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Rethinking health-care systems: a focus on chronicity

Allotey P, Reidpath DD, Yasin S, Chan CK, de-Graft Aikins A

Lancet, 2011 Feb 5;377(9764):450-1.
PMID: 21074257 DOI: 10.1016/S0140-6736(10)61856-9
The relationship between age of smoking initiation and current smoking: an analysis of school surveys in three European countries

Reidpath DD, Ling ML, Wellington E, Al-Sadat N, Yasin S

Nicotine Tob Res, 2013 Mar;15(3):729-33.
PMID: 22990215 DOI: 10.1093/ntr/nts177

INTRODUCTION: It is held that younger smoking initiates are more likely to become regular smokers. The definitions of smoking initiation (a puff, part of a cigarette, a whole cigarette) are inconsistent and raise questions about the robustness of the view. We sought to re-examine the relationship using adolescent smoking data from 3 European countries.
METHODS: A stratified secondary, logistic regression analysis of Global Youth Tobacco Survey data was conducted using a design-based analysis. Subgroup analyses were conducted of 13- to 15-year olds from Latvia (high smoking prevalence), Slovenia (moderate prevalence), and Montenegro (low prevalence) who had initiated smoking. The outcome was current smoking--smoking everyday for the past 30 days, or smoking 10 or more days in the past 30 days. Smoking initiation was operationalized as a single puff of a cigarette, and age of smoking initiation was a derived continuous measure.
RESULTS: In Latvia, there was a significant association between age of smoking initiation and current smoking for males (p < .05) and females (p < .001) when smoking was operationalized as smoking every day. It was only significant in female adolescents (p < .001) for smoking 10 or more days. In Slovenia and Montenegro, there was no significant relationship between age of smoking initiation and current smoking for either males or females.
CONCLUSIONS: The evidence about the relationship between age of smoking initiation and current smoking is not clear. Explanations for the findings may relate to a lack of power, the specificity of the measure, or problems with the theory.
Sex differences in stroke metrics among Southeast Asian countries: Results from the Global Burden of Disease Study 2015

Hwong WY, Bots ML, Selvarajah S, Sivasampu S, Reidpath DD, Law WC, et al.

Int J Stroke, 2019 10;14(8):826-834.
PMID: 30843480 DOI: 10.1177/1747493019832995

BACKGROUND: Sex differences in cardiovascular diseases generally disadvantage women, particularly within developing regions.
AIMS: This study aims to examine sex-related differences in stroke metrics across Southeast Asia in 2015. Furthermore, relative changes between sexes are compared from 1990 to 2015.
METHODS: Data were sourced from the Global Burden of Disease Study. Incidence and mortality from ischemic and hemorrhagic strokes were explored with the following statistics derived: (1) women-to-men incidence/mortality ratio and (2) relative percentage change in rate.
RESULTS: Women had lower incidence and mortality from stroke compared to men. Notable findings include higher ischemic stroke incidence for women at 30-34 years in high-income countries (women-to-men ratio: 1.3, 95% CI: 0.1, 16.2 in Brunei and 1.3, 95% CI: 0.5, 3.2 in Singapore) and the largest difference between sexes for ischemic stroke mortality in Vietnam and Myanmar across most ages. Within the last 25 years, greater reductions for ischemic stroke metrics were observed among women compared to men. Nevertheless, women below 40 years in some countries showed an increase in ischemic stroke incidence between 0.5% and 11.4%, whereas in men, a decline from -4.2% to -44.2%. Indonesia reported the largest difference between sexes for ischemic stroke mortality; a reduction for women whereas an increase in men. For hemorrhagic stroke, findings were similar: higher incidence among young women in high-income countries and greater reductions for stroke metrics in women than men over the last 25 years.
CONCLUSIONS: Distinct sex-specific differences observed across Southeast Asia should be accounted in future stroke preventive guidelines.
A community-based prospective cohort study of dengue viral infection in Malaysia: the study protocol

Jahan NK, Ahmad MP, Dhanoa A, Meng CY, Ming LW, Reidpath DD, et al.

