https://orcid.org/0000-0003-3969-1745
Figures
Abstract
Introduction
Despite the high prevalence of diabetes, hypertension and dyslipidemia among Malaysian adults, there are gaps in management and control of these diseases. Evidence suggests that implementation of the Chronic Care Model in primary health care (PHC) can improve patients’ clinical outcomes, quality of life and reduce the overall social burden. This study aims to describe the PHC interventions for diabetes, hypertension and/or dyslipidemia in Malaysia and to identify existing gaps by mapping against Chronic Care Model domains.
Methods
This study reports a section of a larger scoping review and focuses on studies with interventions. PubMed, Embase, Scopus and MyMedR were searched systematically from inception until 31 December 2024, using keywords pertaining to “diabetes”, “hypertension”, “dyslipidemia”, “PHC” and “Malaysia”. Study selection was independently performed by reviewers in pairs.
Results
A total of 32 interventions were identified across 39 publications. The earliest study was published in 2012 and the highest number of publications was seen in 2020. Most studies were conducted in the states of Kelantan and Selangor. The two most common components of intervention were patient education (n = 16) and the use of decision aids (n = 11). Interventions predominantly targeted type 2 diabetes (72%) and the Chronic Care Model domains of self-management support and delivery system design, with very few addressing community linkages (n = 3). Intermediate clinical outcomes (HbA1c, blood pressure, and cholesterol) were the most common measures.
Discussion/conclusions
This review highlights key gaps in PHC interventions for these three chronic diseases. While self-management and delivery systems are well-addressed, current efforts remain heavily focused on individuals with diabetes, with limited attention to community components and rural populations. There is a need to broaden the intervention scope beyond diabetes and invest in stronger community linkages for a more equitable system in Malaysia.
Citation: Teh XR, Ang SH, Lee PJ, Mohd Ropidi MI, Abdul Samad A, Sivasampu S, et al. (2026) Primary health care interventions targeting diabetes, hypertension or dyslipidemia in Malaysia: A scoping review. PLoS One 21(4): e0346934. https://doi.org/10.1371/journal.pone.0346934
Editor: Mohammed Abutaleb, Jazan Health Cluster, SAUDI ARABIA
Received: December 9, 2025; Accepted: March 24, 2026; Published: April 20, 2026
Copyright: © 2026 Teh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting information files.
Funding: This study was supported by a Malaysia Research Grant from the Ministry of Health Malaysia (NMRR-24-00853-YHT). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Cardiovascular disease (CVD) is the leading cause of mortality globally, reaching 19.8 million deaths in 2022 [1]. Diabetes, hypertension and dyslipidemia are the major modifiable risk factors that contribute substantially to this burden. The prevalence of these three non-communicable diseases (NCDs) continues to rise. Global estimates indicated that 1.3 billion adults were living with hypertension in 2019 [2] and 589 million adults had diabetes in 2024 [3], with 80% of the patients living in low- and middle-income countries.
The latest National Health and Morbidity Survey (NHMS) showed that 15.6% of the adult Malaysian population had diabetes, 29.2% had hypertension and 33.3% had high cholesterol [4]. Malaysia’s primary health care (PHC) system is a dual-sector system with both public and private service providers. Notably, public and private clinics together handle 85.8% patients with diabetes and 84.2% patients with hypertension [4]. PHC is a whole-of-society approach that can help to strengthen national health systems and ensure health and wellbeing services are brought closer to the community [5]. Hence, enhancing the comprehensiveness and effectiveness of patient care in the PHC system remains a key priority.
The Malaysian healthcare system is continuously striving to combat NCDs. The National Strategic Plan for NCD (NSP-NCD) 2016–2025 includes objectives such as strengthening PHC and setting the national targets to reduce the prevalence of raised blood pressure to 26.0% and halt the rise of the prevalence of diabetes and obesity, maintaining them below 15% by 2025 [6]. In 2017, the Enhanced Primary Health Care (EnPHC) Initiative was launched in 20 public clinics and has since rapidly expanded to over 100 clinics. The EnPHC initiative is a multi-faceted interventional package including population enrollment, risk profiling, integrated care pathways, audits and organisational change. Additionally, there is a well-known community-based initiative called “Komuniti Sihat Pembina Negara” (KOSPEN) that aims to empower and involve the community by recruiting them as volunteers to carry out interventions that target to reduce NCD risk factors [6]. Despite continuous efforts, the prevalence and disease controls of these conditions in Malaysia remain suboptimal.
