Regional and Sex Differences in the Prevalence and Awareness of Hypertension: An H3Africa AWI-Gen Study Across 6 Sites in Sub-Saharan Africa

Hypertension knowledge, attitudes and perceptions among adults in the Navrongo Health and Demographic Surveillance Site: a mixed methods analysis

BACKGROUND

This study assessed knowledge, behaviors, and perceptions towards hypertension following community dissemination on cardiovascular disease (CVD) risk within the Navrongo Health and Demographic Surveillance Site in Northern Ghana.

METHODS

A cross-sectional mixed methods study was conducted among middle aged men and women following education on CVD and their risk factors. Knowledge and attitudes of participants regarding hypertension were measured in 310 participants using a survey tool and the resultant data was analyzed with descriptive statistics. Focus group discussions (FDG) were used to assess perceptions of 40 study participants on their lived experiences with hypertension. Recorded interviews were transcribed verbatim and coded into themes using Nvivo 12 software before thematic analysis.

RESULTS

Of the 310 surveyed participants, 54% were women and the mean age was 50 ± 6 years. The results showed that 84% of participants had heard about hypertension, 70% knew it was an increase in blood pressure and could be caused by excess salt intake, poor diet and physical inactivity. About 22.3% of participants were aware of the had hypertension. In terms of management, majority of the participants were aware that hypertension could be treated with antihypertensive medication and that untreated or uncontrolled hypertension could result in adverse health consequences. Few participants had ever had their blood pressure measured and did not access screening or healthcare care services and rather perceived the health system as inadequate to screen, and manage hypertension.

CONCLUSION

Though, knowledge on hypertension was high, awareness of hypertension status and access to screening and healthcare services was low. Community beliefs and perceptions strongly influence treatment, and control of hypertension. Effective sustained community dissemination efforts addressing misperceptions could improve hypertension treatment and control.

Distribution of informal caregiving for older adults living with or at risk of cognitive decline within and beyond family in rural South Africa

Objectives

Aging populations in rural areas of low and middle-income countries will increasingly need care. However, formal support is severely limited and adult children are frequently unavailable due to morbidity, early mortality, employment and migration. We aimed to describe how care is shared within and between households for older adults in a rural South African setting.

Methods

We conducted quantitative interviews with 1012 household members and non-household caregivers of 106 older adults living with or at risk of cognitive decline in rural Mpumalanga, South Africa. Using descriptive statistics and regression analysis, we described how care is shared, with particular attention to generational patterns of care.

Results

Informal care for older persons was spread among family, friends, and neighbours, with minimal paid support. This care was mostly provided by female relatives one or two generations younger than the recipient, and unemployed. However, a smaller number of paid caregivers, also mostly female, provided the most intensive care. Spouses commonly took on the role of primary caregiver for their partner.

Discussion

In our study, care mainly came from household members due to close family ties and practical considerations, with support from outside the household. This reflects shared history, reciprocal relationships, and easy access to care tasks within the household. A deeper understanding of how informal care for older adults is shared in low- and middle-income countries is essential for developing targeted interventions.

Hypertension in sub-Saharan Africa: the current profile, recent advances, gaps, and priorities

Recent global and regional reports consistently confirm the high and increasing prevalence of hypertension in sub-Saharan Africa (SSA), with poor detection, treatment, and control rates. This narrative review summarises the burden of hypertension in SSA and recent findings from community-based hypertension management strategies. We further outline prominent risk factors according to recent data and associated underlying mechanisms for hypertension development. An extensive review of literature showed that most countries have reported on the prevalence of hypertension during 2017-2023, despite limitations linked to the lack of nationally representative studies, heterogeneity of sampling and data collection methods. Task-shifting approaches that assign roles to model patients and community health workers reported improved linkage to healthcare services and adherence to medication, with inconsistent findings on blood pressure (BP)-lowering effects over time. The regularly reported risk factors include unhealthy diet, sedentary lifestyle, increased adiposity and underweight, ageing, level of education, and/or income as well as psychosocial factors. Newer data on the pathophysiological mechanisms leading to hypertension and potential areas of intervention are reported from children and adults and include, among others, salt-handling and volume overload, endothelial function, BP dipping patterns and the role of human immunodeficiency virus . To conclude, significant strides have been made in data reporting from SSA on the burden of hypertension in the region as well as biomarker research to improve understanding and identification of areas of intervention. However, gaps remain on linkage between knowledge generation, translation, and implementation research. Coordinated studies addressing both discovery science and public health are crucial to curb hypertension development and improve management in SSA.

Characteristics and outcomes of patients with symptomatic chronic myocardial injury in a Tanzanian emergency department: A prospective observational study

BACKGROUND

Chronic myocardial injury is a condition defined by stably elevated cardiac biomarkers without acute myocardial ischemia. Although studies from high-income countries have reported that chronic myocardial injury predicts adverse prognosis, there are no published data about the condition in sub-Saharan Africa.

METHODS

Between November 2020 and January 2023, adult patients with chest pain or shortness of breath were recruited from an emergency department in Moshi, Tanzania. Medical history and point-of-care troponin T (cTnT) assays were obtained from participants; those whose initial and three-hour repeat cTnT values were abnormally elevated but within 11% of each other were defined as having chronic myocardial injury. Mortality was assessed thirty days following enrollment.

RESULTS

Of 568 enrolled participants, 81 (14.3%) had chronic myocardial injury, 73 (12.9%) had acute myocardial injury, and 412 (72.5%) had undetectable cTnT values. Of participants with chronic myocardial injury, the mean (± sd) age was 61.5 (± 17.2) years, and the most common comorbidities were CKD (n = 65, 80%) and hypertension (n = 60, 74%). After adjusting for CKD, thirty-day mortality rates (38% vs. 36%, aOR 1.03, 95% CI: 0.52-2.03, p = 0.931) were similar between participants with chronic myocardial injury and those with acute myocardial injury, but significantly greater (38% vs. 13.6%, aOR 3.63, 95% CI: 1.98-6.65, p<0.001) among participants with chronic myocardial injury than those with undetectable cTnT values.

CONCLUSION

In Tanzania, chronic myocardial injury is a poor prognostic indicator associated with high risk of short-term mortality. Clinicians practicing in this region should triage patients with stably elevated cTn levels in light of their increased risk.

The Impact of Regular Screening and Lifestyle Modification on Cardiovascular Disease Risk Factors in South African Women Living With HIV

BACKGROUND

The Integration of cardiovascular disease SCreening and prevention in the HIV MAnagement plan for women of reproductive age study set out to determine the effectiveness of screening and lifestyle modification in modifying cardiovascular disease (CVD) risk factors in women living with HIV (WLHIV).

METHODS

In this prospective, quasiexperimental, intervention study, WLHIV aged 18-<50 years were enrolled from 2 clinics (intervention [I-arm]) and (control arms [C-arm]) in Umlazi, South Africa, between November 2018 and May 2019. Women in the I-arm received lifestyle modification advice on diet, physical activity, alcohol use, and smoking cessation and underwent annual screening for CVD risk. The CVD risk factors were assessed through standardized questionnaires and clinical and laboratory procedures at baseline and at end of 3 years of follow-up. Prevalence of metabolic syndrome and other CVD indices were compared between arms at end-of-study (EOS).

RESULTS

Total of 269 WLHIV (149 I-arm and 120 C-arm) with a mean ± SD age of 36 ± 1 years were included in the EOS analyses after 32 ± 2 months of follow-up. The metabolic syndrome prevalence at EOS was 16.8% (25/149) in the I-arm and 24% (24/120) in the C-arm (risk ratio 0.9; 95% CI: 0.5 to 1.1; P 0.86). Proportion of women with fasting blood glucose >5.6 mmol/L in the I-arm and C-arm were 2.7% (4/149) and 13.3% (16/120) respectively (risk ratio 0.2; 95% CI: 0.069 to 0.646; P < 0.01). High-density lipoprotein improved with the intervention arm from baseline to EOS (95% CI: -0.157 to -0.034; P < 0.05).

CONCLUSIONS

Although there was no significant difference in the prevalence of metabolic syndrome between study arms, we observed decreased blood glucose levels in the I-arm compared with the C-arm and improved high-density lipoprotein within the I-arm, following lifestyle modification and regular screening for CVD risk factors in WLHIV.

No Association Between AGT Gene Polymorphisms with Hypertension in a South African Population

Purpose

Hypertension is a leading cause of cardiovascular-related morbidity and mortality worldwide, with a prevalence increasing at an alarming rate in both middle- and low-income countries. Various environmental and genetic factors have been attributed to play a significant role in the increasing prevalence of hypertension. Single nucleotide polymorphisms (SNPs) in the angiotensinogen (AGT) gene are reported to have a significant association with hypertension; however, there are limited studies done on South African populations. Therefore, this case-control study aimed to investigate the association between AGT SNPs (rs2004776, rs3789678, rs5051 and rs7079) with hypertension in a study population of isiXhosa-speaking participants from the Eastern Cape Province in South Africa.

Materials and Methods

The SNPs were genotyped in 250 hypertensive cases and 237 normotensive controls, using TaqMan genotyping assays.

Results

For the SNP rs2004776, the frequency of CC genotype (18.4%) and C allele (44%) in hypertensive cases showed no significant differences (p = 0.52, χ2 = 1.32), when compared to the normotensive control group (CC: 19.8% and C allele: 43%). Similar results were obtained for the genotypic and allelic frequencies between hypertensive cases and normotensive controls for rs3789678 (p = 0.88, χ2=0.26) and rs5051 (p = 0.57, χ2=1.12), and rs7079 (p = 0.33, χ2=2.23). These findings demonstrate that there were no significant associations between the SNPs rs2004776, rs3789678, rs7079, rs5051 with hypertension in our study population.

Conclusion

These findings suggest that AGT gene polymorphisms are not associated with the development of hypertension in the studied population. The present study represents the first genetic report to investigate the AGT gene polymorphisms with hypertension in an isiXhosa-speaking South African population.

