Awareness, treatment and control of hypertension in Hargeisa, Somaliland

doi:10.21203/rs.3.rs-4978124/v1

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Awareness, treatment and control of hypertension in Hargeisa, Somaliland

https://doi.org/10.21203/rs.3.rs-4978124/v1

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Objective

To assess whether and to what extent hypertension is treated and controlled and to determine risk factors for uncontrolled hypertension among adult patients seeking care at Hargeisa group hospital in Hargeisa, Somaliland.

Methods

We conducted a health facility-based cross-sectional study on 324 patients, aged 18 years and older, at the main referral hospital of Hargeisa, Somaliland. We used a modified WHO STEPS questionnaire to obtain patient information from June 13 to August 15, 2022. We followed a cascade of care approach to analyse the care of hypertension. We applied logistic regression to assess the association between risk factors and uncontrolled hypertension.

Results

There was a high awareness of hypertension among outpatients, as 91.7% (95% confidence interval (CI); 82.1–96.5) knew their condition. Among patients being aware of hypertension, 92.4% (95% CI; 82.5–97.2%) were on treatment for blood pressure control. Only 9.8% (95% CI; 4.1–20.9%) of the patients under treatment had their blood pressure level under control. Results from logistic regression model showed that individuals aged above 64 years, females, those who consumed Khat, those who were obese and those with hypercholesterolaemia had higher odds of uncontrolled blood pressure.

Conclusion

Our results suggest that nine out of ten outpatients in Hargeisa, Somaliland, who were on hypertension treatment, did not reach treatment goals. This considerable gap in blood pressure control is likely to increase the risk of complications such as cardiovascular diseases including heart failure, renal failure and stroke. Hence, there is a pressing need to implement control programme in Somaliland.

Awareness

control

diagnosis

hypertension

treatment

Globally, hypertension is estimated to have caused 7.86 million deaths (95% confidence interval (CI): 6.89–8.82 million deaths) and contributed 146 million disability-adjusted life years (DALYs) (95% CI: 130–162 million DALYs) worldwide in 2019 (1). Overall, low- and middle-income countries (LMICs) have both the highest number of people with, and the highest prevalence of, hypertension (2–4). According to data put forth by the World Health Organization (WHO), the prevalence of hypertension is highest in the African region with 27% compared to other regions (5). As LMICs have weak health systems, the proportion of undiagnosed, untreated and uncontrolled hypertension might be seriously underestimated compared to high-income countries (HICs) (2, 6–8).

The increasing incidence of hypertension, coupled with low level of blood pressure control paving the way for dire complications of uncontrolled hypertension, has important ramifications not only on health, but also for social and economic development (9, 10). Patients with hypertension in LMICs encounter prohibitively expensive care that might lead to catastrophic expenditures pushing patients and their families into dependency and impoverishment (11). Indeed, patients and families also spend substantial amounts of their income on hospitalization and patient care due to recurrent and chronic morbidities associated with uncontrolled hypertension such as heart failure, renal failure and stoke.

A growing body of epidemiologic evidence suggests that there are a number of modifiable risk factors, including obesity, unhealthy dietary habits, physical inactivity, low socio-economic status, and Khat consumption (12–25). Modifying these factors is crucial for primary prevention and early-stage hypertension management. However, it may be more challenging for severe hypertension cases. These risk factors increase the proportion of hypertensive patients who do not reach their required target blood pressure levels while on treatment, which is termed as “uncontrolled hypertension”. Of note, uncontrolled hypertension is the leading attributable risk factor for cardiovascular diseases (CVD). Individual behaviour modifications and adequate use of anti-hypertensive medications, to achieve optimal blood pressure control, is essential for CVD risk reduction (26, 27).

In Somaliland, the 2020 Somaliland Health and Demographic Survey (SLHDS) report showed that among household members who reported a physician-diagnosed chronic disease, only 3.1% of males and 3.9% of females were on treatment (28). However, the report did not mention the rate of control for specific categories of non-communicable diseases (NCDs). To our knowledge, no other study reported the rate of treatment and control of hypertension in Somaliland thus far. Hence, information about the status of treatment and control of hypertension in Somaliland is lacking. The purpose of this paper was to report the gap in treatment and control of hypertension and the underlying risk factors for uncontrolled hypertension among adult patients seeking care at Hargeisa group hospital in Hargeisa, Somaliland.

