One-year routine opportunistic screening for hypertension in formal medical settings and potential improvements in hypertension awareness among older persons in developing countries: evidence from the Study on Global Ageing and Adult Health (SAGE)

Comparing socio-economic inequalities in self-reported and undiagnosed hypertension among adults 45 years and over in India: what explains these inequalities?

BACKGROUND

Hypertension (HTN) is a leading cause of mortality and morbidity in developing countries. For India, the hidden burden of undiagnosed hypertension is a major concern. This study aims to assess and explain socio-economic inequalities among self-reported and undiagnosed hypertensives in India.

METHODS

The study utilized data from the Longitudinal Aging Study in India (LASI), a nationally-representative survey of more than 72,000 older adults. The study used funnel plots, multivariable logistic regression, concentration indices, and decomposition analysis to explain the socio-economic gap in the prevalence of self-reported and undiagnosed hypertension between the richest and the poorest groups.

RESULTS

The prevalence of self-reported and undiagnosed hypertension was 27.4 and 17.8% respectively. Monthly per capita consumption expenditure (MPCE) quintile was positively associated with self-reported hypertension but negatively associated with undiagnosed hypertension. The concentration index for self-reported hypertension was 0.133 (p < 0.001), whereas it was - 0.047 (p < 0.001) for undiagnosed hypertension. Over 50% of the inequalities in self-reported hypertension were explained by the differences in the distribution of the characteristics whereas inequalities remained unexplained for undiagnosed hypertension. Obesity and diabetes were key contributors to pro-rich inequality.

CONCLUSIONS

Results imply that self-reported measures underestimate the true prevalence of hypertension and disproportionately affect the poorer MPCE groups. The prevalence of self-reported HTN was higher in the richest group, whereas socio-economic inequality in undiagnosed hypertension was significantly concentrated in the poorest group. As majority of the inequalities remain unexplained in case of undiagnosed hypertension, broader health systems issues including barriers to access to health care may be contributing to inequalities.

Case identification, retention and blood pressure control in Kenya

BACKGROUND

Prevalence of hypertension in Africa is rising but it remains underdiagnosed and poorly controlled. In Kenya, only 22% of individuals known to have hypertension were on treatment, and only 51.7% were controlled. This study will assess screening outcomes, retention and blood pressure (BP) control of a hypertension programme in Kenya.

DESIGN

This was a retrospective cohort study using data routinely collected between 2015 and 2018. All patients aged >18 years screened and treated in the programme were included.

RESULTS

Of 663,028 screening encounters, 70.4% were female; the median age was 34 years. Overall, 19% of the study population, mainly males and older persons, had high BP higher rates. Of 66,981 patients started on treatment, the majority were females (71.2%); the median age was 55 years. Only 12% of patients were reported as having been retained after 12 months, and 48.6% of patients on treatment 10.5-13.5 months after enrolment had controlled BP. Older age and treatment at primary care level were associated with better retention and females had better BP control.

CONCLUSIONS

The programme screened primarily females and younger individuals at lower risk. Retention was poor and close to half of patients retained had controlled BP. Hypertension programmes should target high-risk individuals, decentralise treatment, incorporate retention strategies and improve longitudinal data management.

Cost-Effectiveness and Distributional Impact of Opportunistic Screening for People at High-Risk of Cardiovascular Disease in Sri Lanka: A Modelling Study

Background

While hypertension, diabetes, hypercholesterolemia and high-risk of cardiovascular disease can be easily diagnosed and treated with cost-effective medicines, a large proportion of people remain undiagnosed. We assessed the potential effectiveness, cost, and distributional impact of opportunistically screening for these chronic conditions at outpatient patient departments in Sri Lanka.

Methods

We used nationally representative data on biomarkers and healthcare utilization in 2019 to model the screening of people aged 40+ without preexisting CVD and without a reported diagnosis of hypertension, diabetes, or hypercholesterolemia. We modelled an intensive one month program that would screen a proportion of those making an outpatient visit to a public or private clinic and follow-up a proportion of those screened to confirm diagnoses. We also modelled a less intensive one year program. The main outcomes were the new diagnoses of any of the chronic conditions. Program costs were calculated and the socioeconomic distributions of individuals screened, new cases diagnosed, and treatments delivered were estimated. Sensitivity analyses varied the probability of screening and follow-up.