Sociodemographic and Behavioral Factors Associated With Hypertension and Depression in 4 Rural Communities in Northern Ghana: A Cross-Sectional Study

OBJECTIVES

The prevalences of hypertension and depression in sub-Saharan Africa are substantial and rising, despite limited data on their sociodemographic and behavioral risk factors and their interactions. We undertook a cross-sectional study in 4 communities in the Upper East Region of Ghana to identify persons with hypertension and depression in the setting of a pilot intervention training local nurses and health volunteers to manage these conditions.

METHODS

We quantified hypertension and depression prevalence across key sociodemographic factors (age, sex, occupation, education, religion, ethnicity, and community) and behavioral factors (tobacco use, alcohol use, and physical activity) and tested for association by multivariable logistic regression.

RESULTS

Hypertension prevalence was higher in older persons (7.6% among 35- to 50-year-olds vs 16.4% among 51- to 70-year-olds) and among those reporting alcohol use (18.9% vs 8.5% between users and nonusers). In multivariable models, only older age (AOR 2.39 [1.02, 5.85]) and residence in the community of Wuru (AOR 7.60 [1.81, 32.96]) were independently associated with hypertension, and residence in Wuru (AOR 23.58 [7.75-78.25]) or Navio (AOR 7.41 [2.30-24.74]) was the only factor independently associated with depression.

CONCLUSIONS

We report a high prevalence of both diseases overall and in select communities, a trend that requires further research to inform targeted chronic disease interventions.

Genome-wide association study meta-analysis of blood pressure traits and hypertension in sub-Saharan African populations: an AWI-Gen study

Most hypertension-related genome-wide association studies (GWASs) focus on non-African populations, despite hypertension (a major risk factor for cardiovascular disease) being highly prevalent in Africa. The AWI-Gen study GWAS meta-analysis for blood pressure (BP)-related traits (systolic and diastolic BP, pulse pressure, mean-arterial pressure and hypertension) from three sub-Saharan African geographic regions (N = 10,775), identifies two novel genome-wide significant signals (p < 5E-08): systolic BP near P2RY1 (rs77846204; intergenic variant, p = 4.95E-08) and pulse pressure near LINC01256 (rs80141533; intergenic variant, p = 1.76E-08). No genome-wide signals are detected for the AWI-Gen GWAS meta-analysis with previous African-ancestry GWASs (UK Biobank (African), Uganda Genome Resource). Suggestive signals (p < 5E-06) are observed for all traits, with 29 SNPs associating with more than one trait and several replicating known associations. Polygenic risk scores (PRSs) developed from studies on different ancestries have limited transferability, with multi-ancestry PRS providing better prediction. This study provides insights into the genetics of BP variation in African populations.

Integration of point-of-care screening for type 2 diabetes mellitus and hypertension into the COVID-19 vaccine programme in Johannesburg, South Africa

BACKGROUND

South Africa grapples with a substantial burden of non-communicable diseases (NCDs), particularly type 2 diabetes (diabetes) and hypertension. However, these conditions are often underdiagnosed and poorly managed, further exacerbated by the strained primary healthcare (PHC) system and the disruptive impact of the COVID-19 pandemic. Integrating NCD screening with large-scale healthcare initiatives, such as COVID-19 vaccination campaigns, offers a potential solution, especially in low- and middle-income countries (LMICs). We investigated the feasibility and effectiveness of this integration.

METHODS

A prospective cohort study was conducted at four government health facilities in Johannesburg, South Africa. NCD screening was incorporated into the COVID-19 vaccination campaign. Participants underwent COVID-19 rapid tests, blood glucose checks, blood pressure assessments, and anthropometric measurements. Those with elevated blood glucose or blood pressure values received referrals for diagnostic confirmation at local PHC centers.

RESULTS

Among 1,376 participants screened, the overall diabetes prevalence was 4.1%, combining previously diagnosed cases and newly identified elevated blood glucose levels. Similarly, the hypertension prevalence was 19.4%, comprising pre-existing diagnoses and newly detected elevated blood pressure cases. Notably, 46.1% of participants displayed waist circumferences indicative of metabolic syndrome, more prevalent among females. Impressively, 7.8% of all participants screened were potentially newly diagnosed with diabetes or hypertension. Approximately 50% of individuals with elevated blood glucose or blood pressure successfully linked to follow-up care within four weeks.

CONCLUSION

Our study underscores the value of utilizing even brief healthcare interactions as opportunities for screening additional health conditions, thereby aiding the identification of previously undiagnosed cases. Integrating NCD screenings into routine healthcare visits holds promise, especially in resource-constrained settings. Nonetheless, concerted efforts to strengthen care linkage are crucial for holistic NCD management and control. These findings provide actionable insights for addressing the NCD challenge and improving healthcare delivery in LMICs.

Multimorbidity, Treatment, and Determinants among Chronic Patients Attending Primary Health Facilities in Tshwane, South Africa

The growing burden of non-communicable diseases amidst the largest burden of HIV in South Africa leads to disease combinations of multimorbidity with the complexity of care. We conducted a cross-sectional study to assess multimorbidity, medication adherence, and associated factors among out-patients with chronic diseases in primary health care (PHC) facilities in Tshwane, South Africa. A structured questionnaire was used to collect data on comorbidities and medication adherence, along with socio-demographic and lifestyle factors. Logistic regression models were used to analyse the determinants of multimorbidity and medication adherence. In all 400 patients with chronic diseases (mean age: 47 ± 12 years) living in poor environments, common chronic conditions were hypertension (62%), diabetes (45%), HIV (44%), TB (33%), hypercholesterolemia (18%), and gout (13%). The proportion of concordant comorbidity (i.e., diseases with similar risk profiles and management) was 72%, more than 28% of discordant comorbidity (i.e., diseases not related in pathogenesis or management). Most patients had two coexisting chronic conditions (75%), while few had more than two chronic conditions (23%) and single-occurring conditions (2%). Prevalence rates for common multimorbidity patterns were 25% (HIV and TB), 17% (hypertension and diabetes), 9% (hypertension, diabetes, and hypercholesterolemia), and 2% (hypertension diabetes and HIV), while medication adherence was estimated at 74%. In multivariate analysis, multimorbidity was associated with an older age and lower socio-economic status, while medication non-adherence was associated with a younger age and socio-economic factors. The study highlights the presence of multimorbidity among primary care patients attributed to hypertension, diabetes, HIV, and TB in South Africa with non-adherence to medication in one-third of patients. Policies are needed for education on multimorbidity with a need to optimize lifestyle modifications, perhaps proactive outreach or nursing contact with high-risk patients with public-health-sensitive conditions, such as HIV and/or TB, as well as patients with a history of non-adherence to medications. Considerations should be given to the development of a medication adherence scale for multiple chronic conditions beyond assessing adherence to a single index medication.

Health systems performance for hypertension control using a cascade of care approach in South Africa, 2011-2017

Hypertension is a major contributor to global morbidity and mortality. In South Africa, the government has employed a whole systems approach to address the growing burden of non-communicable diseases. We used a novel incident care cascade approach to measure changes in the South African health system's ability to manage hypertension between 2011 and 2017. We used data from Waves 1-5 of the National Income Dynamics Study (NIDS) to estimate trends in the hypertension care cascade and unmet treatment need across four successive cohorts with incident hypertension. We used a negative binomial regression to identify factors that may predict higher rates of hypertension control, controlling for socio-demographic and healthcare factors. In 2011, 19.6% (95%CI 14.2, 26.2) of individuals with incident hypertension were diagnosed, 15.4% (95%CI 10.8, 21.4) were on treatment and 7.1% had controlled blood pressure. By 2017, the proportion of individuals with diagnosed incident hypertension had increased to 24.4% (95%CI 15.9, 35.4). Increases in treatment (23.3%, 95%CI 15.0, 34.3) and control (22.1%, 95%CI 14.1, 33.0) were also observed, translating to a decrease in unmet need for hypertension care from 92.9% in 2011 to 77.9% in 2017. Multivariable regression showed that participants with incident hypertension in 2017 were 3.01 (95%CI 1.77, 5.13) times more likely to have a controlled blood pressure compared to those in 2011. Our data show that while substantial improvements in the hypertension care cascade occurred between 2011 and 2017, a large burden of unmet need remains. The greatest losses in the incident hypertension care cascades came before diagnosis. Nevertheless, whole system programming will be needed to sufficiently address significant morbidity and mortality related to having an elevated blood pressure.

Msolomba V, Venter F, Carmona S, Kao K, Gordon A, Meyer-Rath G. Integration of point-of-care screening for type 2 diabetes mellitus and hypertension with COVID-19 rapid antigen screening in Johannesburg, South Africa

AIMS

We sought to evaluate the yield and linkage-to-care for diabetes and hypertension screening alongside a study assessing the use of rapid antigen tests for COVID-19 in taxi ranks in Johannesburg, South Africa.

METHODS

Participants were recruited from Germiston taxi rank. We recorded results of blood glucose (BG), blood pressure (BP), waist circumference, smoking status, height, and weight. Participants who had elevated BG (fasting ≥7.0; random ≥11.1mmol/L) and/or BP (diastolic ≥90 and systolic ≥140mmHg) were referred to their clinic and phoned to confirm linkage.

RESULTS

1169 participants were enrolled and screened for elevated BG and elevated BP. Combining participants with a previous diagnosis of diabetes (n = 23, 2.0%; 95% CI:1.3-2.9%) and those that had an elevated BG measurement (n = 60, 5.2%; 95% CI:4.1-6.6%) at study enrollment, we estimated an overall indicative prevalence of diabetes of 7.1% (95% CI:5.7-8.7%). When combining those with known hypertension at study enrollment (n = 124, 10.6%; 95% CI:8.9-12.5%) and those with elevated BP (n = 202; 17.3%; 95% CI:15.2-19.5%), we get an overall prevalence of hypertension of 27.9% (95% CI:25.4-30.1%). Only 30.0% of those with elevated BG and 16.3% of those with elevated BP linked-to-care.