Wagner et al introduced the Chronic Care Model (CCM) in 1998 [7], emphasising the need to change the care delivery system, provide self-management support, reorganise team function and practice systems, use evidence-based guidelines, and enhance information systems to provide feedback on performance. The locus of care in the CCM model remains to be the personal physician, supported by the team [7]. There are six domains in CCM: (i) self-management support, (ii) delivery system design, (iii) decision support, (iv) clinical information system, (v) health system organization and (vi) community linkages [7]. The CCM model was shown to be effective in reducing HbA1c and blood pressure among adults with type 2 diabetes mellitus (T2DM) in primary care and the effectiveness increased with the number of CCM domains applied [8]. Another systematic review that focused on patients with cardiometabolic multimorbidity in sub-Saharan Africa showed that CCM interventions lower systolic blood pressure, but have mixed results for HbA1c, depressions, medication adherence and quality of life [9].
Hence, this scoping review aims to systematically describe interventions and programs addressing diabetes, hypertension, and/or dyslipidemia at the PHC level in Malaysia. We will summarise the intervention components, their target levels (patient, provider, and/or system) and map the interventions against the six CCM domains to identify gaps that can inform the enhancement of existing interventions or development of new interventions.
Materials and methods
Our scoping review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) [10] and the Joanna Briggs Institute (JBI) guidelines [11](see PRISMA-ScR checklist in S1 Table). This study reports part of the results of a larger scoping review. This scoping review seeks to address that gap by systematically mapping the existing literature on the quality of care and interventions/programmes for adults with T2DM, hypertension, and/or dyslipidemia in the PHC setting in Malaysia. This study focused on the research question of “What type of healthcare interventions to address T2DM, hypertension, and/or dyslipidemia have been implemented in Malaysia?”
Search strategy
Four electronic databases (MEDLINE, Scopus, EMBASE, and MyMedR) were searched from inception until 31 December 2024. We developed the search strategy based on the following concept: (diabetes OR hypertension OR dyslipidemia) AND primary health care AND Malaysia. The detailed search strategy can be found in S2 Table. We did not apply any language restriction. The search results were inputted into the Rayyan web-based review management tool [12] for deduplication and further screening by reviewers. We attempted to contact the corresponding authors for the full text if the paper was not available.
Selection of studies
Two reviewers (X.R.T. & M.I.M.R.) independently reviewed the titles and abstracts, followed by full text screening, based on the inclusion and exclusion criteria. Any disagreements were resolved after discussion or involvement of the third reviewer (S.H.A.). A snowballing method was included where reference lists of the included studies were screened by four reviewers (X.R.T., M.I.M.R., S.H.A. and P.J.L.) to identify possible relevant studies that might have been missed in the database search. In addition, for any study protocols identified during the search, we attempted to locate the corresponding results publication, where available.
Inclusion criteria for the scoping review were studies or programs conducted among adults with T2DM, hypertension or dyslipidemia, or their healthcare providers, in the PHC setting and in Malaysia. Guidelines, book chapters, reviews, study protocols, commentaries, editorials, conference abstracts and letters to editors were excluded. This paper focused on the studies involving the implementation of interventions. Studies that solely described the development of an intervention were excluded.
Data charting and synthesis
Data extraction was done using a pilot-tested form created in Google Sheet. Three reviewers (X.R.T., M.I.M.R., and P.J.L.) extracted the data using the form, and a random cross-check was performed to ensure data validity. Data items that were extracted included the title, first author’s name, study objectives, publication year, study design, study location (state), study population, mean age/age groups, study duration, intervention name, intervention period, brief description of the intervention and outcome measures. The data were tabulated in a narrative way to describe the components of the interventions and the outcome measures used.
