Hypertension Awareness, Treatment, and Control Among Adults Attending Primary Care Clinics in Malaysia

Published: Malaysian Journal of Public Health Medicine, 2006; Vol. 6(1): 38–43

Original URL: MJPHM Volume 6, Issue 1, 2006

Last reviewed: March 2026

Background and Epidemiological Context

Hypertension is the single most important modifiable risk factor for cardiovascular disease, stroke, and chronic kidney disease — conditions that collectively represent the leading causes of death and disability in Malaysia. The epidemiological transition that Malaysia underwent during the latter decades of the twentieth century saw a dramatic shift in the burden of disease from infectious and nutritional conditions to chronic non-communicable diseases, with cardiovascular disease emerging as the number one killer by the 1990s.

The National Health and Morbidity Survey (NHMS), Malaysia’s principal population-based health survey, documented a rising prevalence of hypertension throughout the 1990s and 2000s. The 1996 NHMS estimated that approximately 33% of adults aged 30 years and above had hypertension (defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or current use of antihypertensive medication). By the 2006 NHMS, this figure had risen to approximately 42.6% among the same age group, making hypertension one of the most prevalent chronic conditions in the Malaysian adult population.

These figures placed Malaysia among the countries with the highest hypertension prevalence in the Asia-Pacific region, comparable to or exceeding rates observed in neighbouring countries such as Thailand, Indonesia, and the Philippines. The high prevalence was attributed to a combination of factors including rapid urbanisation, dietary changes (particularly increased salt and processed food consumption), declining physical activity levels, rising obesity rates, population ageing, and genetic predisposition within certain ethnic groups.

The Awareness-Treatment-Control Cascade

Understanding hypertension management at the population level requires examining the awareness-treatment-control cascade — the sequential steps through which individuals with hypertension must progress to achieve blood pressure control. At each step, a proportion of the hypertensive population is lost, resulting in a progressive narrowing of the population that achieves the ultimate goal of controlled blood pressure.

The overall population control rate — the proportion of all hypertensive individuals who had their blood pressure controlled to target — was estimated at approximately 12–18%, a figure that was comparable to or slightly lower than rates observed in other developing countries during the same period but substantially below rates achieved in high-income countries with well-established primary care systems.

Factors Influencing Awareness

The 35% undiagnosed rate among hypertensive individuals reflected several interrelated factors. Hypertension is largely asymptomatic in its early and moderate stages, meaning that individuals have no subjective reason to suspect they have the condition. In the Malaysian context, routine blood pressure screening was integrated into primary care visits, workplace health examinations, and various community health programmes, but these opportunities were not uniformly accessed by all population segments.

Men were consistently less likely to be aware of their hypertension status compared with women, partly because women had more frequent contact with the healthcare system through maternal and child health services, family planning clinics, and other gender-specific health programmes. Younger adults (aged 30–44) were less aware than older adults, likely because they perceived themselves as too young to have cardiovascular risk factors and were less likely to seek preventive health checks. Rural residents and those with lower educational attainment also showed lower awareness rates.

Treatment Patterns and Challenges

Among patients who were aware of their hypertension diagnosis, treatment rates in the mid-2000s were reasonably encouraging, with approximately three-quarters to four-fifths receiving pharmacological treatment. The Malaysian public healthcare system provided antihypertensive medications at heavily subsidised rates or free of charge through government health clinics, removing a significant financial barrier to treatment access.

The pharmacological management of hypertension at Malaysian primary care clinics during this period typically involved first-line use of calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, and thiazide diuretics, consistent with international guidelines. However, several treatment challenges were documented. Monotherapy was used more frequently than combination therapy, even in patients with substantially elevated blood pressure or additional cardiovascular risk factors. There was often clinical inertia in intensifying treatment when blood pressure targets were not met, with clinicians sometimes accepting suboptimal control rather than adding or switching medications.

The Treatment-Control Gap

The most concerning finding was the substantial gap between treatment and control. Only about 25–35% of treated hypertensive patients achieved the target blood pressure of less than 140/90 mmHg — and the target for patients with diabetes or kidney disease was lower still (less than 130/80 mmHg), suggesting even poorer control rates in these high-risk subgroups.

Multiple factors contributed to this treatment-control gap. Patient-related factors included poor medication adherence, inadequate understanding of the chronic nature of hypertension requiring lifelong treatment, belief that medication could be discontinued once blood pressure normalised, concerns about side effects, and the use of traditional or complementary remedies as alternatives to prescribed medication.

Health system factors included suboptimal prescribing practices, limited time for patient education during consultations, lack of systematic follow-up mechanisms for patients who missed appointments, and insufficient use of clinical protocols to guide treatment intensification. The shortage of clinical pharmacists and health educators in primary care settings meant that the burden of patient education fell almost entirely on doctors and nurses who were already managing heavy clinic loads.

Ethnic and Socioeconomic Dimensions

Malaysia’s multi-ethnic population introduced additional complexity to hypertension epidemiology and management. Malay, Chinese, Indian, and indigenous populations differed in hypertension prevalence, risk factor profiles, health-seeking behaviour, and treatment response patterns. Indian Malaysians showed particularly high rates of cardiovascular disease and metabolic syndrome, while certain Malay and indigenous populations in Sabah and Sarawak had elevated prevalence linked to high salt diets and limited access to preventive care.

Socioeconomic gradients in hypertension control were also evident. While the public healthcare system nominally provided equal access to all, individuals from higher socioeconomic backgrounds were more likely to supplement government clinic care with private healthcare, enabling more frequent monitoring and greater flexibility in medication choices. They were also more likely to engage in lifestyle modifications such as dietary changes and regular exercise, which are important adjuncts to pharmacological therapy.

Policy Implications and Subsequent Developments

The findings from hypertension research published in MJPHM during the mid-2000s contributed to several important policy developments. The Ministry of Health issued updated Clinical Practice Guidelines for the management of hypertension, emphasising more aggressive treatment targets, earlier initiation of combination therapy, and the use of standardised treatment algorithms at primary care level. The introduction of the Non-Communicable Disease (NCD) screening programme aimed to improve early detection, while chronic disease management programmes sought to establish systematic follow-up and patient self-management support.

Limitations

Studies from this period were predominantly cross-sectional and clinic-based, capturing only patients who had already presented to health services and potentially missing the most disengaged segments of the hypertensive population. Blood pressure measurements taken in clinical settings may have been affected by white-coat hypertension, potentially overestimating the uncontrolled proportion. Self-reported medication adherence is known to overestimate actual adherence. The use of different blood pressure measurement protocols across studies limited direct comparisons. Longitudinal data on treatment outcomes and cardiovascular event rates were scarce in the Malaysian primary care literature of this period.