Non-Communicable Diseases: Risk Factors and other Health Problems 017 • All households within the selected LQs were included in the study. • All members in the households were also included in the study. Table 2.1: Distribution of Sample by State, NHMS 2019 No. State Enumeration Block Living Quarters Urban Rural Total Urban Rural Total 1. Johor 29 10 39 348 120 468 2. Kedah 16 8 24 192 96 288 3. Kelantan 11 13 24 132 156 288 4. Melaka 22 2 24 264 24 288 5. Negeri Sembilan 17 7 24 204 84 288 6. Pahang 13 11 24 156 132 288 7. Pulau Pinang 24 2 26 288 24 312 8. Perak 20 7 27 240 84 324 9. Perlis 14 10 24 168 120 288 10. Selangor 59 5 64 708 60 768 11. Terengganu 15 9 24 180 108 288 12. Sabah 23 16 39 276 192 468 13. Sarawak 17 13 30 204 156 360 14. WP Kuala Lumpur 25 0 25 300 0 300 15. WP Labuan 23 0 23 276 0 276 16. WP Putrajaya 32 0 32 384 0 384 TOTAL 362 113 475 4,320 1,356 5,676 2.5 Ethical Considerations This study had obtained ethical approval from the Medical Research and Ethics Committee of Ministry of Health Malaysia, and was registered in the National Medical Research Registry, bearing registration number NMRR-18-3085-44207. Before data collection was conducted, the relevant local authorities were contacted and informed. Prior to each interview, the purpose of the survey and methods used during the survey was explained to the respondent and information handed out via the participant’s information sheet. Furthermore, before the interview or any assessment was carried out, informed written consent was taken from each participant or guardian, with an additional assent form signed by participants between 7 to 18 years of age. All participants who were found to require medical attention at the time of the survey were referred using a structured referral letter to the nearest government health clinic for further assessment and management. 2.6 Questionnaire and Other Survey Materials Structured questionnaires were used to collect data based on the scopes of the survey. There were two types of questionnaire; face-to-face interview and self-administered. For the face- to-face interview, the pre-tested questionnaire was bi-lingual (Bahasa Melayu and English) accompanied with questionnaire manual prepared as a guide to the data collectors. The self-administered questionnaires were in four languages; Bahasa Melayu, English, Mandarin, and Tamil. There were flash cards provided in the form of code book to assist in the interview. The face-to-face interview questionnaire was programmed into an application and the data collection was done using tablets. Respondents were given the tablet to fill themselves for the self-administered questionnaires. Hardcopies of the self-administered questionnaires were also prepared should the respondent choose to answer in paper. The modules contained in the questionnaire, as well as the questionnaire used and target age group are presented in Table 2.2. The complete questionnaire and code book for NHMS 2019 is attached in the appendix of this report (Appendix 7 and 8).
