level of attending upper secondary school (AOR 2.53, 95% CI 1.05-6.11), tertiary education (AOR 4.05, 95% CI 1.60-10.25), higher monthly household income of >US$470 (AOR 1.95, 95% CI 1.07-3.56), and those who had sought OHI in the past month (AOR 1.95, 95% CI 1.13-3.36) were associated with a higher eHealth literacy level. Conclusions: This study found a low eHealth literacy level among primary care patients in Malaysia. While the patients were confident in searching for OHI, they lacked skills in appraising them. Our findings inform the interventions for improving eHealth literacy in LMICs, especially educating the public about OHI appraisal.

Knowledge transfer of eLearning objects: Lessons learned from an intercontinental capacity building project.

BACKGROUND: Effective knowledge transfer of eLearning objects can hasten the adoption and dissemination of technology in teaching and learning. However, challenges exist which hinder inter-organisational knowledge transfer, particularly across continents. The ACoRD project aimed to transfer knowledge on digital learning development from UK/EU (provider) to Malaysian (receiver) higher education institutions (HEIs). This study explores the challenges encountered during the knowledge transfer process and lessons learned. METHODS: This is a qualitative study involving both the knowledge providers and receivers in focus group discussions (n = 25). Four focus group discussions were conducted in the early (n = 2) and mid-phase (n = 2) of the project by trained qualitative researchers using a topic guide designed to explore experiences and activities representing knowledge transfer in multi-institutional and multi-cultural settings. The interviews were audio-recorded, transcribed verbatim, and checked. The transcripts were analysed using thematic analysis. RESULTS: Five main themes emerged from this qualitative study: mismatched expectations between providers and receivers; acquiring new knowledge beyond the professional "comfort zone"; challenges in cascading newly acquired knowledge to colleagues and management; individual and organisational cultural differences; and disruption of knowledge transfer during the COVID-19 pandemic. CONCLUSION: This study highlights the need to create a conducive platform to facilitate continuous, timely and bi-directional needs assessment and feedback; this should be done in the early phase of the knowledge transfer process. The challenges and strategies identified in this study could guide more effective knowledge transfer between organisations and countries.

An Automated Patient Self-Monitoring System to Reduce Health Care System Burden During the COVID-19 Pandemic in Malaysia: Development and Implementation Study.

BACKGROUND: During the COVID-19 pandemic, there was an urgent need to develop an automated COVID-19 symptom monitoring system to reduce the burden on the health care system and to provide better self-monitoring at home. OBJECTIVE: This paper aimed to describe the development process of the COVID-19 Symptom Monitoring System (CoSMoS), which consists of a self-monitoring, algorithm-based Telegram bot and a teleconsultation system. We describe all the essential steps from the clinical perspective and our technical approach in designing, developing, and integrating the system into clinical practice during the COVID-19 pandemic as well as lessons learned from this development process. METHODS: CoSMoS was developed in three phases: (1) requirement formation to identify clinical problems and to draft the clinical algorithm, (2) development testing iteration using the agile software development method, and (3) integration into clinical practice to design an effective clinical workflow using repeated simulations and role-playing. RESULTS: We completed the development of CoSMoS in 19 days. In Phase 1 (ie, requirement formation), we identified three main functions: a daily automated reminder system for patients to self-check their symptoms, a safe patient risk assessment to guide patients in clinical decision making, and an active telemonitoring system with real-time phone consultations. The system architecture of CoSMoS involved five components: Telegram instant messaging, a clinician dashboard, system administration (ie, back end), a database, and development and operations infrastructure. The integration of CoSMoS into clinical practice involved the consideration of COVID-19 infectivity and patient safety. CONCLUSIONS: This study demonstrated that developing a COVID-19 symptom monitoring system within a short time during a pandemic is feasible using the agile development method. Time factors and communication between the technical and clinical teams were the main challenges in the development process. The development process and lessons learned from this study can guide the future development of digital monitoring systems during the next pandemic, especially in developing countries.