Study area, design and participants

A detailed description of the study area, participants and methods used, is available elsewhere (29). In brief, a hospital-based cross-sectional study of outpatients who attended the main referral public hospital of Hargeisa, Somaliland, was conducted. A total of 324 adult outpatients were included into the study from June 13 to August 15, 2022. We applied systematic random sampling technique to recruit outpatients into the study. Data were collected using a modified WHO STEPS questionnaire. We followed a cascade of care approach (30, 31) to examine the care of hypertension using the collected data. The cascade of care model determines the proportion of participants in each stage of access to care within the continuum of care, starting with screening (i.e. participants who had their blood pressure measured) and diagnosis (i.e. participants who were told by a doctor or other health professional that they had hypertension), followed by treatment (i.e. participants who were put on blood pressure lowering treatment) and control (i.e. participants who reached the desired blood pressure level while on treatment).

We first identified the number of outpatients whose blood pressure was at or above 140/90 mmHg when their blood pressure was measured at the time of the study. This group was designated as having hypertension. Second, we calculated the number of outpatients who were previously diagnosed by a doctor or other health professional with hypertension. This group was designated as aware of their condition. Third, we subtracted the calculated number of patients who were aware of their condition from those who were identified to have had hypertension. The difference was referred to as the diagnostic gap. Fourth, we determined the number of patients who were taking blood pressure-lowering medications, herbal remedies, or following a prescribed dietary plan. We referred to this group as being on treatment. Fifth, we subtracted the number of patients who were on treatment from those who were aware of their condition. The difference was referred to as the treatment gap. Sixth, we determined the number of patients who achieved the required blood pressure level (< 140/90 mmHg) while on treatment. This group was determined to have controlled their blood pressure. The number of this group was subtracted from the number of those who were on treatment, and the difference was referred to as uncontrolled hypertension.

Definitions of variables

Awareness was defined as being told by a doctor or other health professional that the participant had raised blood pressure or being on pharmacological or non-pharmacological treatment to lower their blood pressure among patients in whom systolic blood pressure (SBP) > 140 or diastolic blood pressure (DBP) > 90 was measured. Treatment of hypertension is defined as being on blood pressure lowering medications, dietary plan or herbal remedies at the time of the study among patients who report a diagnosis of hypertension. Uncontrolled hypertension was defined as having SBP > 140 or DBP > 90 at the time of the study. Participants with uncontrolled hypertension were grouped as being treated or not. Controlled hypertension was defined as being on treatment (pharmacological or otherwise) and having SBP < 140 and DBP < 90. Income is defined as the self-reported amount of money (in US dollars) in response to the question “How much do you earn per month?” Income quantiles were determined from self-reported amount of individual’s monthly income.

Statistical analysis

The characteristics of the study participants were analysed by count data, percentages, mean, and standard deviation, stratified by sex. The proportion of participants who were aware of their condition, receiving treatment, or had controlled blood pressure were determined for each sex and across different age groups. The associations between awareness, treatment and control rates with socio-demographic, behavioral, and biological risk factors were assessed using logistic regression. Furthermore, a subgroup analysis was conducted for participants who had uncontrolled hypertension. To identify the independent predictors of uncontrolled hypertension, logistic regression was used taking into account the interdependency of risk factors and socio-demographic characteristics. All analyses were carried out using R version 4.1.3 and a P-value of less than 0.05 was considered statistically significant.

Characteristics of study participants

Characteristics of the study participants are summarized in Table 1. Of the 324 study participants, 319 had complete data records. There were more males than females (54.2% vs 45.8%). The average age (± standard deviation) of the participants was 40.4 (± 13.7) years. The youngest participant was 20 years while the oldest was 80 years old. Both females and males had similar age distribution patterns. The majority of both females (65.1%) and males (63.5%) were aged between 25 and 44 years. About one-third of females (32.2%) and slightly more than half of males (52.6%) attained secondary school or higher education level. Considering employment status, 32.9% of the females were employed, while the corresponding proportion for males was 66.5%. Regarding marital status, most participants were married with similar proportions for females (68.5%) and for males (68.8%). More than six out of ten (61.8%) earned more than the average reported monthly income.

