The development and evaluation of a mHealth, community education and navigation intervention to improve clinical breast examination uptake in Segamat Malaysia: A randomised controlled trial.

INTRODUCTION: Breast cancer (BC) screening uptake in Malaysia is low and a high number of cases present at a late stage. Community navigation and mobile health (mHealth) may increase screening attendance, particularly by women from rural communities. This randomized controlled study evaluated an intervention that used mHealth and community health workers to educate women about BC screening and navigate them to clinical breast examination (CBE) services in the context of the COVID-19 pandemic. METHODS: Women aged 40-74 years, from Segamat, Malaysia, with a mobile phone number, who participated in the South East Asian Community Observatory health survey, (2018) were randomized to an intervention (IG) or comparison group (CG). The IG received a multi-component mHealth intervention, i.e. information about BC was provided through a website, and telephone calls and text messages from community health workers (CHWs) were used to raise BC awareness and navigate women to CBE services. The CG received no intervention other than the usual option to access opportunistic screening. Regression analyses were conducted to investigate between-group differences over time in uptake of screening and variable influences on CBE screening participation. RESULTS: We recruited 483 women in total; 122/225 from the IG and 144/258 from the CG completed the baseline and follow-up survey. Uptake of CBE by the IG was 45.8% (103/225) whilst 3.5% (5/144) of women from the CG who completed the follow-up survey reported that they attended a CBE during the study period (adjusted OR 37.21, 95% CI 14.13; 98.00, p<0.001). All IG women with a positive CBE attended a follow-up mammogram (11/11). Attendance by IG women was lower among women with a household income ≥RM 4,850 (adjusted OR 0.48, 95% CI 0.20; 0.95, p = 0.038) compared to participants with a household income

Breast cancer and breast cancer screening use-beliefs and behaviours in a nationwide study in Malaysia.

BACKGROUND: Many upper-middle-income countries (UMICs), including Malaysia, continue to face low breast cancer (BC) screening rates and patients with delayed presentation of BC. This study investigated the role of beliefs about BC and use of screening (e.g. beliefs about whether or not screening reduced the possibility of dying from BC). METHODS: A nationwide cross-sectional study was conducted in which a total of 813 women (aged ≥ 40 years old) were randomly selected and surveyed using the validated Awareness and Beliefs about Cancer (ABC) measure. The association between BC screening use, sociodemographic characteristics, and negative beliefs about BC screening were analysed using stepwise Poisson regressions. RESULTS: Seven out of ten Malaysian women believed that BC screening was necessary only when experiencing cancer symptoms. Women > 50 years and from households with more than one car or motorcycle were 1.6 times more likely to attend a mammogram or a clinical breast examination (mammogram: Prevalence Ratio (PR) = 1.60, 95% Confidence Interval (CI) = 1.19-2.14, Clinical Breast Examination (CBE): PR = 1.61, 95% CI = 1.29-1.99). About 23% of women expected to feel anxious about attending BC screening, leading them to avoid the procedure. Women who held negative beliefs about BC screening were 37% less likely to attend a mammogram (PR = 0.63, 95% CI = 0.42-0.94) and 24% less likely to seek a CBE (PR = 0.75, 95% CI = 0.60-0.95). CONCLUSIONS: Public health strategies or behaviour interventions targeting negative beliefs about BC screening among Malaysian women may increase uptake and reduce late presentation and advanced-stage cancer. Insights from the study suggest that women under 50 years, in the lower income group without a car or motorcycle ownership, and of Malay or Indian ethnicity (compared to Chinese-Malay) are more likely to hold beliefs inhibiting BC screening.

Implementation of a home-based colorectal cancer screening intervention in Malaysia (CRC-SIM).