We adapted the inductive approach of Intervention Component Analysis to categorize the interventions based on their nature into different components using the steps of reflexive thematic analysis methods by Braun and Clarke [13]. Two reviewers (X.R.T. and S.H.A.) independently examined the interventions and systematically classified them into 14 components, recognizing that each intervention could encompass multiple components. Each reviewer independently identified the intervention component(s) in each of the intervention, followed by a discussion to achieve consensus. The interventions were also categorized according to whether they were targeted at the patient, provider, and/or system level. Lastly, the interventions were further examined for how they align with the six domains of the CCM following the approach outlined above.
Research registration & ethics approval
This study has been registered with the National Medical Research Register (NMRR-24–00853-YHT) and obtained ethics approval from the Medical Research & Ethics Committee (MREC). The protocol was registered on Open Science Framework (OSF) with the associated project osf.io/gh7b4 and registration DOI: https://doi.org/10.17605/OSF.IO/7GNYM.
Results
Searches on the four databases yielded 1,778 articles. An additional 108 potential articles and two websites were identified through snowballing of reference lists. After applying the inclusion and exclusion criteria, 371 articles were deemed eligible for the main scoping review (Fig 1). Of these, 39 articles focusing on interventions form the basis of this study. Among the 39 included articles involving intervention, there were a total 32 distinct interventions.
Table 1 provides a summary of the study characteristics, while Table 2 outlines the study characteristics in more detail, such as study location, study design, intervention name, intervention period, a brief description of the intervention, intervention components, and the outcome measures. These articles were published between 2012 and 2023. The number of publications per year ranged from one article in 2017 to ten in 2020 (Fig 2)
Study design characteristics
The included articles had different study designs, with the top three being randomised controlled trials (RCTs) (n = 20, 51.3%), followed by quasi-experimental studies (n = 7, 17.9%) and cross-sectional studies (n = 5, 12.8%). Most of the RCTs focused on T2DM patients (n = 16, 41.0%), and two studies focused on dyslipidemia and hypertension, respectively.
The sample size of the included studies ranged from 22 to 12,017 participants. When categorized, the majority (n = 19, 48.7%) fell within the 101–500 range. The sample sizes of the included RCTs ranged from 59 to 888 participants. The study with the highest sample size was a quasi-experimental study.
Study location
When examining the study locations, Selangor emerged as the most frequently included state, appearing in 12 studies (30.8%). This was followed by Kuala Lumpur, Kelantan, and Johor, each represented in six studies. It is important to note that some studies were conducted across multiple states, resulting in overlaps in the location count.
Study population & study duration
Majority of studies targeted patients with diabetes (n = 28, 71.8%) and a small number focused on healthcare providers (n = 4, 10.3%). In addition, three studies (7.7%) were focusing on hypertension, two studies (5.1%) on dyslipidemia, and two studies (5.1%) with mixed populations, respectively. The mean age of the patients in most studies was 50 years or older. Whereas the mean age for healthcare providers ranged from 30–40 years old. The duration of intervention ranged from a single session to two years, with nearly half of the interventions lasting between one to six months (n = 19, 48.7%). Some studies evaluated existing interventions and therefore the duration was not specified.
Intervention components
Summary of intervention components.
The intervention components were highlighted in Table 2. Of the 32 interventions reviewed, ten interventions were multifaceted and included two or more distinct components or implementation strategies. For example, the EnPHC intervention incorporated seven distinct components, such as Family Doctor Concept (FDC), medication therapy adherence clinic (MTAC), care coordinator, audits and feedback, multidisciplinary team, decision aid, and patient management system.
(i) Education (n=16). Education was the most implemented component across interventions, identified in 16 articles. We further categorised it into focused topic education and comprehensive education. Focused interventions addressed specific areas such as insulin injection technique [20,35], education on insulin [16], erectile dysfunction [15], sharp disposal [31], wound care [52], men’s health [49], and self-monitoring of blood glucose (SMBG) [39]. Comprehensive education included structured programs covering broader topics, including home-based education [38], group nutrition counselling [45], multidisciplinary healthy lifestyle course [21], comprehensive training module on diabetes care for providers [51] and patients [29,30], as well as multi-day workshops on emotional, social support and goal setting [32,33].
