nhms_2019.pdf

National Health and Morbidity Survey 2019 Technical Report − Volume I 010 Executive Summary The National Health and Morbidity Survey (NHMS) is carried out to provide community based data to the Ministry of Health Malaysia for review of health programs and priorities. The starting of each cycle of NHMS focuses on non-communicable diseases (NCDs), risk factors for NCDs, healthcare demand and other areas of priority as determined by the Ministry of Health. The year 2019 marks the beginning of a new cycle of NHMS, to study these key areas to determine the health status of the people in Malaysia, as well as monitor the trends of diseases and healthcare utilization in Malaysia. Complex study design, with two stage stratified cluster sampling, was utilized in NHMS 2019. A total of 475 Enumeration Blocks (EBs) were selected across all 13 states and 3 federal territories in Malaysia, with 12 Livings Quarters (LQs) selected from each EB, resulting in almost 5,700 LQs randomly selected to be included in this survey. A trained team, consisting of trained research assistants and nurses carried out face-to-face in - terviews, self-administered questionnaires, clinical assessment as well as point-of-care blood testing. All those living in the selected LQs were eligible for this survey, with a total of 14,965 individuals agreeing to participate, and resulting in a response rate of 87.2%. The NHMS 2019 found that the prevalence of known diabetes to be at 9.4%, while the prevalence of raised blood glucose among unknown diabetes to be 8.9%, resulting in the prevalence of overall raised blood glucose in Malaysia in 2019 to be 18.3%. This was an increase compared to findings of 2011 of 11.2% and 2015 of 13.4%. There were no large differences noted between sexes or urban and rural localities. The prevalence of raised blood glucose by each state showed varying rates, from as low as 9.8% to as high as 33.2%. Over 80% of those with raised blood glucose but unknown to have diabetes were aged 60 years and below. The prevalence of known hypertension was found to be 15.9% in NHMS 2019. Raised blood pressure among unknown hypertension was 14.1%, with an overall prevalence of raised blood pressure in Malaysia to be 30.0%. The trend for raised blood pressure shows a plateau compared to findings of 2011 of 32.6% and 2015 of 30.3%. The prevalence of known hypercholesterolemia was found to be 13.5% with the prevalence of raised blood total cholesterol among unknown hypercholesterolemia to be 24.6%. This is a reduction compared to the 47.7% reported in NHMS 2015. This survey also found that 50.1% of adults in Malaysia were overweight or obese, with 30.4% being overweight and 19.7% obese. A total of 52.6% of adults were found to have abdominal obesity. The trends of overweight, obesity and abdominal obesity continue to rise compared to findings of 2011 and 2015. Among children 5-17 years of age, a total of 15.0% were overweight, with 14.8% being obese. On the other hand, the number of children under 5 years of age being stunted, showed an increase compared to previous years, from 16.6% in 2011, 17.7% in 2015 to 21.8% in 2019. National Health and Morbidity Survey 2019 Technical Report − Volume I 010 Non-Communicable Diseases: Risk Factors and other Health Problems 011 In 2019, the prevalence of adults who are physically inactive was 25.1%. This was an improvement, a reduction from 35.7% in 2011 to 33.5% in 2015. However, a staggering 94.9% of adults were found to not consume adequate fruits and/ or vegetables daily. The awareness of the Healthy Plate Concept (Suku Suku Separuh), was found to be 20.4% in the population, with only 14.0% of the adults who are aware, admitting to practicing it daily. The survey also found the prevalence of current smokers to 21.3%, with the use of e-cigarettes at 4.9%. The number of current alcohol drinkers were found to be 11.8%, with a reduction seen in harmful alcohol use, with the proportion of binge drinkers reducing from 59.4% in 2015 to 45.8% in 2019 and reducing proportion of heavy episodic drinkers from 10.8% in 2015 to 8.4% in 2019. A total of 2.3% of the adults in Malaysia were found to have depression. Among children 5 to 15 years of age, 7.9% of children were found to have mental health problems, and a rise was seen compared to findings of 2015, mainly due to poor interaction with their peers. The prevalence of disability among adults was found to be 11.1%, and 4.7% among children 2 to 17 years of age. A total of 21.3% of adults in Malaysia were found to have anaemia, with 29.9% of women in reproductive age (15 to 49 years of age) to be anaemic. The survey findings also found that 1.5% of the people in Malaysia to have ever used drugs, with 0.5% being current drug users. Marijuana, kratom and amphetamine were found to be the most prevalent substance used. A total of 31.6% of adult men and 36.1% of men over 40 years of age reported having erectile dysfunction. Furthermore 16.3% of men over 40 years of age reported of having lower urinary tract symptoms, suggestive of having benign prostatic hyperplasia. Among women, 49.0% of adult women reported practicing breast self-examination in the past 12 months while 36.6% of women age 20 years and above reported having done a pap smear in the past 12 months. Only 25.0% of women age 40 years and above reported to having ever done a mammogram, while of 21.0% of women had done so in the past 3 years, as recommended by the Ministry of Health Malaysia. Understanding the status and prevalence of NCDs and its risk factors is essential, as it is one of the major causes of mortality and morbidity in Malaysia. We are hopeful that the findings of this survey will aid policy makers and program managers in carrying out their tasks, improving existing programs as well as plan to future needs of the people in Malaysia. Strengthening the delivery of primary healthcare services and empowerment of the people remains the mainstay towards combating this rising problem in Malaysia. The survey findings of rising prevalence rates of several key NCDs and risk factors highlights the critical need for clinicians, researchers, program managers, policy makers and most importantly each and every individual to join hands in combating NCDs in Malaysia. Non-Communicable Diseases: Risk Factors and other Health Problems 011 National Health and Morbidity Survey 2019 Technical Report − Volume I 012 LIST OF ABBREVIATIONS BPH