INTRODUCTION: The Colorectal Cancer Screening Intervention for Malaysia (CRC-SIM) was a CRC study of home-based testing designed to improve low screening uptake using the immunochemical fecal occult blood test (iFOBT) in Malaysia. METHODS: This quasi-experimental study was informed by the Implementation Research Logic Model and evaluated with the RE-AIM framework. Trained data collectors recruited by phone, randomly selected, asymptomatic adults aged 50-75 years from Segamat District, who previously completed a health census form for the South East Asia Community Observatory (SEACO). Participants were posted an iFOBT kit and asked to return a photo of the completed test for screening by health care professionals. A regression analysis of evaluation data was conducted to identify which variables were associated with the outcome indicators of 'study participation' and 'iFOBT completion' and the CRC-SIM was evaluated in terms of its appropriateness, feasibility and acceptability. RESULTS: Seven hundred forty-seven eligible adults (52%) agreed to participate in this study and received an iFOBT kit. Participation was significantly lower amongst Chinese Malaysians (adjusted OR 0.45, 95% CI 0.35 - 0.59, p<0.001) compared to Malays and amongst participants from the rural sub-district (Gemereh) (adjusted OR 0.71, 95% CI 0.54 - 0.92, p=0.011) compared to the urban sub-district (Sungai Segamat). Less than half of participants (42%, n=311/747) completed the iFOBT. Test-kit completion was significantly higher amongst Chinese Malaysians (adjusted OR 3.15, 95% CI 2.11 - 4.69, p<0.001) and lower amongst participants with a monthly household income ≥RM 4,850 (adjusted OR 0.58, 95% CI 0.39 - 0.87, p=0.009) compared to participants with a lower household income. The main reported reason for non-participation was 'not interested' (58.6%) and main implementation challenges related to invalid photographs from participants and engaging iFOBT positive participants in further clinic consultations and procedures. CONCLUSION: Home-testing for CRC (test completion) appeared to be acceptable to only around one-fifth of the target population in Malaysia. However, mindful of the challenging circumstances surrounding the pandemic, the CRC-SIM merits consideration by public health planners as a method of increasing screening in Malaysia, and other low- and middle-income countries.

Prevalence of and factors associated with multimorbidity among 18 101 adults in the South East Asia Community Observatory Health and Demographic Surveillance System in Malaysia: a population-based, cross-sectional study of the MUTUAL consortium.

OBJECTIVES: To assess the prevalence and factors associated with multimorbidity in a community-dwelling general adult population on a large Health and Demographic Surveillance System (HDSS) scale. DESIGN: Population-based cross-sectional study. SETTING: South East Asia Community Observatory HDSS site in Malaysia. PARTICIPANTS: Of 45 246 participants recruited from 13 431 households, 18 101 eligible adults aged 18-97 years (mean age 47 years, 55.6% female) were included. MAIN OUTCOME MEASURES: The main outcome was prevalence of multimorbidity. Multimorbidity was defined as the coexistence of two or more chronic conditions per individual. A total of 13 chronic diseases were selected and were further classified into 11 medical conditions to account for multimorbidity. The conditions were heart disease, stroke, diabetes mellitus, hypertension, chronic kidney disease, musculoskeletal disorder, obesity, asthma, vision problem, hearing problem and physical mobility problem. Risk factors for multimorbidity were also analysed. RESULTS: Of the study cohort, 28.5% people lived with multimorbidity. The individual prevalence of the chronic conditions ranged from 1.0% to 24.7%, with musculoskeletal disorder (24.7%), obesity (20.7%) and hypertension (18.4%) as the most prevalent chronic conditions. The number of chronic conditions increased linearly with age (p<0.001). In the logistic regression model, multimorbidity is associated with female sex (adjusted OR 1.28, 95% CI 1.17 to 1.40, p<0.001), education levels (primary education compared with no education: adjusted OR 0.63, 95% CI 0.53 to 0.74; secondary education: adjusted OR 0.60, 95% CI 0.51 to 0.70; tertiary education: adjusted OR 0.65, 95% CI 0.54 to 0.80; p<0.001) and employment status (working adults compared with retirees: adjusted OR 0.70, 95% CI 0.60 to 0.82, p<0.001), in addition to age (adjusted OR 1.05, 95% CI 1.05 to 1.05, p<0.001). CONCLUSIONS: The current single-disease services in primary and secondary care should be accompanied by strategies to address complexities associated with multimorbidity, taking into account the factors associated with multimorbidity identified. Future research is needed to identify the most commonly occurring clusters of chronic diseases and their risk factors to develop more efficient and effective multimorbidity prevention and treatment strategies.

Implementation of a colorectal cancer screening intervention in Malaysia (CRC-SIM) in the context of a pandemic: study protocol.

