Diabetes knowledge among Malaysian adults: A scoping review and meta-analysis.

Introduction: Optimal self-care promotes glycaemic control and prevents diabetes complications. Its performance is facilitated by an adequate level of diabetes knowledge. This review aimed to evaluate diabetes knowledge among Malaysians by assessing diabetes knowledge scores and their associated factors. Methods: A comprehensive bibliographic search for Malaysian studies on diabetes knowledge was conducted in PubMed, Scopus and Google Scholar. Relevant literature was systematically selected and described; pertinent data were extracted; and data on diabetes knowledge levels and their associated factors were synthesised. The quality of the identified studies was assessed using a Joanna Briggs Institute critical appraisal tool. Results: Thirty Malaysian cross-sectional studies that measured diabetes knowledge levels were retrieved. Nineteen of them used a named diabetes knowledge measurement tool, with 14 using the 14-item Michigan Diabetes Knowledge Test. A low knowledge level was prevalent among patients with diabetes mellitus (pooled mean knowledge score=6.92, proportion of patients with a low knowledge level=47.97%). The knowledge score was associated with some sociodemographic variables, health literacy, self-care and glycaemic control. Conclusion: The association of diabetes knowledge with diabetes outcomes (e.g. self-care and glycaemic control) reflects the potential of the former as a target of intervention. Periodic measurement of diabetes knowledge in healthcare settings and among populations can help in assessing the effectiveness of diabetes educational interventions. Concerted efforts to improve diabetes knowledge among Malaysians have the potential to fill knowledge-practice gaps.

How Socio-economic Inequalities Cluster People with Diabetes in Malaysia: Geographic Evaluation of Area Disparities Using a Non-parameterized Unsupervised Learning Method.

Accurate assessments of epidemiological associations between health outcomes and routinely observed proximal and distal determinants of health are fundamental for the execution of effective public health interventions and policies. Methods to couple big public health data with modern statistical techniques offer greater granularity for describing and understanding data quality, disease distributions, and potential predictive connections between population-level indicators with areal-based health outcomes. This study applied clustering techniques to explore patterns of diabetes burden correlated with local socio-economic inequalities in Malaysia, with a goal of better understanding the factors influencing the collation of these clusters. Through multi-modal secondary data sources, district-wise diabetes crude rates from 271,553 individuals with diabetes sampled from 914 primary care clinics throughout Malaysia were computed. Unsupervised machine learning methods using hierarchical clustering to a set of 144 administrative districts was applied. Differences in characteristics of the areas were evaluated using multivariate non-parametric test statistics. Five statistically significant clusters were identified, each reflecting different levels of diabetes burden at the local level, each with contrasting patterns observed under the influence of population-level characteristics. The hierarchical clustering analysis that grouped local diabetes areas with varying socio-economic, demographic, and geographic characteristics offer opportunities to local public health to implement targeted interventions in an attempt to control the local diabetes burden.

Strengthening national salt reduction strategies using multiple methods process evaluations: case studies from Malaysia and Mongolia.

OBJECTIVE: To understand the extent to which national salt reduction strategies in Malaysia and Mongolia were implemented and achieving their intended outcomes. DESIGN: Multiple methods process evaluations conducted at the mid-point of strategy implementation, guided by theoretical frameworks. SETTING: Malaysia (2018-2019) and Mongolia (2020-2021). PARTICIPANTS: Desk-based reviews of related documents, interviews with key stakeholders (n 12 Malaysia, n 10 Mongolia), focus group discussions with health professionals in Malaysia (n 43) and health provider surveys in Mongolia (n 12). RESULTS: Both countries generated high-quality local evidence about salt intake and levels in foods and culturally specific education resources. In Malaysia, education and reformulation activities were delivered with moderate dose (quantity) but reach among the population was low. Within 5 years, Mongolia implemented education among schools, health professionals and food producers on salt reduction with high reach, but with moderate dose (quantity) and reach among the general population. Both countries faced challenges in implementing legislative interventions (mandatory salt labelling and salt limits in packaged foods) and both could improve the scaling up of their reformulation and education activities. CONCLUSIONS: In the first half of Malaysia's and Mongolia's strategies, both countries generated necessary evidence and education materials, mobilised health professionals to deliver salt reduction education and achieved small-scale reformulation in foods. Both subsequently should focus on implementing regulatory policies and achieving population-wide reach and impact. Process evaluations of existing salt reduction strategies can help strengthen intervention delivery, aiding achievement of WHO's 30 % reduction in salt intake by 2025 target.

