The Effect Of Home-Based Hypertension Screening On Blood Pressure Change Over Time In South Africa

Portable spirometer-based pulmonary function test willingness in China: A nationwide cross-sectional study from the "Happy Breathing Program"

BACKGROUND

Understanding willingness to undergo pulmonary function tests (PFTs) and the factors associated with poor uptake of PFTs is crucial for improving early detection and treatment of chronic obstructive pulmonary disease (COPD). This study aimed to understand willingness to undergo PFTs among high-risk populations and identify any barriers that may contribute to low uptake of PFTs.

METHODS

We collected data from participants in the "Happy Breathing Program" in China. Participants who did not follow physicians' recommendations to undergo PFTs were invited to complete a survey regarding their willingness to undergo PFTs and their reasons for not undergoing PFTs. We estimated the proportion of participants who were willing to undergo PFTs and examined the various reasons for participants to not undergo PFTs. We conducted univariable and multivariable logistic regressions to analyze the impact of individual-level factors on willingness to undergo PFTs.

RESULTS

A total of 8475 participants who had completed the survey on willingness to undergo PFTs were included in this study. Out of these participants, 7660 (90.4%) were willing to undergo PFTs. Among those who were willing to undergo PFTs but actually did not, the main reasons for not doing so were geographical inaccessibility ( n  = 3304, 43.1%) and a lack of trust in primary healthcare institutions ( n  = 2809, 36.7%). Among the 815 participants who were unwilling to undergo PFTs, over half ( n  = 447, 54.8%) believed that they did not have health problems and would only consider PFTs when they felt unwell. In the multivariable regression, individuals who were ≤54 years old, residing in rural townships, with a secondary educational level, with medical reimbursement, still working, with occupational exposure to dust, and aware of the abbreviation "COPD" were more willing to undergo PFTs.

CONCLUSIONS

Willingness to undergo PFTs was high among high-risk populations. Policymakers may consider implementing strategies such as providing financial incentives, promoting education, and establishing community-based programs to enhance the utilization of PFTs.

Effectiveness of community-based interventions for prevention and control of hypertension in sub-Saharan Africa: A systematic review

Hypertension poses a significant public health challenge in sub-Saharan Africa due to various risk factors. Community-based intervention for prevention and control of hypertension is an effective strategy to minimize the negative health outcomes. However, comprehensive systematic review evidence to inform effective community-based interventions for prevention and control of hypertension in low resource settings is lacking. This study aimed to synthesize the effectiveness of community-based interventions on prevention and control of hypertension in sub-Saharan Africa. A comprehensive search for studies was carried out on PubMed, CINAHL, Web of Science Core Collection, Embase, Scopus, and Google scholar databases. The result of the review was reported according to PRISMA guidelines. Studies published in English language were included. Two independent reviewers conducted critical appraisal of included studies and extracted the data using predefined excel sheet. Experimental, quasi experimental, cohort and analytical cross-sectional studies conducted on adults who have received community-based interventions for prevention and controls of hypertension in sub-Saharan Africa were included. In this systematic review, a total of eight studies were included, comprising of two interventional studies, two quasi-experimental studies, three cohort studies, and one comparative cross-sectional study. The interventions included health education, health promotion, home-based screening and diagnosis, as well as referral and treatment of hypertensive patients. The sample sizes ranged from 236 to 13,412 in the intervention group and 346 to 6,398 in the control group. This systematic review shows the effect of community-based interventions on reduction of systolic and diastolic blood pressure. However, the existing evidence is inconsistence and not strong enough to synthesize the effect of community-based interventions for the prevention and control of hypertension in sub-Saharan Africa. Hence, further primary studies need on the effect of community-based interventions for the prevention and control of hypertension in sub-Saharan Africa. Systematic review registration number: PROSPERO CRD42022342823.

Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review

BACKGROUND

Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade.

OBJECTIVE

This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade.

METHODS

The method of this scoping review has been guided by the framework by Arksey and O'Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management.

RESULTS

A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings.

CONCLUSIONS

This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.

