The research, published in BMC Public Health by Chiew Way Ang of Asia Pacific University of Technology and Innovation, Roshidi Ismail of the South East Asia Community Observatory, and Tin Tin Su of Monash University Malaysia and Heidelberg University, tracked more than three thousand Malaysian adults across five years. The team drew on the South East Asia Community Observatory, or SEACO, a health and demographic surveillance system that repeatedly surveys a defined population, allowing researchers to follow the same individuals over time rather than comparing different snapshots. Participants aged 35 and above who had hypertension and took part in both the 2013 and 2018 survey waves formed the analytical cohort of 3,256 people. Because each person served as their own comparison across the two time points, the study could capture genuine transitions in care rather than mere shifts in population composition.

The analytical framework the researchers used is known as the hypertension care cascade, a model borrowed from infectious disease programmes that breaks chronic disease management into sequential stages: being screened, receiving a diagnosis, starting treatment, and finally achieving blood pressure control. A person can stall at any rung. Someone may be screened but never told they have the condition; diagnosed but never prescribed medication; treated but still walking around with dangerously elevated pressures. By classifying each participant’s stage in 2013 and again in 2018, the team could label every individual’s trajectory as improving, worsening, or unchanged, and then use multinomial logistic regression to identify which sociodemographic characteristics predicted movement in each direction.

The headline numbers reveal a system that has become dramatically better at detection while quietly failing at treatment. Screening coverage surged from 74.9 percent of the cohort in 2013 to 95.4 percent in 2018, and the proportion of hypertensive adults who had been formally diagnosed rose from 49.0 percent to 58.1 percent. Both gains were highly statistically significant. Yet over the same five years, the share of participants actually receiving antihypertensive treatment fell from 32.1 percent to 28.4 percent. In other words, while the front door of the health system swung wider, fewer people were being ushered into the rooms where treatment actually happens. The gap between diagnosis and therapy widened into a chasm, leaving a growing pool of people who know they have hypertension but are doing nothing about it.

Perhaps most sobering was what happened among those who were on treatment at both waves. Blood pressure control in this group showed no statistically significant improvement, moving from 39.3 percent in 2013 to 44.2 percent in 2018, a difference the authors report as not significant. Even among people engaged enough with the health system to be taking medication, fewer than half had their condition under control. This is the stage where clinical guidelines, medication adherence, follow-up visits and lifestyle factors all converge, and where Malaysian care appears to be treading water. The statistical significance of each finding was confirmed using McNemar’s test, an appropriate method for paired binary data collected from the same individuals at two time points.

Who moved forward and who slipped backward was far from random. Older age increased the odds of both improving and worsening, a pattern that likely reflects the greater contact older adults have with health services of every kind: they are more likely to be screened and diagnosed, but also more vulnerable to treatment interruptions, medication changes and the physiological volatility that comes with aging arteries. Each additional year of age raised the adjusted odds of improvement by roughly 2.3 percent and the adjusted odds of worsening by roughly 4 percent, according to the study’s regression models. Age, in effect, amplifies whatever trajectory a person is already on.

Sex and ethnicity told a sharper story. Women had significantly higher odds of worsening than men, with an adjusted odds ratio of 1.518, meaning their care was more likely to regress to an earlier stage of the cascade over the five-year window. Participants of Indian ethnicity and other minority ethnic groups, along with those whose educational background fell outside standard schooling, including religious school attendance or no formal education at all, had lower odds of improving. These findings point to structural inequities threaded through Malaysian society: minority communities and people outside the mainstream education system appear to face systematic barriers at precisely the points where the health system should be catching them and pulling them forward. The authors note that their sensitivity analyses were generally consistent with the main results, with the exception of associations involving never-married status, which were less stable.

The implications of the study reach well beyond Malaysia’s borders. Low- and middle-income countries bear the overwhelming share of the global hypertension burden, and the pattern documented here, rapid gains in screening and diagnosis paired with stagnant or declining treatment and control, mirrors what has been observed in many other settings. Detection campaigns, community health screenings and rising health awareness can push the first two rungs of the cascade upward relatively quickly. But converting a diagnosis into sustained, effective treatment requires something harder: reliable drug supply chains, affordable medications, functioning primary care follow-up, patient education, and trust between communities and clinics. The Malaysian data suggest that investment has flowed disproportionately to the easier half of the problem.

There is also a subtle epidemiological warning embedded in the numbers. As screening improves and more people are diagnosed, the untreated pool does not simply shrink; it can grow, because new diagnoses outpace new treatment starts. The study found exactly this dynamic, with the proportion of diagnosed but untreated individuals rising over the five years. From a health system perspective, this is a ticking clock. Every diagnosed but untreated person carries the same elevated cardiovascular risk they carried before their diagnosis, and the act of finding their disease has not yet protected them. The authors argue that bridging this gap from detection to long-term management should now be the central priority, complementing continued efforts to screen those still undiagnosed.

What would success look like? The study’s conclusions point toward strengthening continuity of care: systems that automatically flag diagnosed patients who have not started treatment, community-based follow-up for people who drift out of care, and targeted support for the groups identified as most at risk of regression, including women and ethnic minority communities. Malaysia’s experience demonstrates that the early stages of the hypertension cascade can be fixed within a few years with concerted effort. The harder and more consequential work, keeping people on treatment and actually lowering their blood pressure, is where the next five years of progress will be won or lost. For the one in three Malaysian adults living with hypertension, and for the billions more worldwide, the difference between a diagnosis on paper and a controlled blood pressure reading is, quite literally, a matter of life and death.

Subject of Research: Longitudinal evaluation of the hypertension care cascade among adults in a Malaysian health surveillance cohort

Article Title: Hypertension care cascade among adults in a Malaysian health surveillance cohort: a longitudinal evaluation of screening, diagnosis, treatment, and control

Article References: Ang, C. W., Ismail, R., & Su, T. T. (2026). Hypertension care cascade among adults in a Malaysian health surveillance cohort: a longitudinal evaluation of screening, diagnosis, treatment, and control. BMC Public Health. https://doi.org/10.1186/s12889-026-29648-4

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29648-4

Keywords: hypertension, care cascade, Malaysia, SEACO, longitudinal study, blood pressure control, non-communicable disease, public health, screening, diagnosis, treatment gaps, low- and middle-income countries