GIS-Based Assessments of Neighborhood Food Environments and Chronic Conditions: An Overview of Methodologies.

The industrial revolution and urbanization fundamentally restructured populations' living circumstances, often with poor impacts on health. As an example, unhealthy food establishments may concentrate in some neighborhoods and, mediated by social and commercial drivers, increase local health risks. To understand the connections between neighborhood food environments and public health, researchers often use geographic information systems (GIS) and spatial statistics to analyze place-based evidence, but such tools require careful application and interpretation. In this article, we summarize the factors shaping neighborhood health in relation to local food environments and outline the use of GIS methodologies to assess associations between the two. We provide an overview of available data sources, analytical approaches, and their strengths and weaknesses. We postulate next steps in GIS integration with forecasting, prediction, and simulation measures to frame implications for local health policies. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Assessing data availability of NCD prevention and control in six ASEAN countries based on WHO global monitoring framework and the progress monitor indicators.

BACKGROUND: To tackle noncommunicable disease (NCD) burden globally, two sets of NCD surveillance indicators were established by the World Health Organization: 25 Global Monitoring Framework (GMF) indicators and 10 Progress Monitoring Indicators (PMI). This study aims to assess the data availability of these two sets of indicators in six ASEAN countries: Cambodia, Lao PDR, Malaysia, Myanmar, Thailand, and Vietnam. METHODS: As data on policy indicators were straightforward and fully available, we focused on studying 25 non-policy indicators: 23 GMFs and 2 PMIs. Gathering data availability of the target indicators was conducted among NCD surveillance experts from the six selected countries during May-June 2020. Our research team found information regarding whether the country had no data at all, was using WHO estimates, was providing 'expert judgement' for the data, or had actual data available for each target indicator. We triangulated their answers with several WHO data sources, including the WHO Health Observatory Database and various WHO Global Reports on health behaviours (tobacco, alcohol, diet, and physical activity) and NCDs. We calculated the percentages of the indicators that need improvement by both indicator category and country. RESULTS: For all six studied countries, the health-service indicators, based on responses to the facility survey, are the most lacking in data availability (100% of this category's indicators), followed by the health-service indicators, based on the population survey responses (57%), the mortality and morbidity indicators (50%), the behavioural risk indicators (30%), and the biological risk indicators (7%). The countries that need to improve their NCD surveillance data availability the most are Cambodia (56% of all indicators) and Lao PDR (56%), followed by Malaysia (36%), Vietnam (36%), Myanmar (32%), and Thailand (28%). CONCLUSION: Some of the non-policy GMF and PMI indicators lacked data among the six studied countries. To achieve the global NCDs targets, in the long run, the six countries should collect their own data for all indicators and begin to invest in and implement the facility survey and the population survey to track NCDs-related health services improvements once they have implemented the behavioural and biological Health Risks Population Survey in their countries.

Identifying the necessary capacities for the adaptation of a diabetes phenotyping algorithm in countries of differing economic development status.

BACKGROUND: In 2019, the World Health Organization recognised diabetes as a clinically and pathophysiologically heterogeneous set of related diseases. Little is currently known about the diabetes phenotypes in the population of low- and middle-income countries (LMICs), yet identifying their different risks and aetiology has great potential to guide the development of more effective, tailored prevention and treatment. OBJECTIVES: This study reviewed the scope of diabetes datasets, health information ecosystems, and human resource capacity in four countries to assess whether a diabetes phenotyping algorithm (developed under a companion study) could be successfully applied. METHODS: The capacity assessment was undertaken with four countries: Trinidad, Malaysia, Kenya, and Rwanda. Diabetes programme staff completed a checklist of available diabetes data variables and then participated in semi-structured interviews about Health Information System (HIS) ecosystem conditions, diabetes programme context, and human resource needs. Descriptive analysis was undertaken. RESULTS: Only Malaysia collected the full set of the required diabetes data for the diabetes algorithm, although all countries did collect the required diabetes complication data. An HIS ecosystem existed in all settings, with variations in data hosting and sharing. All countries had access to HIS or ICT support, and epidemiologists or biostatisticians to support dataset preparation and algorithm application. CONCLUSIONS: Malaysia was found to be most ready to apply the phenotyping algorithm. A fundamental impediment in the other settings was the absence of several core diabetes data variables. Additionally, if countries digitise diabetes data collection and centralise diabetes data hosting, this will simplify dataset preparation for algorithm application. These issues reflect common LMIC health systems' weaknesses in relation to diabetes care, and specifically highlight the importance of investment in improving diabetes data, which can guide population-tailored prevention and management approaches.