Infect Dis Poverty, 2016;5(1):76.
PMID: 27510731 DOI: 10.1186/s40249-016-0172-3

Globally, dengue infections constitute a significant public health burden. In recent decades, Malaysia has become a dengue hyper-endemic country with the co-circulation of the four dengue virus serotypes. The cyclical dominance of sub-types contributes to a pattern of major outbreaks. The consequences can be observed in the rising incidence of reported dengue cases and dengue related deaths. Understanding the complex interaction of the dengue virus, its human hosts and the mosquito vectors at the community level may help develop strategies for addressing the problem.
Religiousness and Quality of Life Among Older Adults of Different Ethnic Groups in Malaysia: A Five-Year Follow-up Study

Tan MM, Reidpath DD, Ting RS, Allotey P, Su TT

J Relig Health, 2021 Jul 29.
PMID: 34324099 DOI: 10.1007/s10943-021-01371-x

Research has shown that religion is associated with a better quality of life (QoL). This study aims to examine ethnic differences in the association between religion and the QoL of older adults in a predominantly Muslim population within a multicultural setting. Two-wave data of 3,810 participants consisting of mostly Muslims and older adults aged ≥ 55 years were collected as part of the community health surveys conducted in 2013 and 2018 in the South East Asia Community Observatory (SEACO). Both cross-sectional analyses of baseline data and prospective analyses of longitudinal data were conducted. The associations between religiosity and quality of life were mainly positive in the cross-sectional analysis. In the two-wave analysis, religious importance was negatively associated with QoL among the Malays (B = - 1.103, SE B = 0.029, p
Fulltext Challenges and opportunities for breast cancer early detection among rural dwelling women in Segamat District, Malaysia: A qualitative study

Schliemann D, Hoe WMK, Mohan D, Allotey P, Reidpath DD, Tan MM, et al.

PLoS One, 2022;17(5):e0267308.
PMID: 35594267 DOI: 10.1371/journal.pone.0267308

INTRODUCTION: Breast cancer patients in low- and middle-income countries often present at an advanced stage. This qualitative study elicited views regarding the challenges and opportunities for breast cancer screening and early detection among women in a low-income semi-rural community in Segamat district, Malaysia.
METHODS: Individual semi-structured interviews with 22 people (health professionals, cancer survivors, community volunteers and member from a non-governmental organization) and four focus group discussions (n = 22 participants) with women from a local community were conducted. All participants were purposively sampled and female residents registered with the South East Asia Community Observatory aged ≥40 years were eligible to participate in the focus group discussions. Data were transcribed verbatim and analyzed using thematic analysis.
RESULTS: The thematic analysis illuminated barriers, challenges and opportunities across six domains: (i) personal experiences and barriers to help-seeking as well as financial and travel access barriers; (ii) primary care challenges (related to delivering clinical breast examination and teaching breast-self-examination); (iii) secondary care challenges (related to mammogram services); (iv) disconnection between secondary and primary care breast cancer screening pathways; and (v) opportunities to improve breast cancer early detection relating to community civil service society activities (i.e. awareness raising, support groups, addressing stigma/embarrassment and encouraging husbands to support women) and vi) links between public healthcare personnel and community (i.e. improving breast self-examination education, clinical breast examination provision and subsidised mammograms).
CONCLUSION: The results point to a variety of reasons for low uptake and, therefore, to the complex nature of improving breast cancer screening and early detection. There is a need to adopt a systems approach to address this complexity and to take account of the socio-cultural context of communities in order, in turn, to strengthen cancer control policy and practices in Malaysia.
The Association Between Hospital Characteristics and Nonresponse in Organization Survey: An Analysis of the National Healthcare Establishment and Workforce Survey in Malaysia