(ii) Decision Aid (n=11). The decision aid intervention component can be categorised into two groups: those supporting patients and those supporting providers. Patient-focused decision aids were designed to support patient self-management, enabling individuals to monitor their health and make informed decisions. Examples include the Global Cardiovascular Risks Self-Management Booklet [26,27], food pyramid charts and T2DM booklets [38], and visual aids such as colour-coded HbA1c graphs [41]. In contrast, provider-focused decision aids aimed to standardise care delivery and guide clinical decision-making. These include the Integrated Care Pathways and NCD care form used in the EnPHC intervention [14,50], the Simpler tool for structured counselling [29,30], the CPG quick reference in EMPOWER-PAR intervention [26,27] and prompt sheets to facilitate sensitive consultations [15].
(iii) Self-monitoring (n=6). The self-monitoring component was categorized into technology-assisted and conventional approaches. Technology-assisted self-monitoring involved the use of digital tools such as a gluco-telemeter [28] and a web-enabled glucometer with automated feedback triggered by consecutive out-of-range readings [37]. Conventional self-monitoring approaches include providing patients with a glucometer with reagent test strips [19], post-prandial glucose monitoring [40] and loaning BP monitors for BP monitoring at home [46,48].
(iv) Personalized Care Model (n=6) & Multidisciplinary Team (n=6). The personalized care models were operationalized through the Family Health Team (FHT) in the EnPHC intervention, the FDC, and the Community-Based Cardiovascular Risk Factors Intervention Strategies (CORFIS) program, with the aim of improving continuity and comprehensiveness of care. These models emphasized continuity of care by the same provider or team. All these studies combined personalized care models with a multidisciplinary team, which refers to involvement of allied health professionals, to deliver comprehensive care [14,26,27,46].
(v) Regular follow-up and longer consultation time (n=6). The frequency and duration of in-person follow-ups varied across studies. For example, Tajudin TR (2020) included monthly follow-ups over six months, with each session lasting at least 30 minutes [25]; Ismail M (2013) scheduled doctor visits every two months [39]; and the CORFIS intervention included monthly counselling by trained allied health professionals [46]. In contrast, telephone follow-ups did not involve doctors. These were carried out monthly by pharmacists for prescription refill reminders and medication reassessment [38] or bi-weekly by trained nurse educators [43].
(vi) Medication therapy adherence clinic (MTAC) (n=5) & Care Coordinator (n=2). MTAC components can be diabetes-specific or cardiovascular care-specific. MTAC was done through pharmacist medication reviews and patient adherence monitoring. An additional role – Care Coordinator was implemented in EnPHC [14,50], which involved linking patients with FHTs and coordinating with healthcare providers to manage patient status and referrals.
(vii) Patient management system (n=4). Several studies incorporated the patient management system component, such as the visit checklist in the EnPHC intervention [14,50] and the web-based application in the CORFIS intervention [46,48], to capture patient data, monitor appointments and laboratory results, and coordinate care among providers.
(viii) Audits and feedback (n=3). The audits and feedback component tracked performance through regular reports and additional monitoring indicators [14,49,50]. Both the Care Coordinator component and audits and feedback component did not show improvement in glycemic control.
(ix) Social support (n=3). The social support component was reported in three studies, including a peer- and community-based approach with peer mentors [36], a faith-based intervention involving Quran recitation [44], as well as counselling and motivational interviewing to enhance patient engagement [34].
(x) Screening program (n=2). Two studies included screening programs: free blood tests during diabetes awareness day [25] and eye examinations to screen for retinal disease [24].
(xi) Nutrition therapy (n=1) and dosing time (n=1). One study prescribed structured low-calorie meal plans [34]. Another examined the optimal timing for simvastatin administration, a lipid-lowering drug, comparing doses taken after breakfast, after dinner, or at bedtime [42].
Summary of interventions based on chronic care model
S3 Table showed the summary of the intervention characteristics based on duration, intervention target level and CCM domains. Out of the 32 interventions, 27 of them targeted the patient level, either alone or in combination with provider or system levels (S3 Table). When we matched the interventions to the CCM domains, we found that most of the interventions involved the following two domains: self-management support (n = 24) and delivery system design (n = 21). Community linkage is the domain that was least covered (n = 3). There was no intervention that covers all the CCM domains. Further details are provided in S4 Table.