Community priorities for obesity prevention among low-income adults in Kuala Lumpur: a discrete choice experiment.

Non-communicable diseases and associated risk factors, such as obesity, are prevalent and increasing in Malaysia. To address this burden and the heightened vulnerability of low-income communities to these risk factors, the Better Health Programme Malaysia conducted a partial-profile discrete choice experiment (DCE) to inform the design of a community-based obesity-prevention programme. The DCE survey was conducted with community members (n = 1453) from three publicly supported low-cost, high-rise flat complexes in urban Kuala Lumpur. In the survey, community members were asked to choose between different sets of potential evidence-based interventions for obesity prevention. Their responses to these choice tasks were analysed to quantify preferences for these different health interventions using a random utility maximization model. Based on these results, we determined participants' relative prioritization of the different options. The most preferred interventions were those that reduced the price of fruit and vegetables; altered cooking practices at restaurants and food vendors to reduce salt, sugar and oil; and offered reward incentives for completing online educational activities. Community members did not prioritize several evidence-based interventions, including changes to product placement or product labelling, suggesting that these effective approaches may be less familiar or simply not preferred by respondents. The DCE enabled the clear articulation of these community priorities for evidence-based interventions that focus on the supply and promotion of affordable healthy foods within the local food environment, as well as community demand for healthier food options.

Non-communicable diseases (NCDs) and the factors that increase NCD risk, such as obesity, are widespread and increasing in Malaysia. Low-income communities are particularly vulnerable to these risk factors. The Better Health Programme (BHP) Malaysia conducted a discrete choice experiment (DCE) to elicit community member preferences for evidence-based health promotion interventions to prevent obesity and NCDs. DCE is a research method used to identify participant preferences between different pre-determined options. The DCE survey was conducted with community members (n = 1453) from three publicly supported low-cost, high-rise flat complexes in urban Kuala Lumpur. In the survey, community members were asked to choose between different potential sets of interventions to alter the environment to prevent obesity. Based on their responses, we determined which interventions were most preferred in each community. The most preferred interventions were those that reduced the price of fruit and vegetables; altered cooking practices at restaurants and food vendors to reduce salt, sugar and oil; and offered rewards for completing online educational activities. The survey enabled the clear articulation of these community priorities for evidence-based interventions. These priorities were used to design the BHP Malaysia intervention programme.

Evaluating the sustainability of non-communicable diseases programs in Malaysia.

BACKGROUND: The substantial rise in non-communicable diseases (NCDs) over the last two decades poses a major concern to the healthcare services in Malaysia. This study aimed to evaluate the sustainability of the current NCDs programs and identify the challenges and factors impeding the sustainability of the NCDs program implemented under the National Strategic Plan. METHODS: This study applied the mixed-method approach using the Program Sustainability Assessment Tool (PSAT) to assess the eight domains for program sustainability combined with 5 open-ended questions. The survey was administered to key leaders from the district health offices in Malaysia. The mean score for each sustainability domain and the overall mean sustainability score were determined. Descriptive statistics and thematic analysis were conducted using Statistical Package for the Social Sciences (SPSS) version 25 and NVivo version 12, respectively. RESULTS: A total of 80 key leaders responded to the survey. Overall seven domains scored an average of ≥ 4 with an overall mean sustainability score of 4.2. The highest domain mean scores were 4.5 (communications) and 4.4 (organizational capacity). The lowest mean score domain was 3.8 (funding stability). The open-ended responses revealed challenges faced by department heads, including implementation difficulties, factors impeding the planning of the NCDs program for sustainability, lack of financial resources, lack of human resources, and support for staff training which are largely consistent with the scores of each domain. CONCLUSION: The sustainability factors affecting the NCDs program in Malaysia are qualitatively similar to other countries. For greater sustainability capacity, we should work towards strong leadership, strengthening funding stability, and incorporating evidence-based public health strategies in the implementation of the NCDs program.

