Cardiovascular Disease Healthcare Utilization in Sub-Saharan Africa: A Scoping Review

Geographical, sex, and socioeconomic differences in non-communicable disease indicators: A cross-sectional survey in Eastern Uganda

The prevalence of non-communicable diseases (NCDs) is increasing in many low- and middle-income countries (LMICs). This study examined differences in the burden of NCDs and their risk factors according to geographic, sex, and sociodemographic characteristics in a rural and peri-urban community in Eastern Uganda. We compared the prevalence by sex, location, wealth, and education. Unadjusted and adjusted prevalence ratios (PR) were reported. Indicators related to tobacco use, alcohol use, salt consumption, fruit/vegetable consumption, physical activity, body weight, and blood pressure were assessed. Among 3220 people (53.3% males, mean age: 35.3 years), the prevalence of NCD burden differed by sex. Men had significantly higher tobacco (e.g., current smoking: 7.6% vs. 0.7%, adjusted PR (APR): 12.8, 95% CI: 7.4-22.3), alcohol use (e.g., current drinker: 11.1% vs. 4.6%, APR: 13.4, 95% CI: 7.9-22.7), and eat processed food high in salt (13.4% vs. 7.1, APR: 1.8, 95% CI: 1.8, 95% CI: 1.4-2.4) than women; however, the prevalence of overweight (23.1% vs 30.7%, APR: 0.7, 95% CI: 0.6-0.9) and obesity (4.1% vs 14.7%, APR: 0.3, 95% CI: 0.2-0.3) was lower among men than women. Comparing locations, peri-urban residents had a higher prevalence of current alcohol drinking, heavy episodic drinking, always/often adding salt while cooking, always eating processed foods high in salt, poor physical activity, obesity, prehypertension, and hypertension than rural residents (p<0.5). When comparing respondents by wealth and education, we found people who have higher wealth or education had a higher prevalence of always/often adding salt while cooking, poor physical activity, and obesity. Although the findings were inconsistent, we observed significant sociodemographic and socioeconomic differences in the burden of many NCDs, including differences in the distributions of behavioral risk factors. Considering the high burden of many risk factors, we recommend appropriate prevention programs and policies to reduce these risk factors' burden and future negative consequences.

Improving acute myocardial infarction care in northern Tanzania: barrier identification and implementation strategy mapping

BACKGROUND

Evidence-based care for acute myocardial infarction (AMI) reduces morbidity and mortality. Prior studies in Tanzania identified substantial gaps in the uptake of evidence-based AMI care. Implementation science has been used to improve uptake of evidence-based AMI care in high-income settings, but interventions to improve quality of AMI care have not been studied in sub-Saharan Africa.

METHODS

Purposive sampling was used to recruit participants from key stakeholder groups (patients, providers, and healthcare administrators) in northern Tanzania. Semi-structured in-depth interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview transcripts were coded to identify barriers to AMI care, using the 39 CFIR constructs. Barriers relevant to emergency department (ED) AMI care were retained, and the Expert Recommendations for Implementing Change (ERIC) tool was used to match barriers with Level 1 recommendations for targeted implementation strategies.

RESULTS

Thirty key stakeholders, including 10 patients, 10 providers, and 10 healthcare administrators were enrolled. Thematic analysis identified 11 barriers to ED-based AMI care: complexity of AMI care, cost of high-quality AMI care, local hospital culture, insufficient diagnostic and therapeutic resources, inadequate provider training, limited patient knowledge of AMI, need for formal implementation leaders, need for dedicated champions, failure to provide high-quality care, poor provider-patient communication, and inefficient ED systems. Seven of these barriers had 5 strong ERIC recommendations: access new funding, identify and prepare champions, conduct educational meetings, develop educational materials, and distribute educational materials.

CONCLUSIONS

Multiple barriers across several domains limit the uptake of evidence-based AMI care in northern Tanzania. The CFIR-ERIC mapping approach identified several targeted implementation strategies for addressing these barriers. A multi-component intervention is planned to improve uptake of evidence-based AMI care in Tanzania.

Effect of prior tuberculosis on cardiovascular status in perinatally HIV-1-infected adolescents

Whether, and how, co-occurring HIV-1 infection (HIV) and tuberculosis (TB) impact cardiovascular status, especially in adolescents with perinatally acquired HIV (APHIV), have not been examined. We hypothesized that APHIV with previous active TB have worse cardiac efficiency than APHIV without TB, which is mediated by increased inflammation. Arterial elastance (Ea) and ventricular end-systolic elastance (Ees) were assessed by cardiovascular magnetic resonance, and ventriculoarterial coupling (VAC) estimated as Ea/Ees ratio. Inflammation was measured by high sensitivity C-reactive protein (hsCRP). Previous TB in APHIV was associated with reduced cardiac efficiency, related to an altered ventriculoarterial coupling. However, we did not find evidence of hsCRP mediated effects in the association between prior TB and cardiac efficiency. The clinical significance of these findings requires further study, including a wider range of biomarkers of specific immune pathways.