The global economic burden of chronic obstructive pulmonary disease for 204 countries and territories in 2020-50: a health-augmented macroeconomic modelling study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and imposes a substantial economic burden. Gaining a thorough understanding of the economic implications of COPD is an important prerequisite for sound, evidence-based policy making. We aimed to estimate the macroeconomic burden of COPD for each country and establish its distribution across world regions.

METHODS

In this health-augmented macroeconomic modelling study we estimated the macroeconomic burden of COPD for 204 countries and territories over the period 2020-50. The model accounted for (1) the effect of COPD mortality and morbidity on labour supply, (2) age and sex specific differences in education and work experience among those affected by COPD, and (3) the impact of COPD treatment costs on physical capital accumulation. We obtained data from various public sources including the Global Burden of Disease Study 2019, the World Bank database, and the literature. The macroeconomic burden of COPD was assessed by comparing gross domestic product (GDP) between a scenario projecting disease prevalence based on current estimates and a counterfactual scenario with zero COPD prevalence from 2020 to 2050.

FINDINGS

Our findings suggest that COPD will cost the world economy INT$4·326 trillion (uncertainty interval 3·327-5·516; at constant 2017 prices) in 2020-50. This economic effect is equivalent to a yearly tax of 0·111% (0·085-0·141) on global GDP. China and the USA face the largest economic burdens from COPD, accounting for INT$1·363 trillion (uncertainty interval 1·034-1·801) and INT$1·037 trillion (0·868-1·175), respectively.

INTERPRETATION

The macroeconomic burden of COPD is large and unequally distributed across countries, world regions, and income levels. Our study stresses the urgent need to invest in global efforts to curb the health and economic burdens of COPD. Investments in effective interventions against COPD do not represent a burden but could instead provide substantial economic returns in the foreseeable future.

FUNDING

Alexander von Humboldt Foundation, National Natural Science Foundation of China, CAMS Innovation Fund for Medical Science, Chinese Academy of Engineering project, Chinese Academy of Medical Sciences and Peking Union Medical College project, and Horizon Europe.

TRANSLATIONS

For the Chinese and German translations of the abstract see Supplementary Materials section.

Acceptability and feasibility of home-based hypertension and physical activity screening by community health workers in an under-resourced community in South Africa

Background

Low-middle-income countries (LMICs) face increasing burdens from non-communicable disease (NCDs) requiring primary care task shifting to community health workers (CHWs). This study explored community members' perceptions of NCD-focused, CHW-led home visits in a historically disadvantaged township of South Africa.

Methods

Trained CHWs visited community member homes, performing blood pressure and physical activity (PA) screenings, followed by brief counselling and a satisfaction survey. Semi-structured interviews were conducted within 3 days of the visit to learn about their experiences.

Results

CHWs visited 173 households, with 153 adult community members consenting to participate (88.4%). Participants reported that it was easy to understand CHW-delivered information (97%), their questions were answered well (100%), and they would request home service again (93%). Twenty-eight follow-up interviews revealed four main themes: 1) acceptance of CHW visits, 2) openness to counselling, 3) satisfaction with screening and a basic understanding of the results, and 4) receptiveness to the PA advice.

Conclusion

Community members viewed CHW-led home visits as an acceptable and feasible method for providing NCD-focused healthcare services in an under-resourced community. Expanding primary care reach through CHWs offers more accessible and individualized care, reducing barriers for individuals in under-resourced communities to access support for NCD risk reduction.

Prevalence, awareness, treatment, and control of hypertension in China, 2004-18: findings from six rounds of a national survey

OBJECTIVE

To assess the recent trends in prevalence and management of hypertension in China, nationally and by population subgroups.

DESIGN

Six rounds of a national survey, China.

SETTING

China Chronic Disease and Risk Factors Surveillance, 2004-18.

PARTICIPANTS

642 523 community dwelling adults aged 18-69 years (30 501 in 2004, 47 353 in 2007, 90 491 in 2010, 156 836 in 2013, 162 293 in 2015, and 155 049 in 2018).