CONCLUSION

By opportunistically leveraging existing COVID-19 screening in South Africa to screen for diabetes and hypertension, 22% of participants received a potential new diagnosis. We had poor linkage-to-care following screening. Future research should evaluate options for improving linkage-to-care, and evaluate the large-scale feasibility of this simple screening tool.

Ancestral and environmental patterns in the association between triglycerides and other cardiometabolic risk factors

BACKGROUND

West Africans and African Americans with substantial (∼80%) West African ancestry are characterized by low levels of triglycerides (TG) compared to East Africans and Europeans. The impact of these varying TG levels on other cardiometabolic risk factors is unclear. We compared the strength of association between TG with hypertension, blood pressure, BMI, waist circumference, type 2 diabetes (T2D), and fasting glucose across West African (WA), East African (EA), and European (EU) ancestry populations residing in three vastly different environmental settings: sub-Saharan Africa, United States, and Europe.

METHODS

We analysed data from four cross-sectional studies that included WA in sub-Saharan Africa (n = 7201), the U.S. (n = 4390), and Europe (n = 6436), EA in sub-Saharan Africa (n = 781), and EU in the U.S. (n = 8670) and Europe (n = 4541). Linear regression analyses were used to test the association between TG and cardiometabolic risk factors.

FINDINGS

Higher adjusted regression coefficients were observed in EU compared with WA ancestry for TG on hypertension (EU β [95% CI]: 0.179 [0.156, 0.203], WA β [95% CI]: 0.102 [0.086, 0.118]), BMI (EU β [95% CI]: 0.028 [0.027, 0.030], WA β [95% CI]: 0.015 [0.014, 0.016]), and waist circumference (EU β [95% CI]: 0.013 [0.013, 0.014], WA β [95% CI]: 0.009 [0.008, 0.009) (all ancestry × trait interaction P-values <0.05), irrespective of environmental differences within ancestry groups. Less consistency was observed among EA. Associations of TG with T2D did not follow ancestry patterns, with substantial variation observed between environments.

INTERPRETATION

TG may not be an equally strong associated with other established cardiometabolic risk factors in West and East Africans in contrast to European ancestry populations. The value of TG for identifying individuals at high risk for developing metabolic disorders needs to be re-evaluated for African ancestry populations.

FUNDING

National Institutes of Health, European Commission, Dutch Heart Foundation, Netherlands Organization for Health Research and Development, Centers for Disease Control and Prevention.

Prevalence, Awareness, Treatment, Control of Hypertension, and Availability of Hypertension Services for Patients Living With Human Immunodeficiency Virus (HIV) in Sub-Saharan Africa (SSA): A Systematic Review and Meta-analysis

Sub-Saharan Africa (SSA) is faced with a dual burden of hypertension and human immunodeficiency virus (HIV). In this review we sought to determine the prevalence, awareness, and control of hypertension among persons living with HIV (PLHIV), and the availability of hypertension services at the HIV care points in SSA. We searched the PubMed, Embase, Scopus, Cochrane library, Global index Medicus, African Journal online, and WHO Institutional Repository for Information Sharing (IRIS) for studies on the epidemiology of hypertension, and hypertension services for PLHIV in SSA. Twenty-six articles were identified for the review, with 150,886 participants; weighted mean of age 37.5 years and female proportion of 62.6%. The pooled prevalence was 19.6% (95% confidence interval [CI], 16.6%, 22.5%); hypertension awareness was 28.4% (95% CI, 15.5%, 41.3%), and hypertension control was 13.4% (95% CI, 4.7%, 22.1%). HIV-related factors like CD4 count, viremia, and antiretroviral therapy regimen were not consistently associated with prevalent hypertension. However, high body mass index (BMI) above 25 kg/m² [odds ratio: 1.64, 95% CI (1.26, 2.02)] and age above 45 years [odds ratio: 1.44, 95% CI (1.08, 1.79)] were associated with prevalent hypertension. Even when PLHIV on ART were more likely to be screened for hypertension and monitored, there was infrequent screening and treatment of hypertension in most HIV clinics. Most studies recommended integrating of HIV and hypertension services. We report a high prevalence of hypertension in a relatively young population of PLHIV with suboptimal screening, treatment, and control of hypertension. We recommend strategies to integrate HIV and hypertension services.

Identifying the prevalence and correlates of multimorbidity in middle-aged men and women: a cross-sectional population-based study in four African countries

OBJECTIVES

To determine the prevalence of multimorbidity, to identify which chronic conditions cluster together and to identify factors associated with a greater risk for multimorbidity in sub-Saharan Africa (SSA).

DESIGN

Cross-sectional, multicentre, population-based study.

SETTING

Six urban and rural communities in four sub-Saharan African countries.

PARTICIPANTS

Men (n=4808) and women (n=5892) between the ages of 40 and 60 years from the AWI-Gen study.

MEASURES

Sociodemographic and anthropometric data, and multimorbidity as defined by the presence of two or more of the following conditions: HIV infection, cardiovascular disease, chronic kidney disease, asthma, diabetes, dyslipidaemia, hypertension.

RESULTS

Multimorbidity prevalence was higher in women compared with men (47.2% vs 35%), and higher in South African men and women compared with their East and West African counterparts. The most common disease combination at all sites was dyslipidaemia and hypertension, with this combination being more prevalent in South African women than any single disease (25% vs 21.6%). Age and body mass index were associated with a higher risk of multimorbidity in men and women; however, lifestyle correlates such as smoking and physical activity were different between the sexes.

CONCLUSIONS

The high prevalence of multimorbidity in middle-aged adults in SSA is of concern, with women currently at higher risk. This prevalence is expected to increase in men, as well as in the East and West African region with the ongoing epidemiological transition. Identifying common disease clusters and correlates of multimorbidity is critical to providing effective interventions.

Prevalence and predictors of hypertension among adults in Mbarara City, Western Uganda

OBJECTIVE

The study aim was to evaluate the prevalence and predictors of hypertension among an urban adult population in Mbarara city, Western Uganda.

METHODS

We evaluated blood pressure measurements, social demographic and clinical parameters of adults living in Mbarara city, Uganda. These parameters were extracted from medical records of adults who participated in the Uganda World Kidney Day 2020 health screening activities. A total of 302 adults were evaluated for hypertension using the American College of Cardiology/American Heart Association 2017 (blood pressure threshold 130/80 mmHg) and International Society of Hypertension 2020 guidelines (threshold 140/90 mmHg).

RESULTS

The mean age of the participants was 42.5 years (standard deviation: 15.1) and majority were male 195/302 (64.6%). Using American College of Cardiology/American Heart Association 2017 guidelines, 156/302 (51.7%) adults were newly diagnosed with hypertension compared to 68/302 (22.5%) newly diagnosed with hypertension using International Society of Hypertension 2020 guidelines. Only 23/302 (7.6%) were on treatment. Based on American College of Cardiology/American Heart Association 2017 guidelines, age ≥40 years and overweight/obesity were statistically significant predictors of hypertension (p < 0.05 for all) at multivariate analysis. Using the International Society of Hypertension 2020 guidelines, age ≥40 years predicted hypertension.

DISCUSSION

The prevalence of hypertension is high among this urban adult population irrespective of the guidelines used, highlighting the need for hypertension prevention interventions.

Genome-wide Association Study Meta-analysis of Blood Pressure Traits and Hypertension in Sub-Saharan African Populations: An AWI-Gen Study

Most hypertension-related genome-wide association studies (GWAS) focus on non-African populations, despite hypertension (a major risk factor for cardiovascular disease) being highly prevalent in Africa. The AWI-Gen study GWAS meta-analysis for blood pressure-related traits (systolic and diastolic blood pressure, pulse pressure, mean-arterial pressure and hypertension) from three sub-Saharan African geographic regions (N=10,775), identified two genome-wide significant signals (p<5E-08): systolic blood pressure near P2RY1 (rs77846204; intergenic variant, p=4.25E-08) and pulse pressure near Linc01256 (rs80141533; intergenic variant, p=4.25E-08). No genome-wide signals were detected for the AWI-Gen GWAS meta-analysis with previous African-ancestry GWASs (UK Biobank (African), Uganda Genome Resource). Suggestive signals (p<5E-06) were observed for all traits, with 29 displaying pleiotropic effects and several replicating known associations. Polygenic risk scores developed from studies on different ancestries had limited transferability, with multi-ancestry models providing better prediction. This study provides insights into the genetics and physiology of blood pressure variation in African populations.

Community perspectives on cardiovascular disease control in rural Ghana: A qualitative study

BACKGROUND

Cardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors.

METHODS

We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes.

RESULTS

CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital.

CONCLUSIONS

CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

Association between socio-economic status and non-communicable disease risk in young adults from Kenya, South Africa, and the United Kingdom

There is a pressing need for global health preventions to curb the escalating burden of non-communicable diseases (NCDs). Utilising multi-country study designs can improve our understanding of how socio-economic context shapes the aetiology of NCDs, and this has great potential to advance global health interventions. We examined the association between socio-economic status (SES) and NCD risk, and the potential confounding effects of smoking and alcohol intake in young adults (18-35-year-olds) from Kenya, South Africa (SA), and the United Kingdom (UK). Our study was a cross-sectional online survey that included 3000 respondents (n = 1000 per country, 50% women) conducted in April 2022. We utilised information on twelve NCDs to classify respondents as having "no condition", "one condition", and "multimorbidity" (having two or more conditions). A total household asset score was calculated and used as a proxy of SES, and subsequently categorised into quintiles (Q1-Q5; lowest-highest). Ordered logistic regression was used to test the associations between NCD risk and exposure variables. In the UK sample, we found that those in the second lowest SES quintile (Q2) had lower odds of developing NCDs than their lowest SES counterparts (Q1). In contrast, South African and Kenyan youth with a SES score between middle and highest quintiles (Q3-Q5) were more likely to develop NCDs than the lowest SES quintile group. In all countries, smoking and/or alcohol intake were associated with higher odds of developing NCDs, and showed some confounding effects on the SES-NCD relationships. Specifically, in Kenya, the risk of developing NCD was more than two times higher in those in the middle (Q3) SES group (OR 2.493; 95% CI 1.519-4.091; p < 0.001) compared to their lowest (Q1) SES counterparts. After adjusting for smoking and alcohol, the ORs of middle (Q3) SES group changed from 2.493 to 2.241 (1.360-3.721; p = 0.002). Overall, we found that the strength and direction of SES-NCD associations differed within and between countries. This study highlights how different SES contexts shape the risk of NCDs among young adults residing in countries at different levels of economic development.