National Health and Morbidity Survey 2019 Technical Report − Volume I 018 Table 2.2: Questionnaire Used for NCD Component, NHMS 2019 Module Questionnaire Method Target Age Group Household Information
Face-to-face All Sociodemography
Face-to-face All Diabetes STEPS Face-to-face 18 years and above Hypertension STEPS Face-to-face 18 years and above Hypercholesterolemia STEPS Face-to-face 18 years and above Physical Activity IPAQ – Short Form Face-to-face 16 years and above Smoking Mini GATS Face-to-face 15 years and above Dietary Practice
Face-to-face 18 years and above Health Screening
Face-to-face 18 years and above Alcohol AUDIT Self- Administered 13 years and above Substance Abuse
Self- Administered 18 years and above Disability WG Short Set Face-to-face 18 years and above Child Functioning WG Face-to-face 2 - 17 years Mental Health (Adult) PHQ Self- Administered 18 years and above Mental Health (Children) SDQ-Mall Self- Administered 5 - 15 years Health Literacy HLS-M-Q18 Self- Administered 18 years and above Benign Prostatic Hyperplasia IPSS Self- Administered 40 years and above Erectile Dysfunction IIEF Self- Administered 18 years and above Epilepsy Ottman Epilepsy Screening Face-to-face All Interviews were conducted for respondents aged 13 years and above, while for respondents below 13 years, the parent/guardian responded to the interview on their behalf (by proxy). Similar rules were applied to the self-administered questionnaire. Clinical Assessment (done by nurses): • Anthropometry (weight/height/length and waist circumference): » All ages. • Blood pressure measurement: » Aged 18 years and above. • Biochemistry tests (Fasting Blood Glucose and Cholesterol): » Aged 18 years and above. • Haemoglobin test: » Aged 15 years and above For the assessment of weight, Tanita Personal Scale HD 319 was used for adults, while Tanita Baby Scale 1583 was used for infants. Both tools had been validated and calibrated prior to the survey. For field implementation, a standard weight was supplied for each team for standardisation. For measurement of height, SECA Stadiometer 213 was used for adults, while Measuring Mat SECA 210 was used for infants. Both tools had also been validated and calibrated prior to the survey. All measurements were carried out twice by trained nurses. Omron Japan Model HEM-907 was used for blood pressure assessment, while CardioChek® PA Analyzer was used to assess fasting blood glucose and cholesterol, both tools which had been validated and calibrated prior to the survey. A validated and calibrated HemoCue® Machine Hb 201+ was used to measure haemoglobin level. Any participant who was found to be pregnant, post-natal, bed-ridden, or having physical disabilities or deformities were excluded from the anthropometric assessment. All measurements from the clinical assessment were recorded in the clinical assessment form and subsequently keyed into the tablet by the nurse. 2.7 Field Preparation and Logistic Support Excellent support was provided by the State Health Departments in the preparation for field data collection. A Liaison Officer was appointed in each state to assist in the data collection activities. They assisted in the delivery of information regarding the survey and liaised with the selected communities, relevant District Health Officers and Local Authorities for logistic arrangements. They also assisted in the publicity of the survey through dissemination of relevant information to various stakeholders including the public. Before the implementation of the data collection, scouts were appointed from the District Health Office of the selected districts. The selected LQs were then identified and tagged by the scouts. The members in the selected LQs, communities and related government agencies were also informed about the survey, through information leaflets.
Non-Communicable Diseases: Risk Factors and other Health Problems 019 Field Supervisors for each state were recruited from among the Institute for Public Health, Institute for Health Systems Research, Institute for Health Behavioural Research and other agencies of Ministry of Health Malaysia personnel, to liaise with the Liaison Officers in the arrangement of transportation, accommodation, appointment with respondents and other related logistic issues. Research Assistants were recruited as interviewers to assist in the data collection. A total of 70 teams were established throughout Malaysia, 57 in Peninsular Malaysia and 13 in East Malaysia, comprising Sabah, Sarawak and WP Labuan. Each team was led by a Team Leader and comprised of an additional two Research Assistants, one driver and one Nurse. 2.8 Training A training course for scouts was conducted in March 2019. The scouts were trained on the technique of reading the EB maps, locating the selected LQs, tagging the identified LQs and informing head of the household on the survey. The scouts were also required to update the data collection teams on the basic information of the household members. Prior to data collection, a training course was conducted for the field supervisors, team leaders, nurses and interviewers. The training course was conducted separately for data collectors from Peninsular Malaysia and Sarawak, Sabah and Labuan from 8th to 13th of July 2019. The main objectives of the training were to familiarize the data collection teams with the questionnaire, develop the interpersonal skills and appreciate the need for good teamwork. Briefing on the questionnaire, mock interview in the classroom and individual interviewing practice under supervision were conducted during the training.