INTRODUCTION: Colorectal cancer (CRC) is the second most common cancer in Malaysia and cases are often detected late. Improving screening uptake is key in down-staging cancer and improving patient outcomes. The aim of this study is to develop, implement and evaluate an intervention to improve CRC screening uptake in Malaysia in the context of the COVID-19 pandemic. The evaluation will include ascertaining the budgetary impact of implementing and delivering the intervention. METHODS AND ANALYSIS: The implementation research logic model guided the development of the study and implementation outcome measures were informed by the 'Reach, Effectiveness, Adoption, Implementation and Maintenance' (RE-AIM) framework. This CRC screening intervention for Malaysia uses home-testing and digital, small media, communication to improve CRC screening uptake. A sample of 780 people aged 50-75 years living in Segamat district, Malaysia, will be selected randomly from the South East Asia Community Observatory (SEACO) database. Participants will receive a screening pack as well as a WhatsApp video of a local doctor to undertake a stool test safely and to send a photo of the test result to a confidential mobile number. SEACO staff will inform participants of their result. Quantitative data about follow-up clinic attendance, subsequent hospital tests and outcomes will be collected. Logistic regression will be used to investigate variables that influence screening completion and we will conduct a budget impact-analysis of the intervention and its implementation. Qualitative data about intervention implementation from the perspective of participants and stakeholders will be analysed thematically. ETHICS AND DISSEMINATION: Ethics approval has been granted by Monash University Human Research Ethics Committee (MUHREC ID: 29107) and the Medical Review and Ethics Committee (Reference: 21-02045-O7G(2)). Results will be disseminated through publications, conferences and community engagement activities. TRIAL REGISTRATION NUMBER: National Medical Research Register Malaysia: 21-02045-O7G(2).

Digital health literacy for COVID-19 vaccination and intention to be immunized: A cross sectional multi-country study among the general adult population.

Introduction: It is clear that medical science has advanced much in the past few decades with the development of vaccines and this is even true for the novel coronavirus outbreak. By late 2020, COVID-19 vaccines were starting to be approved by national and global regulators, and across 2021, there was a global rollout of several vaccines. Despite rolling out vaccination programs successfully, there has been a cause of concern regarding uptake of vaccine due to vaccine hesitancy. In tackling the vaccine hesitancy and improving the overall vaccination rates, digital health literacy (DHL) could play a major role. Therefore, the aim of this study is to assess the digital health literacy and its relevance to the COVID-19 vaccination. Methods: An internet-based cross-sectional survey was conducted from April to August 2021 using convenience sampling among people from different countries. Participants were asked about their level of intention to the COVID-19 vaccine. Participants completed the Digital Health Literacy Instrument (DHLI), which was adapted in the context of the COVID Health Literacy Network. Cross-tabulation and logistic regression were used for analysis purpose. Results: Overall, the mean DHL score was 35.1 (SD = 6.9, Range = 12-48). The mean DHL score for those who answered "Yes" for "support for national vaccination schedule" was 36.1 (SD 6.7) compared to 32.5 (SD 6.8) for those who either answered "No" or "Don't know". Factors including country, place of residence, education, employment, and income were associated with the intention for vaccination. Odds of vaccine intention were higher in urban respondents (OR-1.46; C.I.-1.30-1.64) than in rural respondents. Further, higher competency in assessing the relevance of online information resulted in significantly higher intention for vaccine uptake. Conclusion: Priority should be given to improving DHL and vaccination awareness programs targeting rural areas, lower education level, lower income, and unemployed groups.

Diabetes Treatment and Mental Illness: A Call for an Integrated Health Care System in Underserved Semi-Rural Malaysia.

Diabetes mellitus (DM) management imposes a tremendous psychological burden on patients. The study investigates the association between DM treatment with blood glucose (BG) control and common mental health conditions. A cross-sectional study was conducted among 1821 individuals with DM in a community-based survey conducted in 2013. Information on respondents' sociodemographic, mental health, DM treatment, and BG levels was collected. Multinomial logistic regression was employed to examine the association of diabetes treatment with controlled BG levels (<11.1 mmol/L) (42.5%, n = 774) or uncontrolled BG levels (34.3%, n = 625) compared with those not undergoing treatment (23.2%, n = 422) on depression anxiety, and stress. Having DM treatment and controlled BG was associated with high depressive symptoms (Relative Risk Ratio, RRR: 2.42; 95% CI 1.33−4.41) and high anxiety symptoms (1.66; 1.08−2.56) but not with perceived stress. However, treated DM with uncontrolled BG was associated with anxiety (high: 1.64; 1.05−2.56; low: 2.59; 1.10−6.09) but not depression or perceived stress. Our results suggest that being treated for DM, regardless of glucose control status, was associated with anxiety symptoms, whereas being treated with controlled BG was associated with high depressive symptoms. This situation highlights the need for integrative, multidisciplinary care for DM patients with mental health comorbidities.