A quantitative comparison of essential cardiovascular medicines from countries in the Southern African Development Community to the WHO model essential medicines list

BACKGROUND

Globally, cardiovascular disease (CVD) is a leading cause of death and disproportionately affects low- and middle-income countries (LMICs). The WHO Model List of Essential Medicines (WHO EML) is a tool for improving accessibility and availability of medicines. This study compared the 2021 WHO EML CVDs basket of medicines with latest available national essential medicines list (NEMLs) for South Africa and 15 Southern African Development Community (SADC) countries to assess consistency in CVDs medicine listing.

METHODS

This descriptive, desktop review study compared SADC NEMLs. A comparator list was extracted by combining cardiovascular medicines listed in the 2021 WHO EML for adults and children. SADC country NEMLs were obtained from the WHO Essential Medicines and Health Products Information Portal. Consistency of NEMLs was calculated as a percentage coverage of CVD medicines listed in the 2021 WHO EML. SA hospital and primary health care (PHC) level NEMLs were included as separate formularies.

RESULTS

The SA hospital level NEML scored 70% consistency with the 2021 WHO EML. Tanzania (84%), Namibia (81%) and Angola (79%) scored the highest consistency. The mean consistency for SADC NEMLs was 66%. The lowest scoring country was Eswatini at 26%. The SA PHC NEML scored 35%. The least listed medicines were beta-blockers, angiotensin receptor blockers (ARBs), clopidogrel (43%) and paediatric formulations (furosemide (21%); digoxin (43%)). Individual antihypertensive medicines were most commonly listed. Botswana and Lesotho were the only countries to list a single pill combination (SPC) for the treatment of hypertension.

CONCLUSIONS

This comparison indicates that South Africa and most SADC countries are aligned with 2021 WHO EML recommendations. The inclusion of age-appropriate formulations for children as well as ARBs and SPC for the treatment of hypertension may improve patient adherence and cardiovascular outcomes in these countries. More frequent updates to NEMLs should improve consistency. NEMLs were not available for two countries, and these therefore did not form part of this study. Country health expenditure in ranking the consistency of NEMLs was not accounted for. LMICs adopting the essential medicine list strategy should consider imposing minimum consistency thresholds to the WHO EML to improve accessibility and availability of CVD medicines.

TRIAL REGISTRATION

Not applicable.

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.

Facilitators and barriers in prevention of cardiovascular disease in Limpopo, South Africa: a qualitative study conducted with primary health care managers

Background

In the Southern African countries, cardiovascular disease burden is increasing and the second most prevalent cause of death after infectious diseases. The sustainable primary prevention of cardiovascular disease is associated with the engagement of facilitators that support it and hindered by barriers that undermine the support of a healthy lifestyle at the community level. The purpose of the study was to investigate facilitators and barriers at the level of primary health care facilities, on prevention of cardiovascular disease in Limpopo Province of South Africa.

Methods

This study is an exploratory and descriptive qualitative design, where open-ended key informant interviews were conducted among 20 primary health care managers conveniently sampled in their respective health care facilities. Coding and analysis were done using the thematic analysis method with the assistance of Atlas ti qualitative software.

Results

Various facilitators for the prevention of CVD were identified in this study. One of such facilitators is the availability and adherence to CVD treatment guidelines in the district. Other facilitators included top-down health education programme; collaboration with schools, traditional and religious leaders; the use of modern technology; and a structured healthcare system. Barriers were also identified as poor infrastructural development; shortage of medical supplies and equipment; lack of health promotion activities; shortage of nurses and other health care personnel; and poor accessibility to primary health care services.

Conclusion

This study has identified barriers and facilitators that may be harnessed to improve cardiovascular disease prevention, care, and management in a rural setting in South Africa. The facilitators should be strengthened, and barriers identified redressed.

Trial registration number: REC-0310111-031.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02290-1.

An Overview of Vascular Dysfunction and Determinants: The Case of Children of African Ancestry

The balance between dilatory and constrictive factors is important as it keeps blood vessels in a homeostatic state. However, altered physiological processes as a result of obesity, hypertension, oxidative stress, and other cardiovascular risk factors may lead to vascular damage, causing an imbalance of vasoactive factors. Over time, the sustained imbalance of these vasoactive factors may lead to vascular dysfunction, which can be assessed by non-invasive methods, such as flow-mediated dilation, pulse wave velocity, flow-mediated slowing, retinal vessel analysis, peripheral vascular reactivity, and carotid intima-media thickness assessment. Although there is increasing prevalence of cardiovascular risk factors (obesity and hypertension) in children in sub-Saharan Africa, little is known about how this may affect vascular function. This review focuses on vasoactive factors implicated in vascular (dys)function, highlighting the determinants and consequences of vascular dysfunction. It further describes the non-invasive methods used for vascular (dys)function assessments and, last, describes the impact of cardiovascular risk factors on vascular dysfunction in children of African ancestry.