The nurses were trained on the techniques of using the equipment used for clinical assessment in NHMS 2019. They were also briefed on the criteria for referral of respondents with health problems. At the end of training a pilot test for data collection was conducted. 2.9 Publicity A publicity campaign is a vital component in enhancing the response rate of a national level community survey. Its main purpose is to create awareness among the public about the planned survey activities besides obtaining the highest possible participation from the household members of the selected LQs nationwide. The publicity campaign utilised both printed and electronic media and was further emphasized during the listing activities. A publicity team was formed to coordinate all the activities related to publicity. The publicity team was responsible for designing the template and drafting the content of publicity materials such as pamphlets, posters, buntings, banners, car stickers, participant information sheets, media press releases, news stickers and text (both questions and answers) for radio and television interviews based on input from the Principal Investigator and approval of the NHMS Central Committee. In order to ensure the message reached various ethnic groups of the community, most of the printed publicity materials such as pamphlets and respondent information sheets were produced in four main languages – Malay, English, Mandarin and Tamil. Pamphlets were distributed by the scouts during their initial visit as well as utilized by the data collection team. The publicity team liaised closely with their counterparts from the Corporate Communication Unit, MOH especially in making publicity arrangements with the printed media as well as mass media such as television and radio. In addition, the implementation at the state level was strongly supported by the State Health Departments through the State Liaison Officers. Furthermore, the State Liaison Officers or Field Supervisors for each state were also responsible for the arranging of local media interviews and arranging additional publicity strategies when required. The NHMS 2019 also actively utilized the social media, such as Facebook and Instagram, to create awareness of this survey among the public. A summary of publicity activities and material used are as seen in Appendix 9. 2.10 Data Collection Data collection was carried out between 14th July 2019 and 2nd October 2019. An appointment with the eligible household was made by the team leader prior to the actual visit. In case any of the eligible household members were not available during the first visit, the team had to make several visits to ensure a good coverage of all the eligible members in the household. At least three visits were attempted before the household was classified as unsuccessful. Unsuccessful survey at the household level could be due to LQs that refused to participate, that were empty, locked, besides others such as a hostile or dangerous environment. Unsuccessful survey at the individual level could be due to individuals who did not meet the eligibility criteria for the survey, individuals who were not at home during the scheduled visits, those who refused to participate, or language barrier.
National Health and Morbidity Survey 2019 Technical Report − Volume I 020 2.11 Data Management and Monitoring During Data Collection Data processing activities were centralised at the Institute for Public Health. This included receiving data from the field (input from mobile tablet devices to the centralised server) up to handing over the cleaned dataset to the data analysis team. Face-to-face interviews were conducted by the data collection teams using mobile tablet devices based on the questionnaire system application developed. Completed interviews were sent to the Survey Creation System (SCS) server centralised in the Institute for Public Health whenever there was an internet connection. Data in the server were downloaded weekly by the data management team. Datasets were continuously monitored for quality control; especially on accuracy of the respondent ID, outliers or incorrect data. To ensure the quality of data captured, quality checks were also in-built into the application pertaining to eligibility in answering different modules based on age group or sex. Subsequently, the dataset was sent to the data analysis team. Throughout the data collection period, the Central Coordinating Team (CCT) conducted weekly meeting to monitor the progress of each team. These meetings were chaired by the Director of Institute for Public Health (IPH) to discuss on the movements of the teams, logistic issues, response rate, and the publicity. The productivity of each team was monitored by comparing the cumulative targeted LQs with the weekly progress report by the teams and the amount of data received in the server. This information was updated regularly on the monitoring board at the operation centre in IPH together with the status of self-administered questionnaires (SAQ) received. Hardcopy SAQ were sent to the operation centre via courier.
2.12 Data Analysis Data analysis was done together with the Biostatistics and Data Repository team from the National Institutes of Health, Ministry of Health Malaysia. All analyses were carried out according to objectives of the survey, working definitions and dummy tables. Complex samples analysis procedures were used in the analysis and was carried out at 95% confidence interval. A weighting factor was applied to each individual to adjust for non-response and for the varying probabilities of selection. The weight used for estimation is given by: W = W1 × F × PS Where; W1 : the inverse of the probability of selecting the EBs F : the non-response adjustment factor PS : a post-stratification adjustment factor calculated by age, gender and ethnicity