Frequent Eating Out and 10-Year Cardiovascular Disease Risk: Evidence from a Community Observatory in Malaysia.

Despite increasing mortality rates from cardiovascular diseases (CVDs) in low- and middle-income countries, information on the estimation of 10-year CVD risk remains to be sparse. Therefore, this study was aimed at predicting the 10-year CVD risk among community dwellers in Malaysia and at identifying the association of distal (socioeconomic characteristics) and proximal (lifestyle practices) factors with 10-year CVD risk. We calculated the 10-year CVD risk score among 11,897 eligible respondents from the community health survey conducted by the South East Asia Community Observatory (SEACO) using the Framingham risk score (FRS). The findings indicate that 28% of respondents have a high chance of having CVD within the next ten years. After adjusting for the age of respondents, demographic and socioeconomic factors such as gender, ethnicity, marital status, education, income, and occupation had an association with the 10-year CVD risk. In addition, frequent eating out had an association with 10-year CVD risk, while physical activity was found to have no association with predicted CVD risk. CVD remained among the top five mortality causes in Malaysia. Health promotion strategies should emphasize the importance of having home-cooked meals as a healthy dietary behavior, to reduce the mortality rate among Malaysians due to CVDs.

Psychological distress during pandemic Covid-19 among adult general population: Result across 13 countries.

The COVID-19 pandemics caused an unprecedented mortality, distress, and globally poses a challenge to mental resilience. To our knowledge, this is the first study that aimed to investigate the psychological distress among the adult general population across 13 countries. This cross-sectional study was conducted through online survey by recruiting 7091 respondents. Psychological distress was evaluated with COVID-19 Peritraumatic Distress Index (CPDI). The crude prevalence of psychological distress due to COVID-19 is highest in Vietnam, followed by Egypt, and Bangladesh. Through Multivariate Logistic Regression Analysis, the respondents from Vietnam holds the highest level of distress, while the respondents from Sri Lanka holds the lowest level of distress with reference to Nepal.Female respondents had higher odds of having reported psychological distress, and those with tertiary education were less likely to report psychological distress compared to those with lower level of education. The findings indicate that psychological distress is varies across different countries. Therefore, different countries should continue the surveillance on psychological consequences through the COVID-19 pandemic to monitor the burden and to prepare for the targeted mental health support interventions according to the need. The coping strategies and social support should be provided especially to the lower educational attainment group.

Anticipated delay in help-seeking for cancer symptoms: Findings from a nationwide study of Malaysian adults.

BACKGROUND: To investigate the relationship between anticipated delay in help-seeking and cancer symptom recognition and the extent to which this relationship varied according to socio-demographic and health-related characteristics. METHODS: A cross-sectional telephone survey was conducted of 1895 adults aged ≥40 years who were randomly selected across Malaysia and interviewed using the Awareness and Beliefs about Cancer questionnaire, which was previously validated and culturally adapted by the research team. Logistic regression analysis was used to test the associations between anticipated delay for help seeking >2 weeks and socio-demographic and health-related variables. RESULTS: Anticipated delay in help-seeking was reported for persistent cough (19.3 %), rectal bleeding (6.1 %) and breast changes (2.5 %). Difficulty in accessing a doctor was associated with anticipated delayed help-seeking for breast changes and rectal bleeding (adjusted ORs 7.58; 95 % CI 1.98, 28.94 and 2.37; 95 % CI 1.21, 4.66, respectively); not recognising the symptom 'unexplained bleeding' as a colorectal cancer warning sign was associated with anticipated delayed help-seeking for rectal bleeding (adjusted OR 1.54; 95 % CI 1.03, 2.31); and ethnicity was associated with anticipated delay for rectal bleeding and persistent cough. CONCLUSIONS: Generally, anticipated delay to help-seeking for cancer symptoms in Malaysia (a middle-income country) appeared to be a less significant problem compared to other countries including high-income countries. There appeared to be a significant association between social variation indicators in Malaysia and anticipated delay in help-seeking.

The impact of COVID-19 movement restrictions on physical activity in a low-income semi-rural population in Malaysia: A longitudinal study.