Ghana's Adherence to PASCAR's 10-Point Action Plan towards Hypertension Control: A Scoping Review

The continuous increase in the prevalence of hypertension in Ghana has led to various interventions aimed at controlling the disease burden. Nonetheless, these interventions have yielded poor health outcomes. Subsequently, the Pan-African Society of Cardiology (PASCAR), established a 10-point action plan for inclusion in policies to aid control of hypertension. This scoping review assessed the adherence of health policies to the 10-point action plan towards hypertension control/reduction in Ghana. Eight health policies met the inclusion criteria and were assessed. The programme evaluation and policy design framework were used for synthesis and analysis of extracted data. Overall, there was poor adherence to hypertension control observed in the policies. Specifically, there were low levels of integrating hypertension control/reduction measures, a poor task-sharing approach, and poor financial resource allocations to tackle hypertension control/reduction in most of the policies. There was also low support for research to produce evidence to guide future interventions. For Ghana to achieve the global target of reducing hypertension by the year 2025, its health policies must adhere to evidence-based interventions in hypertension management/control. The study recommends a follow-up study among hypertension patients and healthcare professionals to evaluate the factors militating against hypertension management/control in Ghana.

Pre-morbid cardiometabolic risks among South Africans living in informal settlements

AIM

Numerous studies have been conducted on cardiometabolic risk factors in South Africa. However, not much has been done in informal settlement populations faced with their own set of health risks. This study screened for pre-morbid cardiometabolic risks and associated factors among adults living in informal settlements in South Africa.

METHODS

A cross-sectional study used the WHO STEPwise questionnaire to collect data on demography, anthropometry, blood pressure, and glucose and cholesterol levels (n = 329). Cardiometabolic risks were based on the criteria considered by the International Diabetes Federation and the National Cholesterol Education Program Adult Treatment Panel III. Data were analysed using STATA 14.

RESULTS

The median age of the participants was 35 (25-42) years. Cardiometabolic risk factors among the participants were hypertension (66%), overweight/obesity (45%), abdominal obesity (46%), and elevated cholesterol (15%) and glucose levels (7%). The metabolic syndrome was found in 17% of the participants, with a high prevalence observed among participants aged 35-59 years (28%) and ≥ 60 years (40%). The metabolic syndrome was significantly associated with gender [males, adjusted odds ratio (AOR) = 0.4, 95% CI: 0.20-0.90] and age, 35-59 years (AOR = 5.07, 95% CI: 2.24-11.23) and ≥ 60 years (AOR = 6.57, 95% CI; 1.57-27.54).

CONCLUSIONS

Prevalent cardiometabolic risk factors in informal settlements indicate the need for routine screening for all the components of the metabolic syndrome at the primary healthcare level.

Renal Papillary Necrosis (RPN) in an African Population: Disease Patterns, Relevant Pathways, and Management

Renal papillary necrosis (RPN) is characterized by coagulative necrosis of the renal medullary pyramids and papillae. Multiple conditions and toxins are associated with RPN. Several RPN risk factors, or POSTCARDS, have been identified, with most patients presenting with RPN having at least two contributing risk factors. Currently, there is no specific test to diagnose and confirm RPN; however, several imaging tools can be used to diagnose the condition. RPN is currently underdiagnosed in African populations, often with fatal outcomes. In African clinical settings, there is a lack of consensus on how to define and describe RPN in terms of kidney anatomy, pathology, endourology, epidemiology, the identification of African-specific risk factors, the contribution of oxidative stress, and lastly an algorithm for managing the condition. Several risk factors are unique to African populations including population-specific genetic factors, iatrogenic factors, viral infections, antimicrobial therapy, schistosomiasis, substance abuse, and hypertension (GIVASSH). Oxidative stress is central to both GIVASSH and POSTCARDS-associated risk factors. In this review, we present information specific to African populations that can be used to establish an updated consensual definition and practical grading system for radiologists, urologists, nephrologists, nuclear physicians, and pathologists in African clinical settings.

Early Stage and Established Hypertension in Sub-Saharan Africa: Results From Population Health Surveys in 17 Countries, 2010-2017

BACKGROUND

Multiple studies have reported a high burden of hypertension in sub-Saharan Africa, but none have examined early stage hypertension. We examined contemporary prevalence of diagnosed, treated, and controlled stage I (130-139/80-89 mm Hg) and II (≥140/90 mm Hg) hypertension in the general population of sub-Saharan Africa.

METHODS

We analyzed World Health Organization STEPwise Approach to Noncommunicable Disease Risk Factor Surveillance surveys from 17 sub-Saharan Africa countries including 85 371 respondents representing 85 million individuals from 2010 to 2017. We extracted demographic variables, blood pressure, self-reported hypertension diagnosis/awareness, and treatment status to estimate prevalence of stage I and II hypertension and treatment by country. We examined diagnosis and treatment trends by national sociodemographic index, a marker of development.

RESULTS

Stage I hypertension prevalence (regardless of diagnosis/treatment) was >25% in 13 of 17 countries, highest in Sudan (35.3% [95% CI, 33.7%-37.0%]), and lowest in Eritrea (20.2% [18.8%-21.6%]). Combined stages I and II hypertension prevalence was >50% in 13 countries; <20% were diagnosed in every country. Treatment among those diagnosed ranged from 26% to 63%, and control (<140/90 mm Hg) from 4% to 17%. In 8 of 9 countries reporting on behavioral interventions (eg, salt reduction, weight loss, exercise, and smoking cessation), <60% of diagnosed individuals received counseling. Rates of diagnosis, but not treatment, were positively associated with sociodemographic index (P=0.008), although there was substantial variation between countries even at similar levels of development.

CONCLUSIONS

Hypertension is common in sub-Saharan Africa but rates of diagnosis, treatment, and control markedly low. There is a large population with early stage hypertension that may benefit from behavioral counseling to prevent progression. Our analyses suggest that success in population hypertension care may be achieved independently of socioeconomic development, highlighting a need for policymakers to identify best practices in those countries that outperform similar or more developed countries.

Estimating the changing burden of disease attributable to high sodium intake in South Africa for 2000, 2006 and 2012

Background. Elevated sodium consumption is associated with increased blood pressure, a major risk factor for cardiovascular and chronic kidney disease.Objectives. To quantify the deaths and disability-adjusted life years (DALYs) attributed to high sodium intake in persons aged ≥25 years in South Africa (SA) for 2000, 2006 and 2012.Methods. Comparative risk assessment (CRA) methodology was used and population attributable fractions (PAFs) of high sodium intake, mediated through high blood pressure (BP), for cardiovascular and chronic kidney disease were estimated. This was done by taking the difference between the PAF for elevated systolic BP (SBP) based on the estimated SBP level in the population and the PAF based on the estimated SBP that would result if sodium intake levels were reduced to the theoretical minimum risk exposure level (1 g/day) according to population group and hypertension categories. A meta-regression based on data from nine national surveys conducted between 1998 and 2017 was used to estimate the prevalence of hypertension by age, sex and population group. Relative risks identified from international literature were used and the difference in PAFs was applied to local burden estimates from the second South African National Burden of Disease Study. Age-standardised rates were calculated using World Health Organization (WHO) standard population weights. The attributable burden was also estimated for 2012 using an alternative target of 2 g/day proposed in the National Strategic Plan for the Prevention and Control of Non-communicable Diseases (NSP).Results. High sodium intake as mediated through high SBP was estimated to cause 8 071 (95% uncertainty interval (UI) 6 542 - 15 474) deaths in 2012, a drop from 9 574 (95% UI 8 158 - 16 526) in 2006 and 8 431 (95% UI 6 972 - 14 511) in 2000. In 2012, ischaemic heart disease caused the highest number of deaths in persons (n=1 832), followed by haemorrhagic stroke (n=1 771), ischaemic stroke (n=1 484) and then hypertensive heart disease (n=1 230). Ischaemic heart disease was the highest contributor to deaths for males (27%), whereas for females it was haemorrhagic stroke (23%). In 2012, 1.5% (95% UI 1.3 - 2.9) of total deaths and 0.7% (95% UI 0.6 - 1.2) of total DALYs were attributed to high sodium intake. If the NSP target of <2 g/day sodium intake had been achieved in 2012, ~2 943 deaths and 48 870 DALYs would have been averted.Conclusion. Despite a slight decreasing trend since 2006, high sodium intake mediated through raised BP accounted for a sizeable burden of disease in 2012. Realising SA’s target to reduce sodium intake remains a priority, and progress requires systematic monitoring and evaluation.

Sex and Gender Influence on Cardiovascular Health in Sub-Saharan Africa: Findings from Ghana, Gambia, Mali, Guinea, and Botswana

Background

There is an upsurge of cardiovascular diseases (CVDs) in sub-Saharan Africa (SSA). Irrespective of biological sex, gender-related factors could be the precursor of these conditions.

Objective

To examine the associations between biological sex, gender-related variables, and cardiovascular health (CVH) risk factors in SSA countries.

Methods

We used data from the STEPwise approach to surveillance of risk factors for non-communicable disease survey, conducted in adults from Ghana, Gambia, Mali, Guinea, and Botswana. The main outcome was CVH, measured through the health index with values ranging from 0 (worst) to 5 (best or ideal) CVH. Multivariable logistic regression was applied to determine the gender-related factors related to poorer CVH (index less than 4).