Foo CY, Reidpath DD, Sivasampu S

Eval Health Prof, 2017 Jan 01.
PMID: 29179560 DOI: 10.1177/0163278717713569

In any survey where some of the invited participants fail to respond estimates may be biased. The literature on survey nonresponse is substantial, and the intellectual focus has typically been on the nonresponse of individuals. An important yet less scrutinized area in the analysis of nonresponse is in organizational surveys, particularly surveys of health-care organizations. This study used data from the 2010 National Healthcare Establishment and Workforce Survey in Malaysia to examine the relationship between a set of measurable hospital attributes and their probability of survey response and the relationship between this probability and the differences in survey estimates. We found that readily measurable hospital characteristics such as size and geographical location are useful predictors of survey response likelihood. Larger hospitals and hospitals located in less developed geographical regions responded more favorably than their counterparts. We have also illustrated that the resulting response pattern affected some key survey estimates. These findings have the potential to extend our understanding of nonresponse to organization surveys in the health-care sector, potentially allow for the prediction of nonresponse, and help researchers to identify profiles of "reluctant responders" before a survey commences, so that additional engagement strategies may be used.
Fulltext Feasibility and acceptability of a dietary intervention study to reduce salt intake and increase high-nitrate vegetable consumption among middle-aged and older Malaysian adults with elevated blood pressure: a study protocol

McGrattan A, Mohan D, Chua PW, Mat Hussin A, Soh YC, Alawad M, et al.

BMJ Open, 2020 08 27;10(8):e035453.
PMID: 32859661 DOI: 10.1136/bmjopen-2019-035453

INTRODUCTION: Global population ageing is one of the key factors linked to the projected rise of dementia incidence. Hence, there is a clear need to identify strategies to overcome this expected health burden and have a meaningful impact on populations' health worldwide. Current evidence supports the role of modifiable dietary and lifestyle risk factors in reducing the risk of dementia. In South-East Asia, changes in eating and lifestyle patterns under the influence of westernised habits have resulted in significant increases in the prevalence of metabolic, cardiovascular and neurodegenerative non-communicable diseases (NCDs). Low vegetable consumption and high sodium intake have been identified as key contributors to the increased prevalence of NCDs in these countries. Therefore, nutritional and lifestyle strategies targeting these dietary risk factors are warranted. The overall objective of this randomised feasibility trial is to demonstrate the acceptability of a dietary intervention to increase the consumption of high-nitrate green leafy vegetables and reduce salt intake over 6 months among Malaysian adults with raised blood pressure.
METHODS AND ANALYSIS: Primary outcomes focus on feasibility measures of recruitment, retention, implementation and acceptability of the intervention. Secondary outcomes will include blood pressure, cognitive function, body composition and physical function (including muscle strength and gait speed). Adherence to the dietary intervention will be assessed through collection of biological samples, 24-hour recall and Food Frequency Questionnaire. A subgroup of participants will also complete postintervention focus groups to further explore the feasibility considerations of executing a larger trial, the ability of these individuals to make dietary changes and the barriers and facilitators associated with implementing these changes.
ETHICS AND DISSEMINATION: Ethical approval has been obtained from Monash University Human Research Ethics Committee and Medical Research and Ethics Committee of Malaysia. Results of the study will be disseminated via peer-reviewed publications and presentations at national and international conferences.ISRCTN47562685; Pre-results.
Cohorts and community: a case study of community engagement in the establishment of a health and demographic surveillance site in Malaysia

Allotey P, Reidpath DD, Devarajan N, Rajagobal K, Yasin S, Arunachalam D, et al.

Glob Health Action, 2014 Dec;7(1):23176.
PMID: 28672450 DOI: 10.3402/gha.v7.23176

Background Community engagement is an increasingly important requirement of public health research and plays an important role in the informed consent and recruitment process. However, there is very little guidance about how it should be done, the indicators for assessing effectiveness of the community engagement process and the impact it has on recruitment, retention, and ultimately on the quality of the data collected as part of longitudinal cohort studies. Methods An instrumental case study approach, with data from field notes, policy documents, unstructured interviews, and focus group discussions with key community stakeholders and informants, was used to explore systematically the implementation and outcomes of the community engagement strategy for recruitment of an entire community into a demographic and health surveillance site in Malaysia. Results For a dynamic cohort, community engagement needs to be an ongoing process. The community engagement process has likely helped to facilitate the current response rate of 85% in the research communities. The case study highlights the importance of systematic documentation of the community engagement process to ensure an understanding of the effects of the research on recruitment and the community. Conclusions A critical lesson from the case study data is the importance of relationships in the recruitment process for large population-based studies, and the need for ongoing documentation and analysis of the impact of cumulative interactions between research and community engagement.
Forecasting asthma-related hospital admissions in London using negative binomial models