Results

Using data on 2,380 survey participants who met the inclusion criteria, we estimated that the one month program would diagnose 8.2% (95% CI: 6.8, 9.6) of those with a chronic condition who would remain undiagnosed without the program. The one year program would diagnose 26.9% (95% CI: 26.5, 27.4) of the otherwise undiagnosed and would have a cost per person newly diagnosed of USD 6.82 (95% CI: 6.61, 7.03) in the public sector and USD 16.92 (95% CI: 16.37, 17.47) in the private sector. New diagnoses would be evenly distributed over the socioeconomic distribution, with public (private) clinics diagnosing a higher proportion of poorer (richer) individuals. Both programs would reduce underdiagnosis among males relative to females.

Conclusions

Opportunistic screening for cardiovascular diseases at outpatient clinics in Sri Lanka could be cost-effective and equitable.

Missed opportunities for hypertension screening: a cross-sectional study, India

Objective

To assess missed opportunities for hypertension screening at health facilities in India and describe systematic differences in these missed opportunities across states and sociodemographic groups.

Methods

We used nationally representative survey data from the 2017-2018 Longitudinal Ageing Study in India to estimate the proportion of adults aged 45 years or older identified with hypertension and who had not been diagnosed with hypertension despite having visited a health facility during the previous 12 months. We estimated age-sex adjusted proportions of missed opportunities to diagnose hypertension, as well as actual and potential proportions of diagnosis, by sociodemographic characteristics and for each state.

Findings

Among those identified as having hypertension, 22.6% (95% confidence interval, CI: 21.3 to 23.8) had not been diagnosed despite having recently visited a health facility. If these opportunities had been realized, the prevalence of diagnosed hypertension would have increased from 54.8% (95% CI: 53.5 to 56.1) to 77.3% (95% CI: 76.2 to 78.5). Missed opportunities for diagnosis were more common among individuals who were poorer (P = 0.001), less educated (P < 0.001), male (P < 0.001), rural (P < 0.001), Hindu (P = 0.001), living alone (P = 0.028) and working (P < 0.001). Missed opportunities for diagnosis were more common at private than at public health facilities (P < 0.001) and varied widely across states (P < 0.001).

Conclusion

Opportunistic screening for hypertension has the potential to significantly increase detection of the condition and reduce sociodemographic and geographic inequalities in its diagnosis. Such screening could be a first step towards more effective and equitable hypertension treatment and control.

Awareness, treatment, and control of hypertension in adults aged 45 years and over and their spouses in India: A nationally representative cross-sectional study

BACKGROUND

Lack of nationwide evidence on awareness, treatment, and control (ATC) of hypertension among older adults in India impeded targeted management of this condition. We aimed to estimate rates of hypertension ATC in the older population and to assess differences in these rates across sociodemographic groups and states in India.

METHODS AND FINDINGS

We used a nationally representative survey of individuals aged 45 years and over and their spouses in all Indian states (except one) in 2017 to 2018. We identified hypertension by blood pressure (BP) measurement ≥140/90 mm Hg or self-reported diagnosis if also taking medication or observing salt/diet restriction to control BP. We distinguished those who (i) reported diagnosis ("aware"); (ii) reported taking medication or being under salt/diet restriction to control BP ("treated"); and (iii) had measured systolic BP <140 and diastolic BP <90 ("controlled"). We estimated age-sex adjusted hypertension prevalence and rates of ATC by consumption quintile, education, age, sex, urban-rural, caste, religion, marital status, living arrangement, employment status, health insurance, and state. We used concentration indices to measure socioeconomic inequalities and multivariable logistic regression to estimate fully adjusted differences in these outcomes. Study limitations included reliance on BP measurement on a single occasion, missing measurements of BP for some participants, and lack of data on nonadherence to medication. The 64,427 participants in the analysis sample had a median age of 57 years: 58% were female, and 70% were rural dwellers. We estimated hypertension prevalence to be 41.9% (95% CI 41.0 to 42.9). Among those with hypertension, we estimated that 54.4% (95% CI 53.1 to 55.7), 50.8% (95% CI 49.5 to 52.0), and 28.8% (95% CI 27.4 to 30.1) were aware, treated, and controlled, respectively. Across states, adjusted rates of ATC ranged from 27.5% (95% CI 22.2 to 32.8) to 75.9% (95% CI 70.8 to 81.1), from 23.8% (95% CI 17.6 to 30.1) to 74.9% (95% CI 69.8 to 79.9), and from 4.6% (95% CI 1.1 to 8.1) to 41.9% (95% CI 36.8 to 46.9), respectively. Age-sex adjusted rates were lower (p < 0.001) in poorer, less educated, and socially disadvantaged groups, as well as for males, rural residents, and the employed. Among individuals with hypertension, the richest fifth were 8.5 percentage points (pp) (95% CI 5.3 to 11.7; p < 0.001), 8.9 pp (95% CI 5.7 to 12.0; p < 0.001), and 7.1 pp (95% CI 4.2 to 10.1; p < 0.001) more likely to be aware, treated, and controlled, respectively, than the poorest fifth.