Decriminalizing suicide attempt in the 21st century: an examination of suicide rates in countries that penalize suicide, a critical review.

BACKGROUND: Decriminalizing suicide may decrease overall suicide rates because then individuals who are at risk of suicide would be more willing to seek help from the community and from mental health professionals, therefore enabling early interventions for preventing suicidality. We aimed to examine the suicide trends over the last 20 years in 20 countries that still criminalize attempted suicide, and to compare the suicide rates of these 20 countries against the global average suicide rate and to a comparison sample of 20 countries that do not criminalize suicide, matched according to region and majority religion. METHODS: Age-standardized suicide rates were extracted from the WHO Global Health Estimates, available for the period 2000-2019. Population data were extracted from the World Bank. We analyzed only countries which criminalize attempted suicide under its criminal justice system. Countries were further categorized according to their membership in the Commonwealth of Nations and countries in Africa. Countries from the same region and with the same majority religion were chosen as a matching group. Joinpoint analysis was used to compare the trends of the two groups with the global average. RESULTS: Based on the 2019 WHO Global Health Estimates data, there is a large range in the suicide rates of the countries that criminalize attempted suicide, from 2.5 (Brunei) to 40.9 (Guyana) per 100,000 population. The mean suicide rate was 8.3 (Standard Deviation = 10.6). Out of the 20 countries, seven have suicide rates higher than the global average, covering a total population of about 387.3 million. Of these seven countries, five are in the African region. The other thirteen countries have suicide rates between 2.5 to 8.2. Mean scores of the countries which criminalized attempted suicide was lower than the global average and 20 comparison countries over the 20 years, but average annual percentage in the decrease of suicide was greater for countries in which attempted suicide was not criminalized. CONCLUSIONS: Based on our review, there was no substantial evidence here to indicate that countries which criminalized attempted suicide had consistently lower suicide rates compared to the global average. There is a need to acknowledge that the currently available evidence is inadequate to definitively claim that criminalizing suicide is beneficial or harmful for the reduction of suicide rate for the entire populations. Future studies should continue to evaluate the unique effects of decriminalizing attempted suicide while controlling for other key associated factors.

Exploring the impact of COVID-19 movement control orders on eating habits and physical activity in low-resource urban settings in Malaysia.

BACKGROUND: The COVID-19 pandemic led Malaysia to introduce movement control orders (MCOs). While MCOs were intended to slow the spread of COVID-19, the effects of such measures on the noncommunicable disease (NCD) risk factors have not been fully explored. This exploratory study aimed to understand the effect of the MCO on the eating habits and physical activity levels of the urban poor in Malaysia as well as potential health promotion interventions during the COVID-19 pandemic. METHODS: This rapid assessment used a mixed-method approach in three low-cost public flats in Kuala Lumpur targeting the B40, which is the bottom 40% of the economic spectrum. A total of 95 community members participated in a quantitative phone survey, while 21 respondents participated in a qualitative phone survey, including 12 community members and nine community health volunteers (CHVs). RESULTS: The movement restriction imposed during the MCO significantly reduced the frequency and duration of respondents' physical activity. At the same time, respondents reported significantly increased consumption of home-cooked meals. More than half of respondents reduced their consumption of packaged snack foods (53.7%), street desserts (54.7%), fast food (50.5%), soft drinks (50.5%), and 3-in-1 or instant drinks (50.5%) due to limited access during the MCO. B40 communities were receptive to potential interventions to encourage healthier eating and physical activity leveraging digital approaches under the 'new normal'. Reported concerns included internet accessibility and affordability, functionality, and digital literacy. CONCLUSION: The COVID-19 pandemic requires innovation to address diseases and risk factors at the community level. While movement restrictions reduced physical activity, they created opportunities for low-income individuals to have greater control over their diet, enabling them to adopt healthier eating habits. Lifestyle changes experienced by vulnerable populations provide an opportunity for creative and technology-enabled interventions to promote healthy eating and exercise.

