Prevalence, awareness, treatment, and control of hypertension in Bissau, Western Africa

Single-Pill, Triple Antihypertensive Therapy in Rural Sub-Saharan Africa: Preliminary Experience

INTRODUCTION

Worldwide, arterial hypertension is the foremost preventable and modifiable cardiovascular risk factor. In addition to lifestyle changes, recent international guidelines recommend single-pill, low-dose combinations as initial treatment strategy. We investigated whether this approach is feasible in a rural sub-Saharan Africa setting.

METHODS

Diagnosis of hypertension was established over three sets of blood pressure measurements, performed according to the European Society of Hypertension recommendations by trained personnel, using a validated, automated, oscillometric device OMRON M7 IT-HEM-7322-E. In 98 individuals with arterial hypertension, a once-daily, single-pill combination of olmesartan, amlodipine, and hydrochlorothiazide was prescribed at an appropriate dose. Patients were instructed on its administration and potential side effects and encouraged towards lifestyle modifications. The treatment regimen was adjusted, if needed, at each outpatient clinic scheduled after 4, 8, 12, and 16 weeks.

RESULTS

Seventy-nine patients (aged 61 [53-70] years; median and interquartile range) strictly adhered to the treatment schedule, while 19 individuals (70 [65-80] years) dropped out. Blood pressure was < 140/90 mmHg after 4 weeks in 44 (56%), after 8 weeks in 62 (78%), after 12 weeks in 69 (87%), and after 16 weeks in 74 (94%) participants. Excellent tolerance was reported.

CONCLUSIONS

These results provide real-life evidence that hypertension management with a once-daily, single-pill combination of olmesartan, amlodipine, and hydrochlorothiazide as initial treatment is feasible and effective also in a rural sub-Saharan setting. Single-pill combinations should be made available also in rural and remote areas in low- and middle-income countries as a reliable first-line treatment strategy.

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.

Psychometric properties of the Chinese version of the Hypertension Belief Assessment Tool

BACKGROUND

Hypertension is prevalent in China. Hypertensive patients suffer from many health problems in life. Hypertension is a common chronic disease with long-term and lifelong characteristics. In the long run, the existence of chronic diseases will affect the patient's own health beliefs. However, people's health beliefs about Hypertension are not explicit. Therefore, it is vital to find a suitable instrument to comprehend and improve the health beliefs of hypertensive patients, thus, better control of blood pressure and improvement of patient's quality of life are now crucial issues. This study aimed to translate the Hypertension Belief Assessment Tool (HBAT) into Chinese and examine the psychometric properties of the Chinese version of the Hypertension Belief Assessment Tool in hypertensive patients.

METHODS

This is a cross-sectional study. We translated the HBAT into Chinese and tested the reliability and validity of the Chinese version among 325 hypertensive patients.

RESULTS

The Chinese version of the scale contains 21 items. The Exploratory Factor Analysis (EFA) revealed six factors and explained 77.898% of the total variation. A six-factor model eventually showed acceptable fit indices in the Confirmatory Factor Analysis (CFA). With modified Confirmatory Factor Analysis, the fit indices were Chi-square/Degree of Freedom (CMIN/DF) = 2.491, Comparative Fit Index (CFI) = 0.952, Incremental Fit Index (IFI) = 0.952, Root-mean-square Error of Approximation (RMSEA) = 0.068, Tucker Lewis Index (TLI) = 0.941. The HBAT exhibits high internal consistency reliability (0.803), and the scale has good discriminant validity.

CONCLUSION

The results suggest that the HBAT is a reliable and valid instrument for assessing the beliefs of Chinese hypertensive patients.

Care Cascades for Hypertension in Low-Income Settings: A Systematic Review and Meta-Analysis

Objective: High blood pressure is the leading risk factor for cardiovascular disease. The hypertension care cascade (HCC) is increasingly being used to evaluate the effectiveness of interventions. This systematic review aims to examine HCC in low-income settings. Methods: The search strategy included articles published between January 2010 and April 2023. We excluded studies with incomplete HCC, on fragile patients or aged <18 years, reviews. We used the MOOSE guideline. Five researchers retrieved data on the survey year, country, population, HCC and diagnostic methods for hypertension. We used JBI Critical Appraisal Tools for quality assessment. Results: Ninety-five articles were analyzed. Average hypertension prevalence was 33% (95% CI: 31%-34%), lower in LICs than in LMICs (25% vs. 34%). The overall mean awareness of hypertension was 48% (95% CI: 45%-51%), its treatment was 35% (95% IC: 32%-38%) and its control 16% (95% CI: 14%-18%). In almost all steps, percentages were lower in LICs and in Sub-Saharan Africa. Conclusion: Trends in HCC vary between countries, with poorer performance in LICs. This review highlights the need for interventions tailored to low-income settings in order to improve hypertension care.