CONCLUSIONS

Hypertension prevalence was high, and ATC of the condition were low among older adults in India. Inequalities in these indicators pointed to opportunities to target hypertension management more effectively and equitably on socially disadvantaged groups.

May Measurement Month 2017-2019: A Community-Wide Opportunistic Blood Pressure Screening Campaign in Hong Kong

Introduction

Hypertension is a modifiable risk factor for multiple cardiovascular diseases. Early identification and intervention of new cases are crucial to improve patients' outcomes. May Measurement Month (MMM) is an annual global synchronised blood pressure (BP) screening campaign. Participants can have their BP measured at the screening sites. It may be a possible way to identify undiagnosed hypertensive patients in the population.

Methods

It was a cross-sectional study of BP among Hong Kong adults. Multiple screening sites were set in local community pharmacies and on the campus of the Chinese University of Hong Kong. Participants were asked to fill in a questionnaire regarding their demographics, medical history, and social history. Then, they took at least one BP reading using an automated sphygmomanometer after sitting at for 5 minutes. Up to three BP readings were taken and recorded for each participant, with one-minute intervals between readings.

Results

A total of 3224 adults participated in MMM between 2017 and 2019. The average BP among the 3224 participants was 139.8/75.5 mmHg. The prevalence of hypertension was 2282 (70.8%), of which 635 (27.8%) were undiagnosed before MMM. Among the 1647 participants previously diagnosed with hypertension, 1007 (61.1%) had uncontrolled hypertension.

Conclusion

A high number of cases can be identified with untreated, or treated but uncontrolled, hypertension from MMM. Citizens should be encouraged to check BP regularly and take follow-up actions if hypertension is suspected.

May Measurement Month 2017: an analysis of blood pressure screening results from the United Kingdom and the Republic of Ireland-Europe

Elevated blood pressure (BP), or hypertension, is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and acting as a stimulus to improving screening programmes worldwide. In the United Kingdom (UK) nearly 1 in 5 people, and in the Republic of Ireland (RoI) 3 out of 10, have hypertension, of which a large proportion remains undiagnosed. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed a standardized protocol. Screenings sites in hospitals, universities, shopping centres, workplaces, sports clubs, community centres, GP practices, and pharmacies were set up across the UK and RoI as part of this initiative. Seven thousand seven hundred and fourteen individuals were screened during MMM17. After multiple imputation, 3099 (40.3%) had hypertension. Of individuals not receiving antihypertensive medication, 1406 (23.4%) were hypertensive. Of individuals receiving antihypertensive medication, 682 (40.5%) had uncontrolled BP. MMM17 was the largest BP screening campaign ever undertaken in the UK and RoI. These data prove for the first time that a relatively inexpensive, volunteer based, convenience sampling of screening BP in the community identified two out of five individuals as hypertensive, with one in four not receiving treatment. Of major concern is that these data demonstrate that of those individuals receiving treatment, two out of five still did not have controlled BP.

Time to review policy on screening for, and managing, hypertension in South Africa: Evidence from primary care

BACKGROUND

Current policy in South Africa requires measurement of blood pressure at every visit in primary care. The number of patients regularly visiting primary care clinics for routine care is increasing rapidly, causing long queues, and unmanageable workloads.