Soyiri IN, Reidpath DD, Sarran C

Chron Respir Dis, 2013 May;10(2):85-94.
PMID: 23620439 DOI: 10.1177/1479972313482847

Health forecasting can improve health service provision and individual patient outcomes. Environmental factors are known to impact chronic respiratory conditions such as asthma, but little is known about the extent to which these factors can be used for forecasting. Using weather, air quality and hospital asthma admissions, in London (2005-2006), two related negative binomial models were developed and compared with a naive seasonal model. In the first approach, predictive forecasting models were fitted with 7-day averages of each potential predictor, and then a subsequent multivariable model is constructed. In the second strategy, an exhaustive search of the best fitting models between possible combinations of lags (0-14 days) of all the environmental effects on asthma admission was conducted. Three models were considered: a base model (seasonal effects), contrasted with a 7-day average model and a selected lags model (weather and air quality effects). Season is the best predictor of asthma admissions. The 7-day average and seasonal models were trivial to implement. The selected lags model was computationally intensive, but of no real value over much more easily implemented models. Seasonal factors can predict daily hospital asthma admissions in London, and there is a little evidence that additional weather and air quality information would add to forecast accuracy.
Forecasting peak asthma admissions in London: an application of quantile regression models

Soyiri IN, Reidpath DD, Sarran C

Int J Biometeorol, 2013 Jul;57(4):569-78.
PMID: 22886344 DOI: 10.1007/s00484-012-0584-0

Asthma is a chronic condition of great public health concern globally. The associated morbidity, mortality and healthcare utilisation place an enormous burden on healthcare infrastructure and services. This study demonstrates a multistage quantile regression approach to predicting excess demand for health care services in the form of asthma daily admissions in London, using retrospective data from the Hospital Episode Statistics, weather and air quality. Trivariate quantile regression models (QRM) of asthma daily admissions were fitted to a 14-day range of lags of environmental factors, accounting for seasonality in a hold-in sample of the data. Representative lags were pooled to form multivariate predictive models, selected through a systematic backward stepwise reduction approach. Models were cross-validated using a hold-out sample of the data, and their respective root mean square error measures, sensitivity, specificity and predictive values compared. Two of the predictive models were able to detect extreme number of daily asthma admissions at sensitivity levels of 76 % and 62 %, as well as specificities of 66 % and 76 %. Their positive predictive values were slightly higher for the hold-out sample (29 % and 28 %) than for the hold-in model development sample (16 % and 18 %). QRMs can be used in multistage to select suitable variables to forecast extreme asthma events. The associations between asthma and environmental factors, including temperature, ozone and carbon monoxide can be exploited in predicting future events using QRMs.
Let's talk about death: data collection for verbal autopsies in a demographic and health surveillance site in Malaysia

Allotey PA, Reidpath DD, Evans NC, Devarajan N, Rajagobal K, Bachok R, et al.

Glob Health Action, 2015 Jan;8(1):28219.
PMID: 28156759 DOI: 10.3402/gha.v8.28219

Background Verbal autopsies have gained considerable ground as an acceptable alternative to medically determined cause of death. Unlike with clinical or more administrative settings for data collection, verbal autopsies require significant involvement of families and communities, which introduces important social and cultural considerations. However, there is very little clear guidance about the methodological issues in data collection. The objectives of this case study were: to explore the range of bereavement rituals within the multi-ethnic, multi-faith population of the district; to investigate the preparedness of communities to talk about death; to describe the verbal autopsy process; to assess the effects of collecting verbal autopsy data on data collectors; and to determine the most accurate sources of information about deaths in the community. Methods A case study approach was used, using focus group discussions, indepth interviews and field notes. Thematic analyses were undertaken using NVivo. Results Consideration of cultural bereavement practices is importance to acceptance and response rates to verbal autopsies. They are also important to the timing of verbal autopsy interviews. Well trained data collectors, regardless of health qualifications are able to collect good quality data, but debriefing is important to their health and well being. This article contributes to guidance on the data collection procedures for verbal autopsies within community settings.
Fulltext Coming of age, becoming obese: a cross-sectional analysis of obesity among adolescents and young adults in Malaysia

Pell C, Allotey P, Evans N, Hardon A, Imelda JD, Soyiri I, et al.