Contribution of single-pill combinations in the management of hypertension: perspectives from China, Europe and the USA

Uncontrolled hypertension is associated with an increased risk of adverse clinical vascular outcomes and death. Hypertension management guidelines from China and the USA recommend initiation of antihypertensive pharmacotherapy with a single drug for patients without severe hypertension at presentation. Current European hypertension guidelines take a different approach and recommend the use of combination therapy from the time of diagnosis of hypertension for most patients. This article reviews the burden of hypertension in these countries and summarises the evidence base for the use of antihypertensive combination therapy contained within a single tablet (single-pill combinations, SPC). Typically, half or less of populations from China, Europe and the USA who were found to have hypertension were aware of their condition, less than half of those receiving treatment, and fewer still achieved adequate blood pressure (BP) control. The reasons for the unaddressed burden of hypertension are complex and multifactorial, with contributions from factors related to patients, healthcare providers and healthcare systems. The use of SPCs of antihypertensive therapies helps to optimise adherence with therapy and is likely to result in superior BP control. There is a strong evidence base to support current European guideline recommendations on the initiation of antihypertensive therapy with SPCs for the majority of people with hypertension.

How to Improve Awareness, Treatment, and Control of Hypertension in Africa, and How to Reduce Its Consequences: A Call to Action From the World Hypertension League

Hypertension is the leading preventable risk factor for cardiovascular diseases and disability globally. In low- and middle-income countries hypertension has a major social impact, increasing the disease burden and costs for national health systems. The present call to action aims to stimulate all African countries to adopt several solutions to achieve better hypertension management. The following 3 goals should be achieved in Africa by 2030: (1) 80% of adults with high blood pressure in Africa are diagnosed; (2) 80% of diagnosed hypertensives, that is, 64% of all hypertensives, are treated; and (3) 80% of treated hypertensive patients are controlled. To achieve these aims, we call on individuals and organizations from government, private sector, health care, and civil society in Africa and indeed on all Africans to undertake a few specific high priority actions. The aim is to improve the detection, diagnosis, management, and control of hypertension, now considered to be the leading preventable killer in Africa.

Medication Adherence and Blood Pressure Control Among Hypertensive Outpatients Attending a Tertiary Cardiovascular Hospital in Tanzania: A Cross-Sectional Study

Background

Notwithstanding the availability of effective treatments, asymptomatic nature and the interminable treatment length, adherence to medication remains a substantial challenge among patients with hypertension. Suboptimal adherence to BP-lowering agents is a growing global concern that is associated with the substantial worsening of disease, increased service utilization and health-care cost escalation. This study aimed to explore medication adherence and its associated factors among hypertension outpatients attending a tertiary-level cardiovascular hospital in Tanzania.

Methods

The pill count adherence ratio (PCAR) was used to compute adherence rate. In descriptive analyses, adherence was dichotomized and consumption of less than 80% of the prescribed medications was used to denote poor adherence. Logistic regression analyses was used to determine factors associated with adherence.

Results

A total of 849 outpatients taking antihypertensive drugs for ≥1 month prior to recruitment were randomly enrolled in this study. The mean age was 59.9 years and about two-thirds were females. Overall, a total of 653 (76.9%) participants had good adherence and 367 (43.2%) had their blood pressure controlled. Multivariate logistic regression analysis showed; lack of a health insurance (OR 0.5, 95% CI 0.3-0.7, p<0.01), last BP measurement >1 week (OR 0.6, 95% CI 0.4-0.8, p<0.01), last clinic attendance >1 month (OR 0.4, 95% CI 0.3-0.6, p<0.001), frequent unavailability of drugs (OR 0.6, 95% CI 0.3-0.9, p = 0.03), running out of medication before the next appointment (OR 0.6, 95% CI 0.4-0.9, p = 0.01) and stopping medications when asymptomatic (OR 0.6, 95% CI 0.4-0.8, p<0.001) to be independent associated factors for poor adherence.

Conclusion

A substantial proportion of hypertensive outpatients in this tertiary-level setting had good medication adherence. Nonetheless, observed suboptimal blood pressure control regardless of a fairly satisfactory adherence rate suggests that lifestyle modification plays a central role in hypertension management.