Table 1

Characteristics of participants in Somaliland, 2022 (N = 319)
Characteristic	Females (n = 146)¹	Males (n = 173)¹
Age (years)
18–24	5 (3.4%)	3 (1.7%)
25–34	55 (37.7%)	62 (35.8%)
35–44	40 (27.4%)	48 (27.7%)
45–54	18 (12.3%)	21 (12.1%)
55–64	19 (13.0%)	19 (11.0%)
≥ 65	9 (6.2%)	20 (11.6%)
Marital status
Single	29 (19.9%)	50 (28.9%)
Married	100 (68.5%)	119 (68.8%)
Divorced	17 (11.6%)	4 (2.3%)
Educational attainment
No schooling	91 (62.3%)	75 (43.4%)
Primary	8 (5.5%)	7 (4.0%)
Secondary	19 (13.0%)	32 (18.5%)
Tertiary	28 (19.2%)	59 (34.1%)
Employment status
Employed	48 (33.1%)	115 (66.9%)
Unemployed	97 (66.9%)	57 (33.1%)
Income quantile
Low	54 (37.0%)	32 (18.5%)
Lower middle	51 (34.9%)	60 (34.7%)
Upper middle	32 (21.9%)	59 (34.1%)
High	9 (6.2%)	22 (12.7%)
Smoking	0 (0.0%)	52 (30.1%)
Khat consumption	0 (0.0%)	65 (37.6%)
Hypertension²	29 (19.9%)	43 (24.9%)
Diabetes²	20 (13.7%)	10 (5.8%)
Raised cholesterol²	20 (13.7%)	23 (13.3%)
Systolic blood pressure	121.3 ± 17.3	123.0 ± 16.3
Diastolic blood pressure	77.8 ± 14.3	79.6 ± 13.1
Body mass index
Underweight	0 (0.0%)	2 (1.2%)
Optimal weight	70 (47.9%)	140 (80.9%)
Overweight	68 (46.6%)	29 (16.8%)
Obese	8 (5.5%)	2 (1.2%)
Blood Pressure level³
Normal	116 (79.5%)	135 (78.0%)
High-normal	7 (4.8%)	4 (2.3%)
Grade 1 hypertension	16 (11.0%)	27 (15.6%)
Grade 2 hypertension	7 (4.8%)	7 (4.0%)
Frequency (%); mean ± standard deviation ² Hypertension, diabetes and raised cholesterol were self-reported ³ Blood pressure level was determined from blood pressure measured at the time of the study and the classification flows the recommendations of International Society of Hypertension (ISH)

Table 1 ………… to be inserted here.

Prevalence and distribution of awareness, treatment and control of hypertension

Seventy-two (22.5%) participants had hypertension. Among the hypertensive participants, awareness, treatment and control rates were 91.7% (95% CI; 82.1–96.6%), 84.7% (95% CI; 73.9–91.8%) and 8.3% (95% CI; 3.4–17.9%), respectively. Among the aware participants, 92.4% (95% CI; 82.5–97.2%) were under treatment for BP control. While only 9.8% (95% CI; 4.1–20.9%) of the participants who were under treatment had their blood pressure under control (Fig. 1).

Figure 1 ………… to be inserted here.

Among the hypertensive participants, there were six newly diagnosed individuals and 84.7% (61/72) were on blood pressure lowering treatments. Of these, 79.2% (57/72) were on anti-hypertensive medications. In addition, 15.3% (11/72) used medications along with blood pressure lowering dietary plan, another 15.3% (11/72) used herbal remedies along with medications and 33.3% (24/72) were on all three types of regimens (medications, dietary plan and herbal remedies). Another five individuals had no treatment regimen (neither medications, nor dietary plan nor herbal remedies). Furthermore, only one participant reported to have used herbal remedies only and another participant reported to have had dietary plan only (Fig. 2).

Figure 2 ………… to be inserted here.