BMC Public Health, 2016 10 13;16(1):1082.
PMID: 27737680

BACKGROUND: Malaysians have become increasingly obese over recent years. The transition from adolescence to early adulthood is recognized as critical for the development of eating and activity habits. However, little obesity-related research focuses on this life stage. Drawing on data from a health and demographic surveillance site in Malaysia, this article describes obesity and overweight amongst adolescents and young adults in a multi-ethnic population.

METHODS: Data were collected at the South East Asia Community Observatory (SEACO) in Segamat District, Johor. In this dynamic cohort of approximately 40,000 people, 5,475 were aged 16-35 in 2013-2014. The population consists of Malay, Chinese, Indian and Indigenous (Orang Asli) families in proportions that reflect the national ethnic diversity. Data were collected through health profiles (Body Mass Index [BMI] measurements in homes) and self-report questionnaires.

RESULTS: Age and ethnicity were associated with overweight (BMI 25.0-29.9Kg/m2) and obesity (BMI ≥ 30Kg/m2). The prevalence of overweight was 12.8 % at ages 16-20 and 28.4 % at ages 31-35; obesity was 7.9 % and 20.9 % at the same age groups. The main ethnic groups also showed varied patterns of obesity and overweight at the different age groups with Chinese at lowest and Orang Asli at highest risk. Level of education, employment status, physical activity and frequency of eating out were poorly predictive of overweight and obesity.

CONCLUSION: The pattern of overweight and obesity in the 16-35 age group further highlights this as a significant period for changes in health-related behaviours. Further longitudinal research is however needed to confirm the observed pattern and investigate causal factors.
Fulltext Sexual and reproductive health and rights post 2015--challenges and opportunities

Allotey P, Reidpath DD

BJOG, 2015 Jan;122(2):152-5.
PMID: 25394350 DOI: 10.1111/1471-0528.13177
Fulltext The rural bite in population pyramids: what are the implications for responsiveness of health systems in middle income countries?

Jahan N, Allotey P, Arunachalam D, Yasin S, Soyiri IN, Davey TM, et al.

BMC Public Health, 2014;14 Suppl 2:S8.
PMID: 25081203 DOI: 10.1186/1471-2458-14-S2-S8

Health services can only be responsive if they are designed to service the needs of the population at hand. In many low and middle income countries, the rate of urbanisation can leave the profile of the rural population quite different from the urban population. As a consequence, the kinds of services required for an urban population may be quite different from that required for a rural population. This is examined using data from the South East Asia Community Observatory in rural Malaysia and contrasting it with the national Malaysia population profile.
Fulltext A "Roziah" by any other name: a simple Bayesian method for determining ethnicity from names

Komahan K, Reidpath DD

Am J Epidemiol, 2014 Aug 1;180(3):325-9.
PMID: 24944286 DOI: 10.1093/aje/kwu129

Correct identification of ethnicity is central to many epidemiologic analyses. Unfortunately, ethnicity data are often missing. Successful classification typically relies on large databases (n > 500,000 names) of known name-ethnicity associations. We propose an alternative naïve Bayesian strategy that uses substrings of full names. Name and ethnicity data for Malays, Indians, and Chinese were provided by a health and demographic surveillance site operating in Malaysia from 2011-2013. The data comprised a training data set (n = 10,104) and a test data set (n = 9,992). Names were spliced into contiguous 3-letter substrings, and these were used as the basis for the Bayesian analysis. Performance was evaluated on both data sets using Cohen's κ and measures of sensitivity and specificity. There was little difference between the classification performance in the training and test data (κ = 0.93 and 0.94, respectively). For the test data, the sensitivity values for the Malay, Indian, and Chinese names were 0.997, 0.855, and 0.932, respectively, and the specificity values were 0.907, 0.998, and 0.997, respectively. A naïve Bayesian strategy for the classification of ethnicity is promising. It performs at least as well as more sophisticated approaches. The possible application to smaller data sets is particularly appealing. Further research examining other substring lengths and other ethnic groups is warranted.
Re: Targeting NOS as a therapeutic approach for heart failure