BACKGROUND: The COVID-19 pandemic prompted movement restrictions in countries worldwide, impacting on physical activity (PA), a major non-communicable disease risk factor, and thus may have unintentional long-term health implications. In semi-rural areas of low-middle-income-countries (LMICs), where occupational activity is the main source of PA, changes in PA associated with COVID-19 restrictions are unknown. We investigated the impact of Movement Control Order (MCO) restrictions in a semi-rural region of Malaysia. METHODS: The South East Asia Community Observatory (SEACO) is a dynamic prospective community cohort. We contacted a random sample of 1007 adults (18+) who had previously provided PA data in 2018. We asked about PA during the MCO (March-May 2020) and at the time of interview (June 2020). RESULTS: During the MCO, PA reduced by a mean of 6.7 hours/week (95% confidence interval (CI) = 5.3, 8.0) compared to 2018, with the largest reductions among those in employment. By June, PA was 3.4 hours/week (95% CI = 2.0, 4.8) less than 2018, leaving 34% of adults currently inactive (20% in 2018). Reductions in occupational PA were not replaced with active travel or activity at home. Despite these observed reductions, most participants did not think the MCO had affected their PA. CONCLUSIONS: Movement restrictions are associated with lower PA lasting beyond the period of strict restrictions; such longer-term reductions in PA may have a detrimental impact on health. Future MCOs should encourage people to be active, but may additionally need targeted messaging for those who don't necessarily realise they are at risk. In particular, policies developed in more affluent countries may not easily translate to LMICs.

Cancer symptom and risk factor awareness in Malaysia: findings from a nationwide cross-sectional study.

BACKGROUND: Cancer incidence in Malaysia is expected to double by 2040. Understanding cancer awareness is important in order to tailor preventative efforts and reduce the cancer burden. The objective of this research was to assess nationwide awareness about the signs and symptoms as well as risk factors for various cancers in Malaysia and identify socio-demographic factors associated with awareness. METHODS: This cross-sectional study was conducted from March-November 2014 in the form of a telephone survey. Participants aged 40 years and above were randomly selected across Malaysia and interviewed using the validated Awareness Beliefs about Cancer (ABC) measurement tool. Linear regression was conducted to test the association between symptom and risk factor recognition and socio-demographic variables. RESULTS: A sample of 1895 participants completed the survey. On average, participants recognised 5.8 (SD 3.2) out of 11 symptoms and 7.5 (SD 2.7) out of 12 risk factors. The most commonly recognised symptom was 'lump or swelling' (74.5%) and the most commonly recognised risk factor was 'smoking' (88.7%). Factors associated with prompted awareness were age, ethnicity, education and smoking status. CONCLUSION: Recognition of symptom and risk factors for most cancers was relatively low across Malaysia compared to previous studies in high-income countries and to studies conducted in Malaysia. There is a need to conduct regular public health campaigns and interventions designed to improve cancer awareness and knowledge as a first step towards increasing the early detection of cancer.

Statistical methods used to test for agreement of medical instruments measuring continuous variables in method comparison studies: a systematic review.

BACKGROUND: Accurate values are a must in medicine. An important parameter in determining the quality of a medical instrument is agreement with a gold standard. Various statistical methods have been used to test for agreement. Some of these methods have been shown to be inappropriate. This can result in misleading conclusions about the validity of an instrument. The Bland-Altman method is the most popular method judging by the many citations of the article proposing this method. However, the number of citations does not necessarily mean that this method has been applied in agreement research. No previous study has been conducted to look into this. This is the first systematic review to identify statistical methods used to test for agreement of medical instruments. The proportion of various statistical methods found in this review will also reflect the proportion of medical instruments that have been validated using those particular methods in current clinical practice. METHODOLOGY/FINDINGS: Five electronic databases were searched between 2007 and 2009 to look for agreement studies. A total of 3,260 titles were initially identified. Only 412 titles were potentially related, and finally 210 fitted the inclusion criteria. The Bland-Altman method is the most popular method with 178 (85%) studies having used this method, followed by the correlation coefficient (27%) and means comparison (18%). Some of the inappropriate methods highlighted by Altman and Bland since the 1980s are still in use. CONCLUSIONS: This study finds that the Bland-Altman method is the most popular method used in agreement research. There are still inappropriate applications of statistical methods in some studies. It is important for a clinician or medical researcher to be aware of this issue because misleading conclusions from inappropriate analyses will jeopardize the quality of the evidence, which in turn will influence quality of care given to patients in the future.