Figure 3 shows the proportion of participants who were aware, treated and controlled their blood pressure, stratified by sex and age. The proportion of awareness and treatment increased with age, but the proportion of hypertension control did not correlate with age. The overall rates of awareness and treatment were higher in males (23.1% and 20.8%, respectively) than in females (17.8% and 17.1%, respectively). Similarly, the rates of awareness and treatment were higher in males than in females in each age group, except the 35 to 44 year age group. However, the difference was not statistically significant.

Regarding the control of hypertension, older participants (aged 65 and above) have had higher rates of blood pressure control compared to younger age groups in both sexes. Overall rate of control was also higher in males than in females in all age groups. This difference was not statistically significant.

Figure 3 ………… to be inserted here.

Factors associated with awareness, treatment and control of hypertension

The results from three logistic regression models were shown in an additional table file (see Additional file 1). Models I, II and III display how selected factors were associated with awareness, treatment and control of hypertension, respectively. Model I indicates that low educational attainment, diabetes, obesity and hypercholesterolaemia significantly increased the rate of awareness. The association of awareness with the rest of the variables was not statistically significant. Model II indicates no evidence of any association between treatment of hypertension and the selected variables. Model III shows that participants with diabetes and participants with hypercholesterolaemia were 9 times and 7 times more likely to have had their blood pressure under control, respectively.

Uncontrolled hypertension

Overall, 91.7% (95% CI; 82.1–96.6%) of hypertensive participants had uncontrolled hypertension and 90.2% (95% CI; 79.1–95.9%) of the participants who were taking any treatment regimen to lower their blood pressure did not reach the targeted blood pressure level. Table 2 shows the characteristics of participants with uncontrolled hypertension. Among females who had not had their blood pressure under control, slightly over one-fourth were older than 64 years. Among their male counterparts, more than half were older than 64 years.

Table 2

Characteristics of hypertensive patients with uncontrolled blood pressure in Somaliland, 2022 (N = 66)
Characteristic	Female (N = 29)¹	Male (N = 37)¹
Age
≤ 64	21 (72.4%)	18 (48.6%)
> 64	8 (27.6%)	19 (51.4%)
Educational attainment
No schooling	24 (82.8%)	35 (94.6%)
Primary	2 (6.9%)	1 (2.7%)
Secondary	2 (6.9%)	0 (0.0%)
Tertiary	1 (3.4%)	1 (2.7%)
Employment status
Employed	8 (27.6%)	16 (43.2%)
Unemployed	21 (72.4%)	21 (56.8%)
Wealth quantile
Low	9 (31.0%)	7 (18.9%)
Lower middle	9 (31.0%)	14 (37.8%)
Upper middle	9 (31.0%)	11 (29.7%)
High	2 (6.9%)	5 (13.5%)
Smoking	0 (0.0%)	30 (81.1%)
Khat consumption	0 (0.0%)	33 (89.2%)
Diabetes	9 (31.0%)	6 (16.2%)
Raised cholesterol	15 (51.7%)	20 (54.1%)
Systolic blood pressure	149.2 ± 17.8	149.7 ± 12.7
Diastolic blood pressure	101.3 ± 10.9	100.4 ± 8.4
Obesity	7 (24.1%)	1 (2.7%)
¹Frequency (%); Mean ± Standard deviation

For both sexes, most of the participants who did not have their blood pressure under control were not schooled and were unemployed. In addition, the majority of participants with uncontrolled hypertension belonged to the second and third quartiles of income distribution in both sexes.

Among participants who did not have their blood pressure under control, 81.1% smoked and 89.2% consumed Khat among males. None of the females reported to have ever smoked nor consumed Khat.

Regarding comorbidities, among the participants who did not have their blood pressure under control, diabetes and obesity were more prevalent in females than males, while hypercholesterolaemia was slightly more prevalent in males than females (54.1% vs 51.7%).

Table 2 ………… to be inserted here.

Risk factors for uncontrolled hypertension

Figure 4 illustrates the outcome of a logistic regression analysis on the proportion of uncontrolled hypertension, taking into account all the factors depicted in the figure. Factors such as being older than 64 years (adjusted OR = 7.14; 95% CI: 2.18–26.53, p = 0.002), being female (adjusted OR = 6.65; 95% CI: 1.23–66.07, p = 0.055), consuming Khat (adjusted OR = 24.88; 95% CI: 3.49–269.65, p = 0.003), being obese (adjusted OR = 9.23; 95% CI: 1.56 − 57.43, p = 0.014) and having hypercholesterolaemia (adjusted OR = 6.85; 95% CI: 2.64–18.14, p < 0.001) were associated with a higher odds of uncontrolled blood pressure.