Dietary practices, food purchasing, and perceptions about healthy food availability and affordability: a cross-sectional study of low-income Malaysian adults.

BACKGROUND: Malaysia has the highest rate of overweight and obesity among Asian countries. Obesity is increasing particularly among low-income populations. This study aimed to assess dietary practices among low-income adults in urban communities, including gender and ethnic variation, to inform the development of locally tailored, evidence-based interventions for health promotion. METHODS: This cross-sectional study was conducted from August to December 2020. Stratified sampling was employed to recruit 2983 low-income adults from households in the bottom 40% of the economic spectrum (B40) at six public, low-cost housing flats in the Federal Territory of Kuala Lumpur, Malaysia. Face-to-face interviews were conducted using a structured questionnaire to understand dietary practices, perceptions of healthy food availability and affordability, and factors affecting food purchasing decisions. RESULTS: A staggering 89.5% of B40 adults were found to not consume adequate daily amounts of fruits and vegetables. In addition, 68.1% reported consuming sugar-sweetened beverages at least once per week, including commercially packed ready-to-drink beverages, sugar-added self-prepared drinks, and premixed drinks. Intake was statistically significantly higher among men (71.7%), Malays (70.3%), and Indians (69.9%). Bread and other commercially baked goods were the most common processed foods, and 52.9% of respondents consumed it at least once per week. Majorities reported that healthy foods were moderately available and priced. The top three reported factors affecting food purchase choices were price (79.4%), availability (75%), and taste (73%). CONCLUSIONS: Adults in low-cost housing communities have unhealthy dietary patterns with low intake of fruits and vegetables and high intake of ultra-processed foods and calorie-dense local foods, with variations across gender and ethnicity. The study highlighted the need for educating low-income families on diet-disease relationships and possibilities for inexpensive, healthy eating that rely on minimally processed fresh foods. Policymakers engaging the food industry are advised to consider how to increase the affordability and availability of healthy foods in low-income communities in urban areas.

Association of metabolic syndrome with risk of cardiovascular disease mortality and all-cause mortality among Malaysian adults: a retrospective cohort study.

OBJECTIVES: This study is aimed at determining the association between metabolic syndrome and risk of cardiovascular disease (CVD) mortality and all-cause mortality among Malaysian adults. DESIGN: Retrospective cohort study. SETTING: The Malaysian Non-Communicable Disease Surveillance (MyNCDS-1) 2005/2006. PARTICIPANTS: A total of 2525 adults (1013 men and 1512 women), aged 24-64 years, who participated in the MyNCDS-1 2005/2006. METHODS: Participants' anthropometric indices, blood pressure, fasting lipid profile and fasting blood glucose levels were evaluated to determine the prevalence of metabolic syndrome by the Harmonized criteria. Participants' mortality status were followed up for 13 years from 2006 to 2018. Mortality data were obtained via record linkage with the Malaysian National Registration Department. The Cox proportional hazards regression model was applied to determine association between metabolic syndrome (MetS) and risk of CVD mortality and all-cause mortality with adjustment for selected sociodemographic and lifestyle behavioural factors. RESULTS: The overall point prevalence of MetS was 30.6% (95% CI: 28.0 to 33.3). Total follow-up time was 31 668 person-years with 213 deaths (111 (11.3%) in MetS subjects and 102 (6.1%) in non-MetS subjects) from all-causes, and 50 deaths (33 (2.9%) in MetS group and 17 (1.2%) in non-MetS group) from CVD. Metabolic syndrome was associated with a significantly increased hazard of CVD mortality (adjusted HR: 2.18 (95% CI: 1.03 to 4.61), p=0.041) and all-cause mortality (adjusted HR: 1.47 (95% CI: 1.00 to 2.14), p=0.048). These associations remained significant after excluding mortalities in the first 2 years. CONCLUSIONS: Our study shows that individuals with MetS have a higher hazard of death from all-causes and CVD compared with those without MetS. It is thus imperative to prescribe individuals with MetS, a lifestyle intervention along with pharmacological intervention to improve the individual components of MetS and reduce this risk.

The Implementation of Childhood Obesity Related Policy Interventions in Malaysia-A Non Communicable Diseases Scorecard Project.