MAIN OUTCOME MEASURES

Hypertension was defined as a blood pressure of ≥140/90 mm Hg or taking antihypertensive drugs. The main outcome measures were hypertension prevalence and proportion of people with hypertension who were aware of their hypertension, who were treated for hypertension, and whose blood pressure was controlled below 140/90 mm Hg.

RESULTS

The standardised prevalence of hypertension in adults aged 18-69 years in China increased from 20.8% (95% confidence interval 19.0% to 22.5%) in 2004 to 29.6% (27.8% to 31.3%) in 2010, then decreased to 24.7% (23.2% to 26.1%) in 2018. During 2010-18, the absolute annual decline in prevalence of hypertension among women was more than twice that among men (-0.83 percentage points (95% confidence interval -1.13 to -0.52) v -0.40 percentage points (-0.73 to -0.07)). Despite modest improvements in the awareness, treatment, and control of hypertension since 2004, rates remained low in 2018, at 38.3% (36.3% to 40.4%), 34.6% (32.6% to 36.7%), and 12.0% (10.6% to 13.4%). Of 274 million (95% confidence interval 238 to 311 million) adults aged 18-69 years with hypertension in 2018, control was inadequate in an estimated 240 million (215 to 264 million). Across all surveys, women with low educational attainment had higher prevalence of hypertension than those with higher education, but the finding was mixed for men. The gap in hypertension control between urban and rural areas persisted, despite larger improvements in diagnosis and control in rural than in urban areas.

CONCLUSIONS

The prevalence of hypertension in China has slightly declined since 2010, but treatment and control remain low. The findings highlight the need for improving detection and treatment of hypertension through the strengthening of primary care in China, especially in rural areas.

The effect of population-based blood pressure screening on long-term cardiometabolic morbidity and mortality in Germany: A regression discontinuity analysis

BACKGROUND

Hypertension represents one of the major risk factors for cardiovascular morbidity and mortality globally. Early detection and treatment of this condition is vital to prevent complications. However, hypertension often goes undetected, and even if detected, not every patient receives adequate treatment. Identifying simple and effective interventions is therefore crucial to fight this problem and allow more patients to receive the treatment they need. Therefore, we aim at investigating the impact of a population-based blood pressure (BP) screening and the subsequent "low-threshold" information treatment on long-term cardiovascular disease (CVD) morbidity and mortality.

METHODS AND FINDINGS

We examined the impact of a BP screening embedded in a population-based cohort study in Germany and subsequent personalized "light touch" information treatment, including a hypertension diagnosis and a recommendation to seek medical attention. We pooled four waves of the KORA study, carried out between 1984 and 1996 (N = 14,592). Using a sharp multivariate regression discontinuity (RD) design, we estimated the impact of the information treatment on CVD mortality and morbidity over 16.9 years. Additionally, we investigated potential intermediate outcomes, such as hypertension awareness, BP, and behavior after 7 years. No evidence of effect of BP screening was observed on CVD mortality (hazard ratio (HR) = 1.172 [95% confidence interval (CI): 0.725, 1.896]) or on any (fatal or nonfatal) long-term CVD event (HR = 1.022 [0.636, 1.641]) for individuals just above (versus below) the threshold for hypertension. Stratification for previous self-reported diagnosis of hypertension at baseline did not reveal any differential effect. The intermediate outcomes, including awareness of hypertension, were also unaffected by the information treatment. However, these results should be interpreted with caution since the analysis might not be sufficiently powered to detect a potential intervention effect.

CONCLUSIONS

The study does not provide evidence of an effect of the assessed BP screening and subsequent information treatment on BP, health behavior, or long-term CVD mortality and morbidity. Future studies should consider larger datasets to detect possible effects and a shorter follow-up for the intermediate outcomes (i.e., BP and behavior) to detect short-, medium-, and long-term effects of the intervention along the causal pathway.