Chronic care models domains.
- (i). Self-management support (n=24)
Twenty-nine articles included 24 interventions that targeted the self-management support domain. The self-management components usually involve education and continuous follow-up. There was involvement of a multidisciplinary team in some studies, such as trained nurse educators [43], allied health support [21,46,48], and pharmacists-led medication adherence therapy clinic (MTAC) [14,50] or home-based education. Supporting materials such as prompt sheets, flip charts, information booklets, glucometers and measuring spoons were also used. Patients were involved in discussion and goal setting.
- (ii). Delivery System Design (n=21)
Twenty-one interventions, reported across 28 articles, addressed the delivery system design domain of the CCM. Most interventions involved creating a multidisciplinary team for disease management or increasing the frequency of follow-ups or monitoring. Two interventions, namely the FDC and EnPHC, ensure personalised care by assigning patients and populations from the same geographical area to the same primary healthcare team. Some interventions include regular monitoring of patients’ glucose levels using telemonitoring where glucose readings are transmitted to a central server and the participants receive automated feedback on their results [28], or monthly reporting of SMBG results to the nurse [39]. In diabetes MTAC, pharmacists are granted authorization by the physicians to adjust insulin doses and actively participate in recommending medication regimens and laboratory investigations.
- (iii). Decision support (n=8)
Eight interventions, reported across 10 articles, addressed the CCM decision support domain. Interventions that aim to support healthcare providers in their decision-making process, include improving access to clinical practice guidelines, such as by using QR code, agreed protocols, or integrated flow charts for different diseases [14,26,27,46,50]. Besides that, there are workshops or continuous medical education that aim to improve providers’ knowledge and skills [49,51,52] or tools (e.g., flipchart, healthy plate portion guide) as a reminder/guide [15,47].
- (iv). Clinical information system (n=7)
Seven interventions matched the CCM clinical information system domain. An automated feedback mechanism for patient glucose monitoring was incorporated in two studies [28,37]. There was also the use of a web-based application [46] or a visit checklist [14,50] to capture patient data and coordinate patient care. Besides, reminders were performed using either text messages [45] or telephone [38].
- (v). Health System Organization (n=13)
Thirteen interventions aligned with the CCM health system organisation domain. These included changes in healthcare team structure or function, such as the formation of dedicated teams for specific zones like FHT or FDC [14,22,23,50] and multidisciplinary chronic disease management teams [26,27]. MTAC services enabled pharmacists to closely follow up with patients and adjust dosages as needed [14,17–19,50]. Other interventions include establishing a designated diabetic clinic [25] and ophthalmology team screening [24]. Apart from the team structure changes, some interventions increased the frequency of monitoring through telemonitoring [28], SMBG [39] and biweekly group sessions [32,33]. Other interventions include home visits [38], group counselling [45] and change of key performance indicators to improve screening [49].
- (vi). Community Linkages (n=3)
There were three interventions that focused on the community linkages domain. First, in the CORFIS study, patients were provided information about local patient associations and support groups [46]. The Malaysia Healthy Plate (MHP) was a public health intervention to the community by showing the tips about portion size in a plate [47]. Besides that, the diabetes awareness day which offers free blood tests, diabetes meals and talks was also an intervention that fits the CCM community linkage domain [25].
Outcome measures
The most frequently reported outcome measures were the intermediate clinical indicators, including HbA1c (n = 17), blood pressure (n = 12) and cholesterol levels (n = 12). Knowledge, attitude and practice were also commonly measured (n = 10). Other outcome measures were medication adherence, quality of life, patient or provider satisfaction, processes of care, prescription, and emotional distress. A comprehensive list of outcomes is provided in Table 2.
Discussion
This scoping review provides an overview of PHC interventions in Malaysia targeting the management of diabetes, hypertension, and/or dyslipidaemia. Considering the rising prevalence of NCDs, it is encouraging to observe an increase in the number of interventions implemented and evaluated in recent years. This positive trend may reflect growing awareness among healthcare stakeholders, increased investment in NCD programs, and alignment with both national and global priorities for NCD prevention and control. Notably, however, many of the interventions focused on diabetes management, with comparatively few interventions addressing hypertension and/or dyslipidaemia. This imbalance is concerning given the high prevalence of hypertension and dyslipidaemia in Malaysia. Future research and intervention efforts should be more evenly distributed to ensure that these conditions receive adequate attention within the PHC setting.