Why do We Know So Much and Yet So Little? A Scoping Review of Willingness to Pay for Human Excreta Derived Material in Agriculture

Challenges associated with rapid population growth, urbanization, and nutrient mining have seen increased global research and development towards ‘waste to wealth’ initiatives, circular economy models, and cradle-to-cradle waste management principles. Closing the nutrient loop through safe recovery and valorization of human excreta for agricultural use may provide a sustainable method of waste management and sanitation. Understanding the market demand is essential for developing viable waste management and sanitation provision business models. The pathways and processes for the safe recovery of nutrients from human excreta are well-documented. However, only anecdotal evidence is available on the willingness to pay for human excreta-derived material in agriculture. This review closes this gap by identifying and synthesizing published evidence on farmers’ willingness to pay for human excreta-derived material for agricultural use. The Scopus and Web of Science search engines were used to search for the literature. The search results were screened, and the data were extracted, charted, and synthesized using the DistillerSR web-based application. The findings show that understanding willingness to pay for human excreta-derived material is still a nascent and emerging research area. Gender, education, and experience are common factors that influence the farmers’ willingness to pay. The findings show that pelletization, fortification, labeling, packaging, and certification are essential attributes in product development. The wide-scale commercialization can be achieved through incorporation of context-specific socioeconomic, religious and cultural influences on the estimation of willingness to pay. Promoting flexible legislation procedures, harmonization of regional legislations, and creating incentives for sustainable waste recovery and reuse may also promote the commercialization of circular nutrient economy initiatives. More empirical studies are required to validate willingness to pay estimates, especially using the best practice for conducting choice experiments.

Cardiovascular disease prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda

Background

With the growing epidemic of Cardiovascular Disease (CVD) in sub-Saharan Africa, behavioural change interventions are critical in supporting populations to achieve better cardiovascular health. Population knowledge regarding CVD is an important first step for any such interventions. This study examined CVD prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda.

Methods

The study was cross-sectional in design conducted among adults aged 25 to 70 years as part of the baseline assessment by the Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa (SPICES) – project. Data were collected using pretested semi-structured questionnaires, and respondents categorized as knowledgeable if they scored at least five out of six in the knowledge questions. Data were exported into STATA version 15.0 statistical software for analysis conducted using mixed-effects Poisson regression with fixed and random effects and robust standard errors.

Results

Among the 4372 study respondents, only 776 (17.7%) were knowledgeable on CVD prevention. Most respondents were knowledgeable about foods high in calories 2981 (68.2%), 2892 (66.1%) low fruit and vegetable intake and high salt consumption 2752 (62.9%) as CVD risk factors. However, majority 3325 (76.1%) thought the recommended weekly moderate physical activity was 30 min and half 2262 (51.7%) disagreed or did not know that it was possible to have hypertension without any symptoms. Factors associated with high CVD knowledge were: post-primary education [APR = 1.55 (95% CI: 1.18–2.02), p = 0.002], formal employment [APR = 1.69 (95% CI: 1.40–2.06), p < 0.001] and high socio-economic index [APR = 1.35 (95% CI: 1.09–1.67), p = 0.004]. Other factors were: household ownership of a mobile phone [APR = 1.35 (95% CI: 1.07–1.70), p = 0.012] and ever receiving advice on healthy lifestyles [APR = 1.38 (95% CI: 1.15–1.67), p = 0.001].

Conclusions

This study found very low CVD knowledge with major gaps around recommended physical activity duration, diet and whether hypertension is asymptomatic. Observed knowledge gaps should inform suitable interventions and strategies to equip and empower communities with sufficient information for CVD prevention.

Trial registration

ISRCTN Registry ISRCTN15848572, January 2019, retrospectively registered.

Associations of Neighborhood Walkability with Sedentary Time in Nigerian Older Adults

Previous studies have investigated the potential role of neighborhood walkability in reducing sedentary behavior. However, the majority of this research has been conducted in adults and Western developed countries. The purpose of the present study was to examine associations of neighborhood environmental attributes with sedentary time among older adults in Nigeria. Data from 353 randomly-selected community-dwelling older adults (60 years and above) in Maiduguri, Nigeria were analyzed. Perceived attributes of neighborhood environments and self-reported sedentary time were assessed using Nigerian-validated and reliable measures. Outcomes were weekly minutes of total sedentary time, minutes of sitting on a typical weekday, and minutes of sitting on a typical weekend day. In multivariate regression analyses, higher walkability index, proximity to destinations, access to services, traffic safety, and safety from crime were associated with less total sedentary time and sedentary time on both a weekday and a weekend day. Moderation analysis showed that only in men was higher walking infrastructure and safety found to be associated with less sedentary time, and higher street connectivity was associated with more sedentary time. The findings suggest that improving neighborhood walkability may be a mechanism for reducing sedentary time among older adults in Nigeria.