(1) Background: The prevalence of overweight and obesity among children has increased tremendously in the ASEAN region, including Malaysia. In Malaysia, the National Strategic Plan for Non-Communicable Diseases (2015-2025) provides the overall framework for its response to the non-communicable diseases (NCD) epidemic. Preventing childhood obesity is one of the key strategies for early intervention to prevent NCDs. The objective of this research is to examine the current status of policy interventions in addressing childhood obesity in Malaysia. (2) Methods: A panel of 22 stakeholders and experts from Malaysia, representing the government, industry, academia and non-governmental organizations, were sampled using a modified Delphi technique. Data were collected using a modified NCD scorecard under four domains (governance, risk factors, surveillance and research and health systems response). A heat map was used to measure the success of the four realms of the NCD scorecard. For each domain of the NCD scorecard, the final score was grouped in quintiles. (3) Results: A total of 22 participants responded, comprising of eight (36.4%) males and 14 (63.4%) females. All the domains measured in implementing policies related to childhood obesity were of low progress. Nine governance indicators were reported as 22.5% (low progress), four in the risk factors domain, and two in the surveillance. This shows that timely and accurate monitoring, participatory review and evaluation, and effective remedies are necessary for a country's surveillance system. (4) Conclusion: Although Malaysia has published several key strategic documents relating to childhood obesity and implemented numerous policy interventions, we have identified several gaps that must be addressed to leverage the whole-of-government and whole-of-society approach in addressing childhood obesity in the country.

Non-communicable Disease Surveillance in Malaysia: An Overview of Existing Systems and Priorities Going Forward.

In 2012, the World Health Organization (WHO) set a comprehensive set of nine global voluntary targets, including the landmark "25 by 25" mortality reduction target, and 25 indicators. WHO has also highlighted the importance of Non-Communicable Disease (NCD) surveillance as a key action by Member States in addressing NCDs. This study aimed to examine the current national NCD surveillance tools, activities and performance in Malaysia based on the WHO Global Monitoring Framework for NCDs and to highlight gaps and priorities moving forward. A desk review was conducted from August to October in 2020, to examine the current national NCD surveillance activities in Malaysia from multiple sources. Policy and program documents relating to NCD surveillance in Malaysia from 2010 to 2020 were identified and analyzed. The findings of this review are presented according to the three major themes of the Global Monitoring Framework: monitoring of exposure/risk factor, monitoring of outcomes and health system capacity/response. Currently, there is a robust monitoring system for NCD Surveillance in Malaysia for indicators that are monitored by the WHO NCD Global Monitoring Framework, particularly for outcome and exposure monitoring. However, Malaysia still lacks data for the surveillance of the health system indicators of the framework. Although Malaysia has an NCD surveillance in place that is adequate for the WHO NCD Global Monitoring Framework, there are areas that require strengthening. The country must also look beyond these set of indicators in view of the increasing burden and impact of the COVID-19 pandemic. This includes incorporating mental health indicators and leveraging on alternate sources of data relating to behaviors.

Changes in body mass index, glycosylated hemoglobin A1C, blood pressure, and LDL-cholesterol among type 2 diabetes patients in Malaysia: A population-based longitudinal study.

BACKGROUND: This study aimed to describe changes in body mass index, glycosylated hemoglobin A1C, blood pressure, and low-density lipoprotein (LDL)-cholesterol among type 2 diabetes patients in Malaysia. METHODS: A five-year retrospective cohort study was conducted using data from the National Diabetes Registry. Type 2 diabetes patients aged ≥18 years and had ≥2 clinical audits between 2013 and 2017 were included in the analysis. The first audit information formed the baseline characteristics, and the last audit information was used for comparison. Individualized A1C, blood pressure, and LDL-cholesterol goals were adapted from Malaysian Clinical Practice Guidelines on Type 2 Diabetes Management 2020, American Diabetes Association 2020, and European Association for the Study of Diabetes 2019. RESULTS: Of the 18 341 patients, 55.8% were female and 64.9% Malay ethnicity. The baseline mean age was 59.3 ± 10.6 years. During an average of 2.5 person-years of follow-up, the mean body mass index dropped by 0.16 kg/m2 to 27.9 kg/m2 , A1C increased by 0.16% to 8.0%, systolic blood pressure increased by 1.4 mm Hg to 136.2 mm Hg, diastolic blood pressure decreased by 1.0 mm Hg to 77.3 mm Hg and LDL-cholesterol reduced by 0.12 mmol/L to 2.79 mmol/L, P < 0.001 for all. Out of eight categories of individualized goals, most patients achieved the A1C goal of ≤8.0%. The new LDL-cholesterol goal of <1.4 mmol/L was least likely to be achieved. CONCLUSIONS: The body mass index, A1C, blood pressure, and LDL-cholesterol performance remained suboptimal. Standards of care for these clinical parameters remain to be achieved by the majority of diabetes patients.