Aging and hypertension among the global poor-Panel data evidence from Malawi

Hypertension is a rapidly growing disease burden among older persons in low-income countries (LICs) that is often inadequately diagnosed and treated. Yet, most LIC research on hypertension is based on cross-sectional data that does not allow inferences about the onset or persistence of hypertension, its correlates, and changes in hypertension as individuals become older. The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) is used to provide among the first panel analyses of hypertension for older individuals in a sub-Saharan LIC using blood pressure measurements obtained in 2013 and 2017. We find that high blood pressure is very common among mature adults aged 45+, and hypertension is more prevalent among older as compared to middle-aged respondents. Yet, in panel analyses for 2013-17, we find no increase in the prevalence of hypertension as individuals become older. Hypertension often persists over time, and the onset of hypertension is predicted by factors such as being overweight/obese, or being in poor physical health. Otherwise, however, hypertension has few socioeconomic predictors. There is also no gender differences in the level, onset or persistence in hypertension. While hypertension is associated with several negative health or socioeconomic consequences in longitudinal analyses, cascade-of-care analyses document significant gaps in the diagnosis and treatment of hypertension. Overall, our findings indicate that hypertension and related high cardiovascular risks are widespread, persistent, and often not diagnosed or treated in this rural sub-Saharan population of older individuals. Prevalence, onset and persistence of hypertension are common across all subgroups-including, importantly, both women and men. While age is an important predictor of hypertension risk, even in middle ages 45-55 years, hypertension is already widespread. Hypertension among adults aged 45+ in Malawi is thus more similar to a "generalized epidemic" than in high-income countries where cardiovascular risk has strong socioeconomic gradients.

Preliminary Acceptability of a Home-Based Peripheral Blood Collection Device for Viral Load Testing in the Context of Analytical Treatment Interruptions in HIV Cure Trials: Results from a Nationwide Survey in the United States

Frequent viral load testing is necessary during analytical treatment interruptions (ATIs) in HIV cure-directed clinical trials, though such may be burdensome and inconvenient to trial participants. We implemented a national, cross-sectional survey in the United States to examine the acceptability of a novel home-based peripheral blood collection device for HIV viral load testing. Between June and August 2021, we distributed an online survey to people with HIV (PWH) and community members, biomedical HIV cure researchers and HIV care providers. We performed descriptive analyses to summarize the results. We received 73 survey responses, with 51 from community members, 12 from biomedical HIV cure researchers and 10 from HIV care providers. Of those, 51 (70%) were cisgender men and 50 (68%) reported living with HIV. Most (>80% overall) indicated that the device would be helpful during ATI trials and they would feel comfortable using it themselves or recommending it to their patients/participants. Of the 50 PWH, 42 (84%) indicated they would use the device if they were participating in an ATI trial and 27 (54%) also expressed a willingness to use the device outside of HIV cure studies. Increasing sensitivity of viral load tests and pluri-potency of the device (CD4 count, chemistries) would augment acceptability. Survey findings provide evidence that viral load home testing would be an important adjunct to ongoing HIV cure-directed trials involving ATIs. Survey findings may help inform successful implementation and uptake of the device in the context of personalized HIV care.

Pitfalls of Single Measurement Screening for Diabetes and Hypertension in Community-Based Settings

Background:

Cross-sectional screening programs are used to detect and refer individuals with non-communicable diseases to healthcare services. We evaluated the positive predictive value of cross-sectional measurements for Diabetes Mellitus (DM) and hypertension (HTN) as part of a community-based disease screening study, ‘Vukuzazi’ in rural South Africa.

Methods:

We conducted community-based screening for HTN and DM using the World Health Organization STEPS protocol and glycated haemoglobin A1c (HbA1c) testing, respectively. Nurses conducted follow-up home visits for confirmatory diagnostic testing among individuals with a screening BP above 140/90 mmHg and/or HbA1c above 6.5% at the initial screen, and without a prior diagnosis. We assessed the positive predictive value of the initial screening, compared to the follow up measure. We also sought to identify a screening threshold for HTN and DM with greater than 90% positive predictive value.

