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

Abstract

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, Malaysia's 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.

Barriers to Treatment and Control of Hypertension among Hypertensive Participants: A Community-Based Cross-sectional Mixed Method Study in Municipalities of Kathmandu, Nepal

“…Timely maintaining the follow-up visit ensures the good compliance over medication, thus controlling hypertension ( 36 , 37 ). In Malaysia, patients are reluctant to visit physicians for the second time because of their denial of their condition, or, having failed to follow the lifestyle advice on diet and exercise, or low health literacy given by physicians ( 15 ). But, in our study, the majority of the participants missed the follow-up date because of lack of proper information about follow-up need from health-care providers.…”

Wealth and cardiovascular health: a cross-sectional study of wealth-related inequalities in the awareness, treatment and control of hypertension in high-, middle- and low-income countries

“…Those completed so far reveal complex pictures relating to both demand for treatment, influenced by cost of drugs and by how hypertension – a chronic, asymptomatic, but hazardous condition – is conceptualized, and by supply of trained health professionals and medicines [34, 35]. Other data from the Environmental Profile of a Community’s Health study (EPOCH), nested within PURE, also provide insights.…”

Understanding and measuring quality of care: dealing with complexity

“…Patients may sometimes believe an ineffective and unsafe treatment to be good, even when they have access to effective and safe treatments. In Malaysia, for example, many people with hypertension seek potentially ineffective and unsafe treatments from traditional practitioners 21 . Perceptions of the quality of care are based on a mix of individual experience, processed information and rumour.…”