This scoping review identified an uneven geographic distribution of study locations, with a concentration of research particularly in the states of Selangor, Kuala Lumpur, Kelantan, and Johor. Selangor and Kuala Lumpur, being more urbanized and better resourced, likely benefit from stronger healthcare research infrastructure, established academic institutions, and greater access to funding and skilled human resources. Another plausible explanation is that in states with higher prevalence, local health authorities or organizations may have already implemented interventions or programs without formal evaluation or dissemination through peer-reviewed publications, hence not captured in this scoping review. These efforts, while potentially impactful, remain undocumented in the academic literature and therefore contribute little to the national or global evidence base. On the other hand, as the current research focuses more in the urban areas, the unique challenges of managing these three diseases in more rural areas might be overlooked. The lifestyle and environmental factors as well as healthcare accessibility might differ significantly from the urban setting. The geographical imbalance highlights the need for deliberate strategies to enhance research activities, intervention implementation and evaluation in less-studied states, particularly those with high disease burdens and unique local needs. Addressing this gap is essential to ensure that research findings and interventions are representative and relevant across Malaysia’s diverse regions and populations.
Many studies in this review had relatively small sample sizes, which may limit the statistical power and generalisability, particularly in Malaysia’s diverse population where ethnicity, culture, socioeconomic status, and geography influence health behaviours and outcomes. In our review, we found two interventions which are culturally sensitive – the use of Quran recitation audio [44] and Malaysian trans-cultural diabetes nutrition algorithm (tDNA) [34]. From literature, ethnic differences were observed in diabetes control and complication rates, with Chinese patients shown to experience more complications despite having better glycemic control, while Indian patients have been found to have higher rates of nephropathy [53]. Additionally, gender differences influence the factors affecting blood pressure control [54], and also modify the impact of age on glycemic control [55]. A review of hypertension management also emphasized the impact of cultural practices and health beliefs on a patient’s adherence to treatment, highlighting the need for culturally tailored interventions rather than a single, universal strategy [56]. Thus, the “one-size-fits-all” approach is not ideal for NCD management, especially with diabetes, hypertension and dyslipidemia. It is important to consider these sociocultural differences, especially when delivering lifestyle modification interventions and providing educational information. National NCD programs should incorporate sociocultural considerations into prevention and management strategies, develop targeted interventions for high-risk subgroups, and strengthen health communication that is sensitive to cultural and gender-specific determinants to achieve equitable and sustainable impact.
In addition, about half of the interventions identified in this scoping review were implemented over relatively short durations (between one to six months), thereby raising questions regarding their long-term sustainability, scalability, and feasibility for nationwide implementation. Interventions such as EnPHC, Malaysia Health Plate, FDC and DMTAC were designed for nationwide implementation, whereas the others are short term programs. In order for the intervention to be adopted widely as public health programs, despite effectiveness, sustainability and scalability need to be considered [57]. Future interventions should integrate implementation research principles to directly address the requirements for effective, sustainable, and adaptable for nationwide deployment, particularly considering cultural and setting differences across the Malaysian PHC system.
The diversity of intervention components observed in this review reflects the complex interplay of medical, lifestyle, and psychosocial factors in NCD care [58]. The predominance of education and self-monitoring components in these Malaysian interventions aligns with international standards, such as the American Diabetes Association’s Standard of Care 2025 and a Consensus Report for Diabetes Self-Management Education and Support (DSMES), highlighting the need to have DSMES not only at diagnosis, but also during major life transitions and the onset of complications [59,60]. The educational content in these interventions cover a broad range of topics and targeted at both patients and providers. However, none of the reported interventions addressed all seven domains of the ADCES7 Self-Care Behaviours™ (ADCES7) framework. Future programs could incorporate higher-level domains such as “problem solving” and “reducing risks” to comprehensively cover self-care topics [61]. Furthermore, most studies that incorporated education and self-monitoring components focused on immediate outcomes, such as knowledge improvement rather than intermediate clinical outcomes like glycemic control or cardiovascular risk reduction. Furthermore, they were conducted over relatively short durations. These findings highlighted the need to evaluate both the long-term effectiveness and the quality of DSMES delivery to ensure sustained patient engagement and meaningful clinical impact.