Results:

Of 18,027 participants enrolled, 10.2% (1,831) had a screening BP over 140/90 mmHg. Of those without a prior diagnosis, 871 (47.6%) received follow-up measurements. Only 51.2% (451) of those with completed follow-up measurements had a repeat BP>140/90 mmHg at the home visit and were referred to care. To achieve a 90% correct referral rate, a systolic BP threshold of 192 was needed at first screening. For DM screening, 1,615 (9.0%) individuals had an HbA1c > 6.5%, and of those without a prior diagnosis, 1,151 (71.2%) received a follow-up blood glucose. Of these, only 34.1% (395) met criteria for referral for DM. To ensure a 90% positive predictive value i.e. a screening HbA1c of >16.6% was needed.

Conclusions:

A second home-based screening visit to confirm a diagnosis of DM and HTN reduced health system referrals by 48% and 66%, respectively. Two-day screening programmes for DM and HTN screening might save individual and healthcare resources and should be evaluated carefully in future cost effectiveness evaluations.

Global interventions in hypertension: new and emerging concepts

PURPOSE OF REVIEW

Hypertension (HTN) is the most prevalent risk factor for cardiovascular disease (CVD) worldwide, affecting 1.39 billion people. This review discusses recent literature regarding the global burden of HTN and emerging concepts in prevalence, treatment, and control in different regions around the globe.

RECENT FINDINGS

Community-based interventions and telemedicine may be useful in increasing access to care and identifying/assisting patients with HTN, especially in populations with geographical and economic barriers to healthcare. Home blood pressure monitoring is beneficial for HTN control in diverse regions. Polypills have proven benefits to decrease HTN and CVD risk. Continuation of treatment with angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers in high risk COVID-19 patients appears appropriate.

SUMMARY

Extensive research demonstrates that early screening/treatment, lifestyle modification, and pharmacotherapy are essential to control HTN worldwide. This review highlights recent research and novel concepts on effective interventions being used globally.

Variation in the Proportion of Adults in Need of Blood Pressure-Lowering Medications by Hypertension Care Guideline in Low- and Middle-Income Countries: A Cross-Sectional Study of 1 037 215 Individuals From 50 Nationally Representative Surveys

BACKGROUND

Current hypertension guidelines vary substantially in their definition of who should be offered blood pressure-lowering medications. Understanding the effect of guideline choice on the proportion of adults who require treatment is crucial for planning and scaling up hypertension care in low- and middle-income countries.

METHODS

We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults 30 to 70 years of age from nationally representative surveys in 50 low- and middle-income countries (N = 1 037 215). We aimed to determine the effect of hypertension guideline choice on the proportion of adults in need of blood pressure-lowering medications. We considered 4 hypertension guidelines: the 2017 American College of Cardiology/American Heart Association guideline, the commonly used 140/90 mm Hg threshold, the 2016 World Health Organization HEARTS guideline, and the 2019 UK National Institute for Health and Care Excellence guideline.

RESULTS

The proportion of adults in need of blood pressure-lowering medications was highest under the American College of Cardiology/American Heart Association, followed by the 140/90 mm Hg, National Institute for Health and Care Excellence, and World Health Organization guidelines (American College of Cardiology/American Heart Association: women, 27.7% [95% CI, 27.2-28.2], men, 35.0% [95% CI, 34.4-35.7]; 140/90 mm Hg: women, 26.1% [95% CI, 25.5-26.6], men, 31.2% [95% CI, 30.6-31.9]; National Institute for Health and Care Excellence: women, 11.8% [95% CI, 11.4-12.1], men, 15.7% [95% CI, 15.3-16.2]; World Health Organization: women, 9.2% [95% CI, 8.9-9.5], men, 11.0% [95% CI, 10.6-11.4]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood pressure-lowering medications were largest in the oldest (65-69 years) age group (American College of Cardiology/American Heart Association: women, 60.2% [95% CI, 58.8-61.6], men, 70.1% [95% CI, 68.8-71.3]; World Health Organization: women, 20.1% [95% CI, 18.8-21.3], men, 24.1.0% [95% CI, 22.3-25.9]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood pressure-lowering medicines, whereas the South and Central Americas had the lowest.

CONCLUSIONS

There was substantial variation in the proportion of adults in need of blood pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policy makers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.