Integrated non-communicable disease risk factor intervention: Customised and personalised approach

Non-Communicable Diseases (NCD) are increasing at an alarming rate in Malaysia. Various NCD screenings have been introduced at the primary care level from the 1990s using various approaches. These separate systems have since matured, and starting in 2008, has been unified under an 'integrated and life course approach'.

While the initial screening will identify individuals at high risk, this is only the entry point into the NCD risk factor intervention. To further refine the risk analysis and characterisation, we have developed a tool to assess the clients' cardiovascular risk globally, while quantifying their levels of daily physical activity, fitness tatus and dietary habits. All these information will enable us to customise the NCD intervention programme for each unique client. We call this tool 'MyHeSS' (My Health Status Surveillance System). It is available as a computer application, but can also be utilised as a paper-based tool.

Using the information that we obtained through the MyHeSS application, the health care professional are able to quantitatively and qualitatively prescribe a detailed life-style modification intervention to the clients to manage their NCD risk factors. Subsequent follow-ups and repeat assessments using MyHeSS also enables the health care professional to monitor improvements in physical activity status, fitness level and dietary habits, in addtion to the usual clinical and biochemical indicators.

Expansion of the implementation of the various demonstration projects nationwide has been hindered by several factors. The key factors in the success of this NCD intervention is that, firstly, it must be integrated into the existing primary care services; secondly, adequate funds must be allocated for training of suitably identified health care professional, and thirdly, making related manuals, guidelines and standard operating procedures available at the primary care level.