Results

Data included 15,356 adults (61.4% females, mean age 36.9 years). The prevalence of hypertension (21.6% vs. 13.8%) and overweight/obesity (48.3% vs. 27.5%) was higher among females as compared to males. Females were more likely to be unemployed (17.3% vs. 9.7%) or reported unpaid work (36.8% vs. 15.2%). Overall, females showed worse CVH than males (OR_female = 0.95, 95% CI:0.91-0.99). Being married was associated with better CVH compared with being single, more so for males (OR_male = 1.09, 95% CI:0.96-1.24, p_interaction < 0.01). Males with unpaid work (OR_male = 1.28, 95% CI:1.12-1.47) had better CVH than their unpaid female counterparts (OR_female = 1.08, 95% CI:1.01-1.17).

Conclusion

In SSA populations, being female was associated with poorer CVH given the disproportionate burden of hypertension and overweight/obesity. Gender-related factors such as marital status and unpaid work were associated with better CVH in males compared to females.

Clinicians' Perceptions towards Precision Medicine Tools for Cardiovascular Disease Risk Stratification in South Africa

Cardiovascular diseases (CVDs) are a leading cause of mortality and morbidity in South Africa. Risk stratification is the preferred approach to disease prevention, but identifying patients at high risk for CVD remains challenging. Assessing genetic risk could improve stratification and inform a clinically relevant precision medicine (PM) approach. Clinicians are critical to PM adoption, thus, this study explores practicing clinicians’ perceptions of PM-based CVD risk stratification in South Africa’s public health setting. Practicing clinicians (n = 109) at four teaching hospitals in Johannesburg, South Africa, completed an electronic self-administered survey. The effect of demographic and professional characteristics on PM-based CVD risk stratification perceptions was assessed. Fewer than 25% of respondents used clinical genetic testing, and 14% had formal genetics training. 78% had a low mean knowledge score, with higher scores associated with genetic training (p < 0.0005) and research involvement (p < 0.05). Despite limited knowledge and resources, 84% perceived PM approaches positively. 57% felt confident in applying the PM-based approach, with those already undertaking CVD risk stratification more confident (p < 0.001). High cost and limited access to genetics services are key barriers. Integrating genetic information into established clinical tools will likely increase confidence in using PM approaches. Addressing the genetics training gap and investment into the country’s genomics capacity is needed to advance PM in South Africa.

A retrospective database study of the demographic features and glycemic control of patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo

BACKGROUND

The Kin-Antwerp project aimed at improving the quality of care provided to patients with diabetes in Kinshasa, the Democratic Republic of the Congo in Central Africa, including the digitalisation of routine clinical data to improve patients' follow-up. We aim to analyse the data of a study population of Kin-Antwerp to characterise their demographic features, assess their achievement of glycemic target over time, and identify groups requiring prioritised attention.

METHODS

We performed a secondary database analysis of routinely collected information from primary care patients with type 2 diabetes followed from 1991 to 2019. Data included demographics (age, sex), anthropometrics (weight, height), clinical parameters (blood pressure, plasma glucose), and anti-diabetic treatments. Achievement of glycemic target, defined as fasting plasma glucose < 126 mg/dL, over time was assessed using a multilevel mixed-effects logistic regression model.

RESULTS

Our study population of patients with type 2 diabetes (N = 8976) comprised a higher proportion of women (67%) and patients between 40 and 65 years old (70.4%). At the first follow-up, most patients were on treatment with insulin (56.5%) and had glycemic levels under the target (79.9%). Women presented more often with obesity (27.4%) and high systolic blood pressure (41.8%) than men (8.6% and 37.0%, respectively). Patients had a median follow-up of 1.8 (interquartile range: 0.5-3.4) years. Overall, the odds of achieving glycemic target increased by 18.4% (odds ratio: 1.184, 95% CI: 1.130 to 1.239; p < 0.001) per year of follow-up. Stratified analyses suggested that the odds of achieving glycemic control over time increased among older patients (> 40 years), but not among younger patients (< 40 years).

CONCLUSION

In our study population, an overall poor glycemic control was observed albeit with a modest improvement in the achievement of glycemic target throughout patients' follow-up. Younger patients may benefit from prioritised attention to achieve glycemic targets. Based on the information provided by the database, continue monitoring and improvement of the project Kin-Antwerp is recommended. Introducing further efforts to improve type 2 diabetes management should include robust glycemia-monitoring tools and haemoglobin A1c, as well as further outlining self-management strategies.

Modelling of South African Hypertension: Application of Panel Quantile Regression

Hypertension is one of the crucial risk factors for morbidity and mortality around the world, and South Africa has a significant unmet need for hypertension care. This study aims to establish the potential risk factors of hypertension amongst adults in South Africa attributable to high systolic and diastolic blood pressure over time by fitting panel quantile regression models. Data obtained from the South African National Income Dynamics Study (NIDS) Household Surveys carried out from 2008 to 2018 (Wave 1 to Wave 5) was employed to develop both the fixed effects and random effects panel quantile regression models. Age, BMI, gender (males), race, exercises, cigarette consumption, and employment status were significantly associated with either one of the BP measures across all the upper quantiles or at the 75th quantile only. Suggesting that these risk factors have contributed to the exacerbation of uncontrolled hypertension prevalence over time in South Africa.

Living kidney donation in a developing country

Background

Living kidney donation has been advocated as a means to ameliorate the chronic shortage of organs for transplantation. Significant rates of comorbidity and familial risk for kidney disease may limit this approach in the local context; there is currently limited data describing living donation in Africa.

Methods

We assessed reasons for non-donation and outcomes following donation in a cohort of 1208 ethnically diverse potential living donors evaluated over a 32-year period at a single transplant centre in South Africa.

Results

Medical contraindications were the commonest reason for donor exclusion. Black donors were more frequently excluded (52.1% vs. 39.3%; p<0.001), particularly for medical contraindications (44% vs. 35%; p<0.001); 298 donors proceeded to donor nephrectomy (24.7%). Although no donor required kidney replacement therapy, an estimated glomerular filtration rate below 60 ml/min/1.73 m2 was recorded in 27% of donors at a median follow-up of 3.7 years, new onset albuminuria >300 mg/day was observed in 4%, and 12.8% developed new-onset hypertension. Black ethnicity was not associated with an increased risk of adverse post-donation outcomes.

Conclusion

This study highlights the difficulties of pursuing live donation in a population with significant medical comorbidity, but provides reassurance of the safety of the procedure in carefully selected donors in the developing world.

Non-pharmacological interventions to achieve blood pressure control in African patients: a systematic review

OBJECTIVES

This systematic review aims to evaluate the evidence of non-pharmacological strategies to improve blood pressure (BP) control in patients with hypertension from African countries.

DESIGN

We performed a systematic review and searched Medline, Central, CINAHL and study registers until June 2020 for randomised studies on interventions to decrease BP of patients with hypertension in African countries. We assessed the study quality using the Cochrane risk of bias tool and narratively synthesised studies on non-pharmacological hypertension interventions.

SETTING

We included studies conducted in African countries.

PARTICIPANTS

Adult African patients with a hypertension diagnosis.

INTERVENTIONS

Studies on non-pharmacological interventions aiming to improve BP control and treatment adherence.

OUTCOMES

Main outcomes were BP and treatment adherence.

RESULTS

We identified 5564 references, included 23 with altogether 18 153 participants from six African countries. The studies investigated educational strategies to improve adherence (11 studies) and treatment by healthcare professionals (5 studies), individualised treatment strategies (2 studies), strategies on lifestyle including physical activity (4 studies) and modified nutrition (1 study). Nearly all studies on educational strategies stated improved adherence, but only three studies showed a clinically relevant improvement of BP control. All studies on individualised strategies and lifestyle changes resulted in clinically relevant effects on BP. Due to the type of interventions studied, risk of bias in domain blinding of staff/participants was frequent (83%). Though incomplete outcome data in 61% of the studies are critical, the general study quality was reasonable.

CONCLUSIONS

The identified studies offer diverse low-cost interventions including educative and task-shifting strategies, individualised treatment and lifestyle modifications to improve BP control. Especially trialled physical activity interventions show clinically relevant BP changes. All strategies were trialled in African countries and may be used for recommendations in evidence-based guidelines on hypertension in African settings.

PROSPERO REGISTRATION NUMBER

CRD42018075062.

Twin epidemics: the effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019

Background

Sub-Saharan African settings are experiencing dual epidemics of HIV and hypertension. We investigate effects of each condition on mortality and examine whether HIV and hypertension interact in determining mortality.

Methods

Data come from the 2010 Ha Nakekela population-based survey of individuals ages 40 and older (1,802 women; 1,107 men) nested in the Agincourt Health and socio-Demographic Surveillance System in rural South Africa, which provides mortality follow-up from population surveillance until mid-2019. Using discrete-time event history models stratified by sex, we assessed differential mortality risks according to baseline measures of HIV infection, HIV-1 RNA viral load, and systolic blood pressure.

Results

During the 8-year follow-up period, mortality was high (477 deaths). Survey weighted estimates are that 37% of men (mortality rate 987.53/100,000, 95% CI: 986.26 to 988.79) and 25% of women (mortality rate 937.28/100,000, 95% CI: 899.7 to 974.88) died. Over a quarter of participants were living with HIV (PLWH) at baseline, over 50% of whom had unsuppressed viral loads. The share of the population with a systolic blood pressure of 140mm Hg or higher increased from 24% at ages 40-59 to 50% at ages 75-plus and was generally higher for those not living with HIV compared to PLWH. Men and women with unsuppressed viral load had elevated mortality risks (men: adjusted odds ratio (aOR) 3.23, 95% CI: 2.21 to 4.71, women: aOR 2.05, 95% CI: 1.27 to 3.30). There was a weak, non-linear relationship between systolic blood pressure and higher mortality risk. We found no significant interaction between systolic blood pressure and HIV status for either men or women (p>0.05).

Conclusions

Our results indicate that HIV and elevated blood pressure are acting as separate, non-interacting epidemics affecting high proportions of the older adult population.

PLWH with unsuppressed viral load were at higher mortality risk compared to those uninfected. Systolic blood pressure was a mortality risk factor independent of HIV status. As antiretroviral therapy becomes more widespread, further longitudinal follow-up is needed to understand how the dynamics of increased longevity and multimorbidity among people living with both HIV and high blood pressure, as well as the emergence of COVID-19, may alter these patterns.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12791-z.