• Benign Prostatic Hyperplasia BMI
• Body Mass Index CI
• Confidence Interval CPRD
• Commercially Packed Ready to Drink EB
• Enumeration Block ED
• Erectile Dysfunction FBG
• Fasting Blood Glucose FOBT
• Faecal Occult Blood Tests GATS
• Global Adult Tobacco Surveillance HEPA
• Health-Enhancing Physical Activity HPV
• Human Papilloma Virus IPAQ
• International Physical Activity Questionnaire LQ
• Living Quarter LUTS
• Lower Urinary Tract Symptoms MDG
• Malaysian Dietary Guidelines MOH
• Ministry of Health NADA
• National Anti-Drug Agency NASPAL - National Strategic Plan for Active Living NCD
• Non-Communicable Disease NGO
• Non-Government Organization NHMS - National Health and Morbidity Survey NSPTC - National Strategic Plan on Tobacco Control OSCA
• One Stop Centre for Addiction POA
• Plan of Action PHQ
• Patient Health Questionnaire PWD
• Person with Disabilities QoL
• Quality of Life SCS
• Survey Creation System SDG
• Sustainable Development Goals SDQ
• Strength and Difficulties Questionnaire SSB
• Sugar Sweetened Beverage UNICEF - United Nations Children’s Fund WC
• Waist Circumference WG
• The Washington Group on Disability Statistics WHO
• World Health Organization

Non-Communicable Diseases: Risk Factors and other Health Problems 013 Introduction