Bonsu KO, Kadirvelu A, Reidpath DD

Pharmacol Ther, 2014 Sep;143(3):350.
PMID: 24769330 DOI: 10.1016/j.pharmthera.2014.04.003
Is obesity an ineluctable consequence of development? A case study of Malaysia

Davey TM, Allotey P, Reidpath DD

Public Health, 2013 Dec;127(12):1057-62.
PMID: 24268545 DOI: 10.1016/j.puhe.2013.09.008

Effective population-level solutions to the obesity pandemic have proved elusive. In low- and middle-income countries the problem may be further challenged by the perceived internal tension between economic development and sustainable solutions which create the optimal conditions for human health and well-being. This paper discusses some of the ecological obstacles to addressing the growing problem of obesity in 'aspiring' economies, using Malaysia as a case study. The authors conclude that current measures to stimulate economic growth in Malaysia may actually be exacerbating the problem of obesity in that country. Public health solutions which address the wider context in which obesity exists are needed to change the course of this burgeoning problem.
Multi-country health surveys: are the analyses misleading?

Masood M, Reidpath DD

Curr Med Res Opin, 2014 May;30(5):857-63.
PMID: 24328497 DOI: 10.1185/03007995.2013.875466

BACKGROUND: The aim of this paper was to review the types of approaches currently utilized in the analysis of multi-country survey data, specifically focusing on design and modeling issues with a focus on analyses of significant multi-country surveys published in 2010.
METHODS: A systematic search strategy was used to identify the 10 multi-country surveys and the articles published from them in 2010. The surveys were selected to reflect diverse topics and foci; and provide an insight into analytic approaches across research themes. The search identified 159 articles appropriate for full text review and data extraction.
RESULTS: The analyses adopted in the multi-country surveys can be broadly classified as: univariate/bivariate analyses, and multivariate/multivariable analyses. Multivariate/multivariable analyses may be further divided into design- and model-based analyses. Of the 159 articles reviewed, 129 articles used model-based analysis, 30 articles used design-based analyses. Similar patterns could be seen in all the individual surveys.
CONCLUSION: While there is general agreement among survey statisticians that complex surveys are most appropriately analyzed using design-based analyses, most researchers continued to use the more common model-based approaches. Recent developments in design-based multi-level analysis may be one approach to include all the survey design characteristics. This is a relatively new area, however, and there remains statistical, as well as applied analytic research required. An important limitation of this study relates to the selection of the surveys used and the choice of year for the analysis, i.e., year 2010 only. There is, however, no strong reason to believe that analytic strategies have changed radically in the past few years, and 2010 provides a credible snapshot of current practice.
Fulltext Statins in heart failure: do we need another trial?

Bonsu KO, Kadirvelu A, Reidpath DD

Vasc Health Risk Manag, 2013;9:303-19.
PMID: 23807852 DOI: 10.2147/VHRM.S44499

Statins lower serum cholesterol and are employed for primary and secondary prevention of cardiovascular events. Clinical evidence from observational studies, retrospective data, and post hoc analyses of data from large statin trials in various cardiovascular conditions, as well as small scale randomized trials, suggest survival and other outcome benefits for heart failure. Two recent large randomized controlled trials, however, appear to suggest statins do not have beneficial effects in heart failure. In addition to lowering cholesterol, statins are believed to have many pleotropic effects which could possibly influence the pathophysiology of heart failure. Following the two large trials, evidence from recent studies appears to support the use of statins in heart failure. This review discusses the role of statins in the pathophysiology of heart failure, current evidence for statin use in heart failure, and suggests directions for future research.

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