Hypertension in the South African public healthcare system: a cost-of-illness and burden of disease study

OBJECTIVES

To quantify the health and economic burden of hypertension in the South African public healthcare system.

SETTING

All inpatient, outpatient and rehabilitative care received in the national public healthcare system.

PARTICIPANTS

Adults, aged ≥20 years, who receive care in the public healthcare system.

OUTCOMES

Worksheet-based models synthesised data from multiple sources to estimate the burden of disease, direct healthcare costs, and societal costs associated with hypertension. Results were disaggregated by sex.

RESULTS

Approximately 8.22 million (30.8%, 95% CI 29.5% to 32.1%) South African adults with no private health insurance have hypertension. Hypertension was estimated to cause 14 000 (95% CI 11 100 to 17 200) ischaemic heart disease events, 13 300 (95% CI 10 600 to 16 300) strokes and 6100 (95% CI 4970 to 7460) cases of chronic kidney disease annually. Rates of hypertension, hypertension-related stroke and hypertension-related chronic kidney disease were greater for women compared with men.The direct healthcare costs associated with hypertension were estimated to be ZAR 10.1 billion (95% CI 8.98 to 11.3 billion) or US$0.711 billion (95% CI 0.633 to 0.793 billion). Societal costs were estimated to be ZAR 29.4 billion (95% CI 26.0 to 33.2 billion) or US$2.08 billion (95% CI 1.83 to 2.34 billion). Direct healthcare costs were greater for women (ZAR 6.11 billion or US$0.431 billion) compared with men (ZAR 3.97 billion or US$0.280 billion). Conversely, societal costs were lower for women (ZAR 10.5 billion or US$0.743 billion) compared with men (ZAR 18.9 billion or US$1.33 billion).

CONCLUSION

Hypertension exerts a heavy health and economic burden on South Africa. Establishing cost-effective best practice guidelines for hypertension treatment requires further research. Such research will be essential if South Africa is to make progress in its efforts to implement universal healthcare.

C-reactive protein and hypertension among Ghanaian migrants and their homeland counterparts: the Research on Obesity and Diabetes among African Migrants study

BACKGROUND

Hypertension (HTN) is a growing public health problem in sub-Saharan Africa (SSA) and SSA migrants in Europe. Elevated levels of inflammatory marker C-reactive protein (CRP) have been linked to HTN but the relationship of CRP and HTN among SSA populations has not been studied. To address this knowledge gap, we studied the association between CRP and HTN in migrant and nonmigrant SSA populations residing in different settings.

METHODS

Cross-sectional data from the multicentre Research on Obesity and Diabetes among African Migrants (RODAM) study were analysed including 5683 Ghanaians aged at least 18 years, residing in rural and urban Ghana, and Europe. Multivariate logistic regression analyses were used to assess the association between high levels of CRP (≥3 mg/l) and HTN (SBP ≥140 mmHg and/or DBP ≥90 mmHg and/or use of antihypertensive medication) per geographical site and sex.

RESULTS

The association between CRP levels and HTN varied by sex and geographical location. In age-adjusted models, there was an association between high CRP levels and HTN in urban-Ghanaian women (odds ratio 1.50, 95% confidence interval 1.10-2.03), and European-Ghanaian men (1.68, 1.16-2.43) and women (1.63, 1.28-2.07). However, these associations were attenuated after adjustment for conventional risk factors, especially BMI. No association was found in rural-Ghanaians or urban-Ghanaian men.

CONCLUSION

Our findings show an association between CRP and HTN among Ghanaian migrants and urban-Ghanaian women, however, this was largely explained by conventional risk factors. Thus, prevention of conventional risk factors, in particular obesity, may help to reduce the potentially low-grade inflammatory mechanism underlying HTN.

A roadmap to increase diversity in genomic studies

Two decades ago, the sequence of the first human genome was published. Since then, advances in genome technologies have resulted in whole-genome sequencing and microarray-based genotyping of millions of human genomes. However, genetic and genomic studies are predominantly based on populations of European ancestry. As a result, the potential benefits of genomic research-including better understanding of disease etiology, early detection and diagnosis, rational drug design and improved clinical care-may elude the many underrepresented populations. Here, we describe factors that have contributed to the imbalance in representation of different populations and, leveraging our experiences in setting up genomic studies in diverse global populations, we propose a roadmap to enhancing inclusion and ensuring equal health benefits of genomics advances. Our Perspective highlights the importance of sincere, concerted global efforts toward genomic equity to ensure the benefits of genomic medicine are accessible to all.

Pancreatic ductal adenocarcinoma: Prognostic indicators of advanced disease

BACKGROUND/OBJECTIVES

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy associated with high metastatic risk. Prognosis remains poor even after resection. Previously our group identified biomarkers that improved diagnostic accuracy in PDAC beyond the established diagnostic tumour marker, CA19-9. Risk factors, symptoms and circulating biomarkers associated with a PDAC diagnosis may differ from those that alter disease progression and metastasis. This study aimed at assessing the risk factors, presenting symptoms and potential prognostic biomarkers in PDAC and determine their relationship with PDAC stage and/or metastatic status.

METHODS

Seventy-two PDAC patients with imaging available for TNM staging at presentation were enrolled following informed consent. Demographic and clinical data were captured. Blood was collected and 38 cytokines/angiogenic factors measured. Nonparametric association tests, univariate and multivariate logistic regression were performed using STATA version 14.2. A p-value≤0.05 was considered significant and odds ratios reported for effect size.

RESULTS

Most risk factors and symptoms did not differ across the stages of cancer. Although male gender and smoking are risk factors for PDAC, the majority of study patients with metastatic PDAC were non-smoking females. In addition to CA19-9, the platelet count (p<0.01), IL-15 (p = 0.02) and GM-CSF (p<0.01) were significant, independent negative predictors of metastatic PDAC. Moreover, using specific cut-off values in a combined panel, the odds in a patient with all three biomarker levels below the cut-offs is 21 times more likely to have metastatic PDAC (p<0.0001).

CONCLUSIONS

Platelet count, IL-15 and GM-CSF are potential prognostic indicators of metastatic disease in PDAC patients from our local South African population.

Practice Change Needed for the Identification of Pediatric Hypertension in Marginalized Populations: An Example From South Africa

INTRODUCTION

Hypertension in children has increased globally over the past 20 years; yet, little is known about this issue among disadvantaged communities from low- and middle-income countries. Age-, sex-, and height-adjusted normative tables are the "gold" standard for the diagnosis and estimation of pediatric hypertension worldwide, but it is unclear whether the use of international standards is appropriate for all contexts. The purpose of this study was to evaluate and compare different international references to identify hypertension among South African school-aged children from disadvantaged communities.

METHODS

Blood pressure, weight, and height were measured in a cohort of 897 children aged 8-16 years from eight peri-urban schools in the Eastern Cape of South Africa. Cross-sectional prevalence of hypertension was calculated according to American, German, and global normative tables, as well as pseudo-normative data from the own study population. Isolated systolic hypertension and body mass index (BMI) were considered markers for cardiovascular disease. Multinomial logistic regression was used to compare the likelihood of blood pressure categorization with increasing BMI levels.

RESULTS

Hypertension prevalence ranged from 11.4% with the pseudo-normative study tables to 28.8% based on the German reference. Global guidelines showed the highest agreement both among international standards (92.5% with American guidelines) and with the study reference (72.5%). While the global and the American references presented higher systolic over diastolic hypertension rates (23.6 vs. 10.6% and 24.2 vs. 14.7%, respectively), the American guidelines predicted the highest increased risk for hypertension stage 2 [odds ratio, 1.72 (95% confidence interval: 1.43-2.07)] with raising levels of BMI.

CONCLUSION

Our results support the heterogeneity of blood pressure estimates found in the South African literature, and highlight the underrepresentation of African children in international guidelines. We call for caution in the use of international standards in different contexts and advocate for the development of normative tables that are representative of the South African pediatric population necessary to ensure an accurate identification of hypertension both from the clinical and epidemiological perspective.

Modelling of South African Hypertension: Comparative Analysis of the Classical and Bayesian Quantile Regression Approaches

Hypertension has become a major public health challenge and a crucial area of research due to its high prevalence across the world including the sub-Saharan Africa. No previous study in South Africa has investigated the impact of blood pressure risk factors on different specific conditional quantile functions of systolic and diastolic blood pressure using Bayesian quantile regression. Therefore, this study presents a comparative analysis of the classical and Bayesian inference techniques to quantile regression. Both classical and Bayesian inference techniques were demonstrated on a sample of secondary data obtained from South African National Income Dynamics Study (2017–2018). Age, BMI, gender male, cigarette consumption and exercises presented statistically significant associations with both SBP and DBP across all the upper quantiles (τ∈{0.75,0.95}). The white noise phenomenon was observed on the diagnostic tests of convergence used in the study. Results suggested that the Bayesian approach to quantile regression reveals more precise estimates than the frequentist approach due to narrower width of the 95% credible intervals than the width of the 95% confidence intervals. It is therefore suggested that Bayesian approach to quantile regression modelling to be used to estimate hypertension.

Social and demographic correlates of cardiovascular mortality in the Kassena-Nankana districts of Ghana: a verbal post-mortem analysis

BACKGROUND

The burden of cardiovascular disease (CVD) in Ghana is rising, but details on its epidemiology are scarce. We sought to quantify mortality due to CVD in two districts in rural Ghana using verbal post-mortem (VPM) data.

METHODS

We conducted a proportional sub-hazards analysis of 10 232 deaths in the Kassena-Nankana East and West districts from 2005 to 2012, to determine adult mortality attributed to CVD over time. We stratified results by age, gender and socio-economic status (SES), and compared CVD mortality among SES and gender strata over time. A competing risk model estimated the cumulative effect of eliminating CVD from the area.