Predictors of glycosylated haemoglobin A1C trend among type 2 diabetes patients in a multi-ethnic country.

Good control of glycosylated haemoglobin A1C in diabetes patients prevents cardiovascular complications. We aim to describe the A1C trend and determine the predictors of the trend among type 2 diabetes patients in Malaysia. Longitudinal data in the National Diabetes Registry from 2013 to 2017 were analysed using linear mixed-effects modelling. Among 17,592 patients, 56.3% were females, 64.9% Malays, and the baseline mean age was 59.1 years. The U-shaped A1C trend changed marginally from 7.89% in 2013 to 8.07% in 2017. The A1C excess of 1.07% as reported in 2017 represented about 22% higher risk of diabetes-related death, myocardial infarction, and stroke, which are potentially preventable. The predictors for higher baseline A1C were non-Chinese ethnicity, younger age groups, longer diabetes duration, patients on insulin treatment, polypharmacy use, patients without hypertension, and patients who were not on antihypertensive agents. Younger age groups predicted a linear increase in the A1C trend, whereas patients on insulin treatment predicted a linear decrease in the A1C trend. Specifically, the younger adults and patients of Indian and Malay ethnicities had the poorest A1C trends. Targeted interventions should be directed at these high-risk groups to improve their A1C control.

Proposal for development of a guideline in maintaining quality cancer care during and post-covid-19 in an upper middle-income country with universal health coverage.

BACKGROUND: During periods of high community transmission of COVID-19, the public hospitals in Malaysia, an upper middle-income country, have been forced to scale down elective surgeries, prioritize cancer treatments based on treatment benefits, and postpone non-emergency imaging procedures. These inevitably led to disruptions in cancer care delivery within the public health care system. This study aims to explore the facilitators and barriers faced by healthcare providers and cancer survivors in cancer care, and to co-design a guideline to maintain the delivery of cancer care amid the disaster situations. METHOD: In-depth interviews (IDIs) will be conducted with Malaysian healthcare providers and cancer survivors and findings will be analysed thematically. The insights will be used in a subsequent phase to co-design a guideline to maintain the delivery of quality cancer care in Malaysia via a three-round modified Delphi survey with a broad range of cancer stakeholders. EXPECTED RESULTS: Findings derived from IDIs and existing literature will be included for rating across three rounds by the expert panel. Feedback provided will be refined until consensus on the best practises for cancer care continuity during crises is achieved. CONCLUSION: The output of the present study is not only expected to ensure the continuity of delivery of high-quality cancer care in Malaysia during the ongoing pandemic but also to be adapted during unforeseen crises in the near future. POLICY SUMMARY STATEMENT: Collaborative work between policy makers, public health physicians, members of the multidisciplinary oncology team as well as cancer survivors is vital in developing an evidenced- based contingency plan for maintaining access to cancer care.

Development and evaluation of a digital, community-based intervention to reduce noncommunicable disease risk in a low-resource urban setting in Malaysia: a research protocol.

