title: Understanding the modifiable health systems barriers to hypertension management in Malaysia: a multi-method health systems appraisal approach.
abstract: BACKGROUND
  The 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.
  
  
  METHODS
  A 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.
  
  
  RESULTS
  The 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.
  
  
  CONCLUSIONS
  Despite having a relatively well funded health system offering good access to care, Malaysia's health system still has significant barriers to effective hypertension management.
  
  
  CONCLUSIONS
  The 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.
authors.affiliation: London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. isabellerissogill@gmail.com.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Risso-Gill
authors.affiliation: London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. dina.balabanova@lshtm.ac.uk.
authors.forename: Dina
authors.initials: D
authors.lastname: Balabanova
authors.affiliation: Universiti Teknologi MARA, Kuala Lumpur, Malaysia. fadhlina.majid@gmail.com.
authors.forename: Fadhlina
authors.initials: F
authors.lastname: Majid
authors.affiliation: National Defence University of Malaysia, Kuala Lumpur, Malaysia. kien@upnm.edu.my.
authors.forename: Kien Keat
authors.initials: KK
authors.lastname: Ng
authors.affiliation: Universiti Teknologi MARA, Kuala Lumpur, Malaysia. k.yusoff@salam.uitm.edu.my.|UCSI University, Kuala Lumpur, Malaysia. k.yusoff@salam.uitm.edu.my.
authors.forename: Khalid
authors.initials: K
authors.lastname: Yusoff
authors.affiliation: Universiti Teknologi MARA, Kuala Lumpur, Malaysia. dr.feisul@moh.gov.my.
authors.forename: Feisul
authors.initials: F
authors.lastname: Mustapha
authors.affiliation: London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. charlotte.kuhlbrandt@lshtm.ac.uk.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Kuhlbrandt
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Ontario, Canada. Robby.Nieuwlaat@phri.ca.
authors.forename: Robby
authors.initials: R
authors.lastname: Nieuwlaat
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Ontario, Canada. schwalj@mcmaster.ca.
authors.forename: J-D
authors.initials: JD
authors.lastname: Schwalm
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Ontario, Canada. tara.mccready@phri.ca.
authors.forename: Tara
authors.initials: T
authors.lastname: McCready
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Ontario, Canada. Koon.Teo@phri.ca.
authors.forename: Koon K
authors.initials: KK
authors.lastname: Teo
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Ontario, Canada. Salim.Yusuf@phri.ca.
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
authors.affiliation: London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. martin.mckee@lshtm.ac.uk.
authors.forename: Martin
authors.initials: M
authors.lastname: McKee
mesh_terms: D000328:Adult; D000368:Aged; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D006078:Government Programs; D006282:Health Personnel; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D007407:Interviews as Topic; D008296:Malaysia; D008297:Male; D008483:Medical Assistance; D008875:Middle Aged; D017149:Private Sector; D036301:Qualitative Research; D012424:Rural Population; D011795:Surveys and Questionnaires