RESULTS

From 2005 to 2012, CVD mortality more than doubled overall, from 0.51 deaths for every 1000 person-years in 2005 to 1.08 per 1000 person-years in 2012. Mortality peaked in 2008 at 1.23 deaths per 1000 person-years. Increases were comparable in men (2.0) and women (2.3), but greater among the poorest residents (3.3) than the richest (1.3), and among persons aged 55-69 years (2.1) than those aged ≥70 years (1.8). By 2012, male and female CVD mortality was highest in middle-SES persons. We project that eliminating CVD would increase the number of individuals reaching age 73 years from 35% to 40%, adding 1.6 years of life expectancy.

CONCLUSIONS

The burden of CVD on overall mortality in the Upper East Region is substantial and markedly increasing. CVD mortality has especially increased in lower-income persons and persons in middle age. Further initiatives for the surveillance and control of CVD in these vulnerable populations are needed.

Constructing a Nurse-led Cardiovascular Disease Intervention in Rural Ghana: A Qualitative Analysis

Background

Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana's Upper East Region.

Objective

This study sought to identify non-physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana's current primary health care structure.

Methods

Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants.

Findings

Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies.

Conclusions

Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.

Hypertension incidence among middle-aged and older adults: findings from a 5-year prospective study in rural South Africa, 2010-2015

OBJECTIVES

There is a scarcity of longitudinal cohort studies in sub-Saharan Africa to understand the epidemiology of cardiovascular disease as a basis for intervention. We estimated incident hypertension and associated sociodemographic, health and behavioural risk factors in a population aged 40 years and older over a 5-year period.

DESIGN

We assessed the association between incident hypertension and sociodemographic, health and behavioural factors using Poisson regression. We adjusted for non-response in 2015 using inverse probability sampling weights from a logistic regression including sex and age at baseline.

SETTING

Rural South Africa.

PARTICIPANTS

We used a population-based cohort of normotensive adults in 2010 who were aged 40 years and older at retest in 2015.

RESULTS

Of 676 individuals completing baseline and 5-year follow-up, there were 193 incident cases of hypertension. The overall hypertension incidence rate was 8.374/100 person-years. In multivariable analyses, those who became hypertensive were more likely to be older, have a high waist circumference (incidence rate ratio (IRR): 1.557, 95% CI: 1.074 to 2.259) and be employed (IRR: 1.579, 95% CI: 1.071 to 2.329) at baseline. Being HIV positive and not on antiretroviral therapy at baseline was associated with lower risk of incident hypertension.

CONCLUSIONS

Over a 5-year period, 29% of respondents developed hypertension. Given the high burden of hypertension in South Africa, continued longitudinal follow-up is needed to understand the complex interplay of non-communicable and infectious diseases and their underlying and modifiable risk factors to inform public health prevention strategies and programmes.

Race, geographical location and other risk factors for hypertension: South African National Health and Nutrition Examination Survey 2011/12

BACKGROUND

Hypertension is the leading cardiovascular disease in Africa. It is increasing in prevalence due partly to the epidemiological transition that African countries, including South Africa, are undergoing. This epidemiological transition is characterised by a nutrition transition andurbanisation; resulting in behavioural, environmental and stress changes that are subject to racial and geographic divides. The South African National Health and Nutrition Examination Survey (SANHANES) examined the association of traditional risk factors; and less traditional risk factors such as race, geographical location, social stressors and psychological distress with hypertension in a national population-based sample of South Africans.

METHODS

Data were analysed on individuals ≥15 years who underwent a physical examination in the SANHANES (n = 7443). Hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension medication usage. Stepwise regression examined the association of demographic, socioeconomic, life stressors, and health risk factors with systolic blood pressure, diastolic blood pressure, and hypertension. Secondly, the risk factor associations and geographical location effects were investigated separately for the African race group.

RESULTS

Increasing age (AOR = 1.069, p < 0.001); male gender (AOR = 1.413, p = 0.037); diabetes (AOR = 1.66, p = 0.002); family history of high blood pressure (AOR = 1.721, p < 0.001); and normal weight, overweight and obesity (relative to underweight: AOR = 1.782, p = 0.008; AOR = 2.232, p < 0.001; AOR = 3.874, p < 0.001 respectively) were associated with hypertension. Amongst African participants (n = 5315) age (AOR = 1.068, p < 0.001); male gender (AOR = 1.556, p = 0.001); diabetes (AOR = 1.717, p = 0.002); normal weight, overweight and obesity (relative to underweight: AOR = 1.958, p = 0.006; AOR = 2.118, p = 0.002; AOR = 3.931, p < 0.001); family history of high blood pressure (AOR = 1.485, p = 0.005); and household crowding (AOR = 0.745, p = 0.037) were associated with hypertension. There was a significantly lower prevalence of hypertension in rural informal compared to urban formal settings amongst African participants (AOR = 0.611, p = 0.005). Other social stressors and psychological distress were not significantly associated with hypertension.

CONCLUSION

There was no significant association between social stressors or psychological distress and hypertension. However, the study provides evidence of high-risk groups for whom hypertension screening and management should be prioritised, including older ages, males, people with diabetes or with family history of hypertension, and Africans who live in urban formal localities.

Hypertension care cascade in the Ingwavuma rural community, uMkhanyakude District, KwaZulu-Natal province of South Africa

Background

Treatment and control of hypertension are associated with a substantial reduction in adverse cardiovascular disease outcomes. Although South Africa aims to reduce the burden of cardiovascular diseases, there is limited evidence on the hypertension care cascade (HCC) performance in rural areas where stroke and hypertension are high. This study estimated HCC performance and identified predictors of hypertension screening among adults in the Ingwavuma community of KwaZulu-Natal, South Africa.

Methods

This was a cross-sectional study. Data were collected using the WHO STEPwise approach to surveillance (STEPS) questionnaire from 400 adult participants, excluding pregnant women and those with physical or cognitive impairments. Three hundred and ninety-three participants had complete data, and 131 had high blood pressure. We calculated progression rates for screening, diagnosis, treatment and control of hypertension from the sub-sample of participants with high blood pressure and assessed the bivariate association between HCC stages and participant characteristics and their effect sizes. We used binary and multivariable logistic regression to identify predictors of hypertension screening.

Results

Eighty-eight per cent of participants reported prior screening for hypertension. However, only 53.5% of patients under pharmacological treatment for hypertension had controlled blood pressure. In bivariate regression, employed participants were 80.3% (COR = 0.197, 95% CI [0.042–0.921]) more likely to be screened. In multivariable regression, the likelihood of hypertension screening was 82.4% (AOR = 0.176, 95% CI [0.047–0.655]) lower among participants in a cohabiting union than single participants. Similarly, employed participants were 87.4% (AOR = 0.129, 95% CI [0.017–0.952]) less likely to be screened than their unemployed counterparts.

Conclusions

The considerable attrition from the HCC across socio-demographic categories indicates a need for community-wide interventions. Empowering health care workers for community-based health promotion and hypertension management through point-of-care diagnostic tools could improve HCC performance. Efforts to improve the HCC should also focus on social determinants of health, notably gender and formal educational attainment.

Rising prevalence, and improved but suboptimal management, of hypertension in South Africa: A comparison of two national surveys

Aim

To examine the changes in prevalence, awareness, treatment and control of hypertension between 1998 and 2016 in ≥15-year-old South African men and women and the sociodemographic characteristics associated with those changes.

Methods

In nationally representative surveys in 1998 and 2016, multi-stage sampling was used to select, interview and collect blood pressure and anthropometric measurements in ≥15-year-old adults. Logistic regression analyses evaluated the independent effects of selected sociodemographic characteristics on hypertension management.

Results

Among 13,217 participants in 1998 and 7830 in 2016 (59-60% women in both surveys), hypertension prevalence increased from 27% to 45% in men and 31% to 48% in women. Hypertension increased equally in participants with and without obesity and in daily cigarette smokers vs. their counterparts. Prevalence of awareness among participants with hypertension increased from 7% to 18% (men) and from 17% to 29% (women). Among those aware, hypertension treatment improved markedly from 8% to 85% (men) and from 12% to 82% (women). Hypertension control among those on treatment increased from 17% to 26% (men) and from 21% to 30% (women). Increasing age and survey year were consistently associated with higher prevalence, awareness, treatment and control of hypertension. The richest vs. poorer women, and lower vs. higher educated women were more likely to be treated for hypertension.

Conclusions

The high and rising hypertension burden together with suboptimal awareness and control levels warrant greater attention to curb hypertension-related morbidity and mortality in South Africans. Novel strategies involving community-based or workplace hypertension programmes may overcome some barriers to optimal care.

Awareness, Treatment, and Control of Hypertension among the Adult Population in Burkina Faso: Evidence from a Nationwide Population-Based Survey

Background

Hypertension is the leading cause of cardiovascular disease, particularly in low- and middle-income countries. Improved awareness of hypertension status can significantly increase early treatment, thereby reducing cardiovascular complications and premature death. This study aimed to report the prevalence of the awareness, treatment, and control of hypertension among the adult population in Burkina Faso.

Method

We performed a secondary analysis of the first national population-based survey on common risk factors of noncommunicable diseases in Burkina Faso. It was a national representative cross-sectional survey among adults aged 25–64 years. Awareness of hypertension was defined by blood pressure ≥140/90 mmHg or a prior diagnosis by a health worker or the use of any antihypertensive drugs. A modified Poisson regression model using a generalized estimating equation was used to identify factors associated with awareness of hypertension.

Result

A total of 4628 people with valid blood pressure measurements were considered. Of them, 828 had hypertension. Among people with hypertension, the prevalence of awareness was 17.5% (95% CI: 14.4%–21.1%), and 47.3% (95% CI: 37.6%–57.3%) of them had taken antihypertensive medications for their hypertension. One-third (35.5% (95% CI: 23.3%–49.9%)) of those who took medications had controlled hypertension. The prevalence of awareness was significantly higher among women (21.1% (95% CI: 16.4%–26.7%)) compared with men (13.8% (95% CI: 10.4%–17.9%)) (p = 0.019). The prevalence of awareness increased with increasing age and education level. Nearly one-third (29.3% (95% CI: 25.3%–33.6%)) of people with hypertension needed antihypertensive drug treatment.