Figure 4 …….. to be inserted here.

We observed a very high rate of uncontrolled hypertension (91.8% of patients on treatment) among outpatients seeking care at the main referral hospital in Hargeisa, Somaliland, despite the fact that large proportion of the studied population were aware of their raised blood pressure. In addition, we found that a large proportion of participants were on blood pressure lowering medications, prescribed diet or herbal remedies to control their blood pressure. Our findings suggest that this outpatient population potentially has an increased risk for dreadful consequences of uncontrolled hypertension, including heart failure, renal failure and stroke (7). Our findings thus highlight the need for strategies to control blood pressure in this population and early preventive measures to cardiovascular events (32, 33). Screening efforts to improve diagnosis and treatment of hypertension are potentially very important to improve control (34).

As no previous study was conducted on the control and treatment of hypertension in Somaliland, we compared our findings with results from studies conducted elsewhere in Africa and across the globe. Most of the studies that reported awareness, treatment and control in Africa mainly reported from national level estimates or surveys (30, 35–42). Only few health-facility based studies that used a similar approach as reported here could be located. Hence, caution is indicated when comparing and generalising results. Our study in Somaliland has shown a higher prevalence of awareness and treatment than most of the previous studies conducted elsewhere. However, the rate of blood pressure control in our study was far lower than what was reported in most of the previous studies. A potential explanation is that patients who seek care at referral hospital are a selected group of people who have high self-awareness or may have other underlying conditions that could have contributed to their conditions.

The prevalence of awareness in our study among hypertensive patients was 91.7%. In our population sample, six (8.3%) new hypertensive patients who did not receive previous diagnosis were detected in this study, which represents a relatively low diagnostic gap. On the other hand, neither life style modification nor antihypertensive treatment was reported by any of the five individuals who were aware of their elevated blood pressure. Limited trust of some patients to the existing health care system, as the main providers in Somaliland are the private pharmacies and clinics, is a possible explanation for the hesitancy to treatment.

Noteworthy is the high rate of uncontrolled hypertension among participants who were aware of their condition. The prevalence of uncontrolled hypertension in our study (77.8%) was considerably higher than that which was reported from a hospital-based cross-sectional study (52.5%) (15) and a pooled prevalence of uncontrolled hypertension in Ethiopia (48%) (43). It was also higher than that reported from Kenya (33.4%) (44), Sudan (36.0%) (45) and Tanzania (29.9%) (46). Our findings corroborate with the results of a scoping review on the magnitude of uncontrolled hypertension in East Africa (88.5%) (47) and a systematic review and meta-analysis of hypertension control in the Middle East and North Africa (81.0%) (48).

Suboptimal control of hypertension is not only a challenge to LMICs but high rates of patients in high-income countries (HICs) also reported to have had uncontrolled hypertension. For example, a study in Switzerland revealed that about 82% of patients with doctor-diagnosed hypertension have had treatment prescribed and only 40% of the cases kept their blood pressure within the target range (49). On another note, a systematic review on the disparities of hypertension control in both HICs and LMICs showed that the rate of uncontrolled hypertension was higher in LMICs than in HICs (50). Poor blood pressure control may have resulted from insufficient public health interventions, lack of hypertension management guidelines, unaffordable cost of medications, unrealistic expectations of treatment, lack of knowledge of lifestyle modifications, limited access to quality care, low quality of available medications, limited compliance to prescribed medications and inadequate self-care (51–53). Furthermore, other studies have reported that health systems may not facilitate patients to take control of their blood pressure level and continue medication as prescribed. The actual reasons of this gap remain unknown, although some of the reasons mentioned above may play parts of the puzzle. Nonetheless, we cannot tell for sure the magnitude of their relative contributions, as no research investigated the challenges faced by hypertensive patients in Somaliland.