Personalized care models enhance continuity, foster patient-provider trust, and improve coordination, while multidisciplinary teams bring together diverse expertise to address the medical, nutritional, and psychosocial needs of people with diabetes. Both align closely with the delivery system design and health system organization domains of the CCM, which emphasizes proactive, patient-centred, and team-based care. However, only two interventions in this review (EnPHC and CORFIS) employed a combination of both components, suggesting a gap as well as an opportunity for advancement of diabetes, hypertension and dyslipidemia management in Malaysian PHC. The barriers to wider adoption of these models include workforce shortages, particularly the limited number of family medicine specialists, diabetes educators, physiotherapists, and dieticians, along with competing demands of multiple parallel programs within the clinic, high staff turnover, and limited interprofessional training [62,63]. Given the variability in structure, manpower and equipment across clinics, strong and committed leadership together with innovative strategies such as structured task-shifting protocols, protected time for team-based care discussions, integrated one-stop diabetes services and leverage on technology, are needed to integrate personalized care models and multidisciplinary teams into routine PHC practice [63].
Community linkage was the least targeted CCM domain in this review. A similar trend was observed in other reviews that included studies from various countries [64,65]. In this present review, the interventions addressing community linkage consisted of public awareness events with diabetes screening, health campaigns like the Malaysia Healthy Plate, and provision of information on local support groups. These activities, while valuable, fall short of establishing a sustained, structured partnership between healthcare teams and community organizations. The experiences from other countries demonstrated that robust and high-impact community linkage requires dedicated, continuous mechanisms, such as formalized collaborations between academic centres, physicians, and non-governmental organizations [66], or the utilization of trained Community Health Workers to provide in-home support and counselling [67]. This review underscores the urgent need to create more robust community linkages in Malaysia that can extend the reach of clinic-based care, reinforce self-management, and provide social and emotional support to patients.
This scoping review’s strength is the systematic mapping of interventions to the six CCM domains and a detailed breakdown of intervention components, which offers insights into strategies that were used in Malaysian PHC. By presenting the interventions by component, this review provides a practical reference for policymakers and practitioners seeking to adapt similar approaches. We also uncover research gaps in hypertension and dyslipidaemia, as well as community linkage for NCD management. This information can serve as a guide for future research opportunities in Malaysia. Besides that, our broad search strategy, which included a local database (MyMedR), no language restrictions, and snowballing, helped to maximise the inclusion of relevant studies. However, we have several limitations, that includes the absence of formal quality assessment or critical appraisal of included studies, as our focus was on describing interventions and mapping them to the CCM domains. The scoping nature of the review prevents conclusions about intervention effectiveness to be drawn, as outcomes were not systematically synthesized or compared. Besides that, potential publication bias was inherent in this review as interventions implemented but not published in peer-reviewed literature may have been missed.
Conclusion
This review reveals a significant imbalance in Malaysia’s PHC interventions for NCDs; while self-management and clinical systems are well-addressed, a heavy focus on diabetes and a critical neglect of community linkages leave major gaps in managing the high burden of these three diseases in Malaysia. The challenge for Malaysian policymakers is not only to scale effective and culturally tailored interventions but to strategically invest in community partnerships as well as broaden research focus beyond diabetes and urban areas. Closing these gaps is essential for creating a sustainable and equitable PHC system capable of tackling the full spectrum of NCDs.
Supporting information
S1 Table. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.
https://doi.org/10.1371/journal.pone.0346934.s001
(DOCX)
S3 Table. Characteristics of interventions* (n = 32).
https://doi.org/10.1371/journal.pone.0346934.s003
(DOCX)
S4 Table. Descriptions of the interventions in terms of intervention levels and CCM domains.
https://doi.org/10.1371/journal.pone.0346934.s004
(DOCX)
Acknowledgments
We would like to thank the Director General of Health Malaysia for his permission to publish this article.
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