BACKGROUND: Noncommunicable disease burden is rising in Malaysia, accounting for 72% of all deaths. Urbanization and globalization have contributed to changing patterns of diet and physical activity, creating an obesogenic environment that increases noncommunicable disease risk, especially in low-income populations. Community-based and technological interventions can play an important role in addressing structural determinants that influence noncommunicable disease burden. The Better Health Programme Malaysia aims to co-create and develop a community-based digital intervention for low-income populations to enable community stakeholders to address obesogenic environments and improve people's knowledge, attitudes, and practices related to noncommunicable disease risk. METHODS: This quasi-experimental study will assess community member and community health volunteer knowledge, attitudes, and practices on noncommunicable disease prevention, risk factors, and health-seeking behavior in three geographical areas of Kuala Lumpur, each representing a different ethnicity (Malay, Indian, and Chinese). Assessment will take place before and after a 9-month intervention period, comparing intervention areas with matched control geographies. We plan to engage 2880 community members and 45 community health volunteers across the six geographic areas. A digital health needs assessment will inform modification of digital health tools to support project aims. Intervention co-creation will use a discrete choice experiment to identify community preferences among evidence-based intervention options, building from data collected on community knowledge, attitudes, and practices. Community health volunteers will work with local businesses and other stakeholders to effect change in obesogenic environments and NCD risk. The study has been approved by the Malaysian Ministry of Health Medical Research Ethical Committee. DISCUSSION: The Better Health Programme Malaysia anticipates a bottom-up approach that relies on community health volunteers collaborating with local businesses to implement activities that address obesogenic environments and improve community knowledge, attitudes, and practices related to NCD risk. The planned co-creation process will determine which interventions will be most locally relevant, feasible, and needed. The effort aims to empower community members and community health volunteers to drive change that improves their own health and wellbeing. The learnings can be useful nationally and sub-nationally in Malaysia, as well as across similar settings that are working with community stakeholders to reduce noncommunicable disease risk. TRIAL REGISTRATION: National Medical Research Register, Malaysia; NMRR-20-1004-54787 (IIR); July 7, 2020.

Clinical inertia in type 2 diabetes management in a middle-income country: A retrospective cohort study.

BACKGROUND: Clinical inertia can lead to poor glycemic control among type 2 diabetes patients. However, there is paucity of information on clinical inertia in low- and middle-income countries including Malaysia. This study aimed to determine the time to treatment intensification among T2D patients with HbA1c of ≥7% (≥53 mmol/mol) in Malaysian public health clinics. The proportion of patients with treatment intensification and its associated factors were also determined. MATERIAL AND METHODS: This was a five-year retrospective open cohort study using secondary data from the National Diabetes Registry. The study setting was all public health clinics (n = 47) in the state of Negeri Sembilan, Malaysia. Time to treatment intensification was defined as the number of years from the index year until the addition of another oral antidiabetic drug or initiation of insulin. Life table survival analysis based on best-worst case scenarios was used to determine the time to treatment intensification. Discrete-time proportional hazards model was fitted for the factors associated with treatment intensification. RESULTS: The mean follow-up duration was 2.6 (SD 1.1) years. Of 7,646 patients, the median time to treatment intensification was 1.29 years (15.5 months), 1.58 years (19.0 months) and 2.32 years (27.8 months) under the best-, average- and worst-case scenarios respectively. The proportion of patients with treatment intensification was 45.4% (95% CI: 44.2-46.5), of which 34.6% occurred only after one year. Younger adults, overweight, obesity, use of antiplatelet medications and poorer HbA1c were positively associated with treatment intensification. Patients treated with more oral antidiabetics were less likely to have treatment intensification. CONCLUSION: Clinical inertia is present in the management of T2D patients in Malaysian public health clinics. We recommend further studies in lower- and middle-income countries to explore its causes so that targeted strategies can be developed to address this issue.

Variations in the Delivery of Primary Diabetes Care in Malaysia: Lessons to Be Learnt and Potential for Improvement.

BACKGROUND: The article describes variations in the organization of clinical services for diabetes patients in 10 public primary health clinics in Malaysia with the view to learn from current innovations and improve diabetes service provision. METHODS: This study combined the use of secondary data and a qualitative multicase study approach applying observations in 10 randomly selected Ministry of Health (MOH) health clinics in Kuala Lumpur and Selangor and semistructured interviews of the family medicine specialists from the same clinics. RESULTS: Although there are specific MOH guidelines for diabetes care, some clinics had introduced innovations for diabetes care such as the novel 'personalized care', 'one-stop-centre' and utilization of patients' waiting time for health education. Analysis showed that there was room for improvement in terms of task shifting to free precious time of staff with specialized functions, streamlining appointments for various examinations, increasing continuity of consultations with same doctors, and monitoring of performance. CONCLUSION: We contend that there is a potential for increased effectiveness and efficiency of primary diabetes care in Malaysia without increasing the resources - a potential that may be tapped into by systematic learning from ongoing innovation.