Conclusion

There was a poor level of awareness, treatment, and control of hypertension among adults in Burkina Faso. Effective control strategies to increase the screening of hypertension in primary care and at the community level are necessary in Burkina Faso.

Patient and health provider costs of integrated HIV, diabetes and hypertension ambulatory health services in low-income settings - an empirical socio-economic cohort study in Tanzania and Uganda

BACKGROUND

Integration of health services might be an efficient strategy for managing multiple chronic conditions in sub-Saharan Africa, considering the scope of treatments and synergies in service delivery. Proven to promote compliance, integration may lead to increased economies-of-scale. However, evidence on the socio-economic consequences of integration for providers and patients is lacking. We assessed the clinical resource use, staff time, relative service efficiency and overall societal costs associated with integrating HIV, diabetes and hypertension services in single one-stop clinics where persons with one or more of these conditions were managed.

METHODS

2273 participants living with HIV infection, diabetes, or hypertension or combinations of these conditions were enrolled in 10 primary health facilities in Tanzania and Uganda and followed-up for up to 12 months. We collected data on resources used from all participants and on out-of-pocket costs in a sub-sample of 1531 participants, while a facility-level costing study was conducted at each facility. Health worker time per participant was assessed in a time-motion morbidity-stratified study among 228 participants. The mean health service cost per month and out-of-pocket costs per participant visit were calculated in 2020 US$ prices. Nested bootstrapping from these samples accounted for uncertainties. A data envelopment approach was used to benchmark the efficiency of the integrated services. Last, we estimated the budgetary consequences of integration, based on prevalence-based projections until 2025, for both country populations.

RESULTS

Their average retention after 1 year service follow-up was 1911/2273 (84.1%). Five hundred and eighty-two of 2273 (25.6%) participants had two or all three chronic conditions and 1691/2273 (74.4%) had a single condition. During the study, 84/2239 (3.8%) participants acquired a second or third condition. The mean service costs per month of managing two conditions in a single participant were $39.11 (95% CI 33.99, 44.33), $32.18 (95% CI 30.35, 34.07) and $22.65 (95% CI 21.86, 23.43) for the combinations of HIV and diabetes and of HIV and hypertension, diabetes and hypertension, respectively. These costs were 34.4% (95% CI 17.9%, 41.9%) lower as compared to managing any two conditions separately in two different participants. The cost of managing an individual with all three conditions was 48.8% (95% CI 42.1%, 55.3%) lower as compared to managing these conditions separately. Out-of-pocket healthcare expenditure per participant per visit was $7.33 (95% CI 3.70, 15.86). This constituted 23.4% (95% CI 9.9, 54.3) of the total monthly service expenditure per patient and 11.7% (95% CI 7.3, 22.1) of their individual total household income. The integrated clinics' mean efficiency benchmark score was 0.86 (range 0.30-1.00) suggesting undercapacity that could serve more participants without compromising quality of care. The estimated budgetary consequences of managing multi-morbidity in these types of integrated clinics is likely to increase by 21.5% (range 19.2-23.4%) in the next 5 years, including substantial savings of 21.6% on the provision of integrated care for vulnerable patients with multi-morbidities.

CONCLUSION

Integration of HIV services with diabetes and hypertension control reduces both health service and household costs, substantially. It is likely an efficient and equitable way to address the increasing burden of financially vulnerable households among Africa's ageing populations. Additional economic evidence is needed from longer-term larger-scale implementation studies to compare extended integrated care packages directly simultaneously with evidence on sustained clinical outcomes.

Egocentric social network characteristics and cardiovascular risk among patients with hypertension or diabetes in western Kenya: a cross-sectional analysis from the BIGPIC trial

OBJECTIVES

Management of cardiovascular disease (CVD) is an urgent challenge in low-income and middle-income countries, and interventions may require appraisal of patients' social networks to guide implementation. The purpose of this study is to determine whether egocentric social network characteristics (SNCs) of patients with chronic disease in western Kenya are associated with overall CVD risk and individual CVD risk factors.

DESIGN

Cross-sectional analysis of enrollment data (2017-2018) from the Bridging Income Generation with GrouP Integrated Care trial. Non-overlapping trust-only, health advice-only and multiplex (trust and health advice) egocentric social networks were elicited for each participant, and SNCs representing social cohesion were calculated.

SETTING

24 communities across four counties in western Kenya.

PARTICIPANTS

Participants (n=2890) were ≥35 years old with diabetes (fasting glucose ≥7 mmol/L) or hypertension.

PRIMARY AND SECONDARY OUTCOMES

We hypothesised that SNCs would be associated with CVD risk status (QRISK3 score). Secondary outcomes were individual CVD risk factors.

RESULTS

Among the 2890 participants, 2020 (70%) were women, and mean (SD) age was 60.7 (12.1) years. Forty-four per cent of participants had elevated QRISK3 score (≥10%). No relationship was observed between QRISK3 level and SNCs. In unadjusted comparisons, participants with any individuals in their trust network were more likely to report a good than a poor diet (41% vs 21%). SNCs for the trust and multiplex networks accounted for a substantial fraction of variation in measures of dietary quality and physical activity (statistically significant via likelihood ratio test, adjusted for false discovery rate).

CONCLUSION

SNCs indicative of social cohesion appear to be associated with individual behavioural CVD risk factors, although not with overall CVD risk score. Understanding how SNCs of patients with chronic diseases relate to modifiable CVD risk factors could help inform network-based interventions.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02501746; https://clinicaltrials.gov/ct2/show/NCT02501746.

Community burden of hypertension and treatment patterns: An in-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - Nyive Phase I)

BACKGROUND

This study aimed to describe the burden, treatment patterns and, age threshold for predicting hypertension among rural adults in Nyive in the Ho Municipality of the Volta Region, Ghana.

METHODS

A population-based cross-sectional study design was employed. A total of 417 adults aged 20 years and above were randomly selected from households within the Nyive community. The WHO STEPwise approach for non-communicable diseases risk factor surveillance (STEPS) instrument was used to obtain socio-demographic and clinical information including age, gender, educational background, marital status, and occupation as well as hypertension treatment information. Blood pressure was measured using standard methods. The risk of hypertension and the critical age at risk of hypertension was determined using binary logistic regression model and the receiver-operator characteristics (ROC) analysis.

RESULTS

The direct and indirect age-standardized hypertension prevalence was higher in males (562.58/487.34 per 1000 residents) compared to the females (489.42/402.36 per 1000 residents). The risk of hypertension among the study population increased by 4.4% (2.9%-5.9% at 95% CI) for one year increase in age while the critical age at risk of hypertension was >39 years among females and >35 years among males. About 64(46.72%) of the hypertensive participants were not on treatment whereas only 42(30.66%) had their blood pressure controlled.

CONCLUSION

Rural hypertension is high among adults in Nyive. The critical age at risk of hypertension was lower among males. The estimated annual increase of risk of hypertension was 4.7% for females and 3.1% for males. High levels of undiagnosed and non-treatment of hypertension and low levels of blood pressure control exist among the rural folks.

Prevalence of hypertension in Ghanaian society: a systematic review, meta-analysis, and GRADE assessment

BACKGROUND

Hypertension has become an important public health concern in the developing world owing to rising prevalence and its adverse impact on ailing health systems. Despite being a modifiable risk factor for cardiovascular disease, hypertension has not received the needed attention in Ghana as a result of various competing interests for scarce health resources. This systematic review and meta-analysis provides a comprehensive and updated summary of the literature on the prevalence of hypertension in Ghana.

METHODS

Major databases such as MEDLINE, EMBASE, and Google Scholar and local thesis repositories were accessed to identify population-based studies on hypertension among Ghanaians. Data extracted from retrieved reports were screened independently by two reviewers. The quality of eligible studies was evaluated and reported. A reliable pooled estimate of hypertension prevalence was calculated utilizing a random-effects model and reported according to the GRADE framework. Additionally, a meta-regression analysis was performed to analyze the contribution of study-level variables to variance in hypertension prevalence.

RESULTS

In general, a total of 45,470 subjects (n = 22,866 males and 22,604 females) were enrolled from urban (n = 12), rural (n = 8), and mixed populations (n = 7). Blood pressure (BP) was measured across studies according to a validated and clinically approved protocol by trained field workers or healthcare workers including nurses and physicians. A combined total of 30,033 participants across twenty studies reporting on the population prevalence of hypertension were pooled with 10,625 (35.4%) identified to satisfy study criteria for elevated BP. The pooled prevalence across 24 studies was 30.3% (95% CI 26.1-34.8%) after fitting a random effects model. Prevalence of hypertension was 30.1% (95% CI 25.6-36.0%) among females and 34.0% (95% CI 28.5-40.0%) among males. Significant differences in pooled estimates across regions emerged from subgroup comparisons of regional estimates with an increasing trend in the north-to-south direction and with increasing age. Compared to rural settings, the burden of hypertension in urban populations was significantly higher. Age structure and population type accounted for 65.0% of the observed heterogeneity in hypertension estimates.

CONCLUSIONS

The prevalence of hypertension in Ghana is still high. The gap in hypertension prevalence between rural and urban populations is closing especially in elderly populations. These findings must claim the attention of public health authorities in Ghana to explore opportunities to reduce rural hypertension.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this review has been published previously with PROSPERO ( CRD42020215829 ).

Secondary hypertension: An update on the diagnosis and localisation of a pheochromocytoma or paraganglioma

Most cases of hypertension are because of essential hypertension, however 5% – 15% of cases can be a result of a secondary cause. In this article, we focus on the endocrine causes of secondary hypertension with a particular focus on pheochromocytomas (PCCs) and paragangliomas (PGLs). Around 15 endocrine disorders can initially present with hypertension. Amongst those PCCs and PGLs are rare but potentially life-threatening causes. An early diagnosis and timely referral can be life-saving. Herein, we present an approach for screening and diagnosis of these patients and focus on the importance of genetic testing.