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

Hypertension affects over one billion people worldwide, yet control rates remain suboptimal, particularly in low- and middle-income countries (LMICs). In Malaysia, one in three adults has hypertension, but awareness and control are low. This study investigates five-year changes in the hypertension care cascade and identifies sociodemographic factors associated with transitions in care among Malaysian adults. Data were obtained from the South East Asia Community Observatory (SEACO) health and demographic surveillance system, collected in 2013 and 2018. Adults aged 35 years and above with hypertension who participated in both survey waves were included ( N = 3,256). Hypertension care cascade stages (screened, diagnosed, treated, and controlled) were assessed at both time points. Based on each participant’s stage in 2013 and 2018, transitions were classified as: improving (advancement to a later stage, e.g., uncontrolled to controlled, or untreated to treated), worsening (regression to an earlier stage, e.g., controlled to uncontrolled), or no change (remaining in the same stage). Multinomial logistic regression examined sociodemographic factors associated with transitions. Between 2013 and 2018, screening increased from 74.9% to 95.4% and diagnosis from 49.0% to 58.1%, while treatment decreased from 32.1% to 28.4% (all p < 0.001, McNemar’s test). Among participants treated at both waves, hypertension control did not change significantly (39.3% vs. 44.2%, p = 0.154). Older age was associated with both improvement (AOR = 1.023, 95% CI: 1.013, 1.033) and worsening (AOR = 1.040, 95% CI: 1.029, 1.051). Females had higher odds of worsening compared with males (AOR = 1.518, 95% CI: 1.256, 1.835). Indian and other ethnicities and non-standard education (e.g., religious school or no formal education) were associated with lower odds of improvement. Findings were generally consistent in sensitivity analyses, except for associations with never-married status. While Malaysia has made progress in hypertension screening and diagnosis, substantial gaps remain in treatment initiation and retention. The increasing proportion of diagnosed but untreated individuals highlights the need for interventions that bridge the gap from detection to long-term management. These findings suggest that strengthening continuity of care, together with continued screening of those not yet diagnosed, may be an important initiative in reducing the cardiovascular disease burden.