Implications of the findings

Lack of reliable health data and absence of surveillance platforms prevent public health agencies to track and respond to diseases appropriately (54). This study provides valuable data on the importance of hypertension and its control in Somaliland. Our findings should encourage the development of national programme to improve public awareness of hypertension and to train health care providers for better screening and treatment of hypertension. Appropriate screening strategies are important for the early identification of people with raised blood pressure (55, 56), but to date there is no standard clinical guidelines neither for screening nor for treatment of hypertension in Somaliland. The implementation of a pilot project adapting WHO-PEN disease intervention (57) using total CVD risk-based assessment approach (58) at the primary care settings, might be of value for the prevention and control of hypertension. Such a project may set a foundation for a national programme on the integrated management of NCDs and their underlying risk factors in Somaliland. Measurable improvement in awareness, treatment and control of hypertension were achieved in countries where PEN interventions were implemented (59). In addition, such interventions might enable concerned stakeholders to better understand the operational prospects and value for investment for early detection and management of NCDs and their risk factors.

Moreover, our study findings indicate that a considerable proportion of outpatients used traditional remedies to lower their blood pressure. Hence, further research is recommended to gain a better understanding of the potential blood pressure-lowering effects of these remedies.

Strengths and limitations

To our knowledge, this is the first hospital-based study on hypertension in Somaliland. The systematic sampling strategy applied strengthens the generalizability of our findings to other health facilities. However, our study has some limitations. Because of the cross-sectional design employed, we could not establish causal relationship between the reported risk factors and hypertension. The absence of biochemical measurements, due to financial constraints, limited the diagnostic assurance of the self-reported conditions such as diabetes and raised cholesterol. We also acknowledge that potential biases may have been introduced by our focus on outpatients attending a referral hospital and the short duration of data collection. A longer-term study spanning a year or more would provide more comprehensive and representative findings. Finally, we did not stratify our analysis into rural and urban settings, as we did not capture enough information to do so.

Our results show that over 90% of outpatients in Hargeisa, Somaliland, who have had antihypertensive medications prescribed, did not reach treatment goals. This considerable gap in blood pressure control is likely to increase the risk of complications such as CVD, including heart failure, renal failure and stroke. Consequently, the Ministry of Health Development in Somaliland should establish educational campaigns to inform the public about the critical importance of managing and treating hypertension to improve people’s health and wellbeing. In addition, research on the outcomes of patients with hypertension and other NCDs in Somaliland is essential. In conclusion, our findings point towards the need for strategies to improve hypertension control in Somaliland.

Ethics approval and consent to participate

The Research Ethics Committee of the University of Hargeisa approved the study (reference no. DRCS/53/05/2022). The Somaliland Ministry of Health Development (MoHD) gave permission to conduct the study (reference no. MOHD/VM: 3/537/2022). Following the principles of the Helsinki Declaration, all participants provided written informed consent and they could withdraw from the study at any time without further obligations.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

All authors declare that they have no conflict of interest.

Funding

This work was supported by the Swiss Tropical and Public Health Institute.

Authors’ contributions

FN & MIA planned, conducted and supervised the study. MIA conducted data entry. FN conceptualized the study, analysed the data, interpreted the findings and drafted the manuscript. AC, JU and NPH contributed to the interpretation of the results and critically reviewed the manuscript. JU & NPH provided overall guidance, were involved in data analysis and data interpretation, assessed the methodological quality and critically reviewed the manuscript.

Acknowledgments

Our deep appreciation goes to the study participants. We also thank the data collectors, Hargeisa group hospital and University of Hargeisa for their kind support. FN is grateful for the financial support of his PhD studies at the Swiss Tropical and Public Health Institute. The contents of this article are the sole responsibility of the authors and do not necessarily reflect the views of any of the institutions named here.

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Awareness, treatment and control of hypertension in Hargeisa, Somaliland

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Abstract

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Introduction

Methods

Study area, design and participants

Definitions of variables

Statistical analysis

Results

Characteristics of study participants

Prevalence and distribution of awareness, treatment and control of hypertension

Factors associated with awareness, treatment and control of hypertension

Uncontrolled hypertension

Risk factors for uncontrolled hypertension

Discussion

Implications of the findings

Strengths and limitations

Conclusion

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