National Health and Morbidity Survey 2019 Technical Report − Volume I 014 Introduction 1.1 Background The National Health and Morbidity Survey (NHMS) is carried out to obtain community-based data on the pattern of health problems and health needs of the people in Malaysia. This data is essential for the Ministry of Health to review its priorities and programs, plan future allocation of resources and evaluate the impact of current strategies. The first NHMS was carried out in 1986. Subsequent surveys (NHMS II in 1996 and NHMS III in 2006) were conducted in 10-yearly intervals, to review the health status in Malaysia. Since 2011, taking into account the need for updated and recent health data for policy formulation, the NHMS was structured to be carried out every year, in 4 yearly cycles. The start of each cycle focuses on non-communicable diseases (NCDs) and healthcare demand, as well as other areas of priority as determined by the Ministry of Health (MOH). The scopes of study within each survey is determined by the NHMS Steering Committee, chaired by the Director General of Health Malaysia, and consists of members from both the Ministry of Health as well as representatives from local universities. Several rounds of discussions are also held with local stakeholders to determine the topics and best methods of study in NHMS. NCDs are the leading cause of death worldwide. In Malaysia, NCDs account for 67% of premature mortality, and over 70% of disease burden in 2014. The previous survey in 2015 had reported high and increasing prevalence of NCDs and NCD risk factors in Malaysia. The year 2019 marks the start of a new cycle of NHMS, the 6th cycle, to monitor the changes and trends in NCDs, following the pattern of the previous surveys carried out in 2011 and 2015. The data obtained from NHMS 2019 is important to assist the Ministry of Health Malaysia to make evidence-based policies, and review the status of non-communicable diseases in Malaysia, as well as determine the utilization and expenditure of health services. The data is also used by multiple agencies, including monitoring of international indicators such as the Sustainable Development Goals (SDG). 1.2 Objectives General objective To provide community-based data and evidence to the Ministry of Health Malaysia on non-communicable diseases, risk factors of non-communicable diseases, and healthcare demand for review of national health priorities and programmes. Specific objectives for the NCD component: To determine prevalence of; • Diabetes • Hypertension • Hypercholesterolemia • Nutritional Status • Dietary Practice • Physical Activity • Tobacco Use • Alcohol Consumption • Substance Abuse • Anaemia • Depression • Disability • Men’s Health (ED & BPH) • Women’s Health (Cancer Screening) • Epilepsy • Health Literacy

Non-Communicable Diseases: Risk Factors and other Health Problems 015 02 Methodology

National Health and Morbidity Survey 2019 Technical Report − Volume I 016 Methodology 2.1 Target Population The NHMS 2019 covered both urban and rural areas in all 13 states and 3 federal territories in Malaysia. The target population was the residence in the non-institutional living quarters (LQs). Institutional population such as those staying in hotel, hostels, hospitals, etc. were excluded from this survey. 2.2 Sampling Frame The geographical areas in Malaysia were divided into Enumeration Blocks (EBs). Each EB is defined and classified into either urban or rural areas by Department of Statistics based on the population size of the gazetted area. The definition of urban area is a gazetted area which has a combined population of 10,000 or more. A gazetted area with a combined population of less than 10,000 is classified as rural area. There were over 75,000 EBs in Malaysia. Each EB usually contains between 80 to 120 LQs with an average population of 500 to 600 people. The sampling frame consists of selected EBs same as that was provided by Department of Statistics Malaysia in NHMS 2015. 2.3 Sample Size Determination Sample size was calculated using a single proportion formula for estimation of prevalence. nSRS ≥ Z2 α/2 P(1-P) e2 The sample size calculation was based on a few criteria as below: i. Variance of proportion of the variable of interest (Based on NHMS 2015 or other literatures) ii. Margin of error (e) (Between 0.02 to 0.07) iii. Confidence Interval of 95% To ensure optimum sample size, few adjustments were made: i. Adjusted for finite population (Based on 2019 projected population) ii. Adjusted for the design effect (deff) (Based on previous survey: NHMS 2015)

n(complex)= n(srs) * deff iii. Adjusted the n(complex) taking into account expected non-response rates of 35%

n(adj) = n(complex) * (1 + non-response rate) The sample size was then adjusted according to the need of the analysis, whether the prevalence estimate was at the national, or state level. Based on the core objectives and above mentioned considerations, the optimum sample size required was 5,676 LQs. The allocation of samples to the states, urban and rural was done proportionally to the population size. Bigger number of samples were allocated to states with bigger population size such as Selangor, Johor and Sabah, and lesser number of samples were allocated to states with smaller population size such as Melaka, Perlis and Labuan. 2.4 Sampling Design To ensure national representativeness, two stage stratified random sampling was used. The two strata are primary stratum, which made up of states of Malaysia, including Federal Territories, and secondary stratum, which made up of urban and rural strata formed within the primary stratum. Sampling involved two stages; the Primary Sampling Unit (PSU), which were the EBs and the Secondary Sampling Unit (SSU), which were the LQs within the selected EBs. For NHMS 2019, a total of 5,676 LQs were selected from the selected 475 EBs in Malaysia, where 362 and 113 EBs were selected from urban and rural areas respectively. Twelve LQs were randomly selected from each selected EB. The distribution of selected sample by state is presented in Table 2.1. All individuals with their primary residence and residing for at least 2 weeks prior to data collection, in the selected LQ were eligible to participate in this survey.