METHODS

We used data collected during a randomised control trial in primary care clinics in South Africa to estimate how changes in policy might affect workloads and improve identification of undiagnosed hypertension.

RESULTS

The prevalence of raised blood pressure increased with age; 65% of individuals aged over 60 years had a raised blood pressure, and 49% of them were not on any treatment. Over three months, eight health facilities saw 8,947 individual chronic disease patients, receiving 22,323 visits from them. Of these visits, 60% were related to hypertension, with or without HIV, and a further 35% were related to HIV alone. Long waits for blood pressure checks caused friction at all levels of the clinics. Blood pressure machines frequently broke down due to heavy use, and high blood pressures readings were often ignored. If chronic disease patients without a diagnosis of hypertension had their blood pressure checked only once a year, the number of checks would be reduced by more than 80%. Individuals with hypertension had a blood pressure check on average once every 7 weeks, but South African guidelines recommend that this should be done every 3 months at most.

CONCLUSIONS

The numbers of chronic disease patients in primary care clinics in South Africa is rising rapidly. New policies for measuring blood pressure in these patients attending clinics are urgently needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12128227 5th March 2014.

Access to hypertension care and services in primary health-care settings in Vietnam: a systematic narrative review of existing literature

Background: Health care in Vietnam is challenged by a high burden of hypertension (HTN). Since 2000, several interventions were implemented to manage HTN; it is not clear what is the status of patient access to HTN care. Objective: This article aims to perform a systematic narrative review of the available evidence on access to HTN care and services in primary health-care settings in Vietnam. Methods: Search engines were used to identify relevant records of scientific and grey literature. Data from selected articles were analysed using standardised spreadsheets and MaxQDA and following a framework synthesis methodology. Results: There has been increasing interest in research and policy concerning the burden of HTN in Vietnam, covering many aspects of access to treatment at the primary health-care level. Vietnam's National HTN Programme is managed as a vertical programme and its services integrated into the network of primary health-care facilities across the public sector in selected provinces. The Programme financed population-wide screening campaigns for the early detection of HTN among people above 40 years of age. There was no information on the acceptability of HTN health services, especially regarding the interaction between patients and health professionals. In general, articles reported good availability of medication, but problems in accessing them included: fragmentation and lack of consistency in prescribing medication between different levels and short timespans for dispensing medication at primary health-care facilities. There was limited information related to the cost and economic impact of HTN treatment. Treatment adherence among hypertensive patients based on four studies did not exceed 70%. Conclusions: Although the Vietnamese health-care system has taken steps to accommodate some of the needs of HTN patients, it is crucial to scale-up interventions that allow for regular, systematic, and integrated care, especially at the lowest levels of care.

May Measurement Month 2017: an analysis of blood pressure screening results worldwide

BACKGROUND

Increased blood pressure is the biggest contributor to the global burden of disease and mortality. Data suggest that less than half of the population with hypertension is aware of it. May Measurement Month was initiated to raise awareness of the importance of blood pressure and as a pragmatic interim solution to the shortfall in screening programmes.

METHODS

This cross-sectional survey included volunteer adults (≥18 years) who ideally had not had their blood pressures measured in the past year. Each participant had their blood pressure measured three times and received a a questionnaire about demographic, lifestyle, and environmental factors. The primary objective was to raise awareness of blood pressure, measured by number of countries involved, number of people screened, and number of people who have untreated or inadequately treated hypertension (defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, or both, or on the basis of receiving antihypertensive medication). Multiple imputation was used to estimate the mean of the second and third blood pressure readings if these were not recorded. Measures of association were analysed using linear mixed models.

FINDINGS

Data were collected from 1 201 570 individuals in 80 countries. After imputation, of the 1 128 635 individuals for whom a mean of the second and third readings was available, 393 924 (34·9%) individuals had hypertension. 153 905 (17·3%) of 888 616 individuals who were not receiving antihypertensive treatment were hypertensive, and 105 456 (46·3%) of the 227 721 individuals receiving treatment did not have controlled blood pressure. Significant differences in adjusted blood pressures and hypertension prevalence were apparent between regions. Adjusted blood pressure was higher in association with antihypertensive medication, diabetes, cerebrovascular disease, smoking, and alcohol consumption. Blood pressure was higher when measured on the right arm than on the left arm, and blood pressure was highest on Saturdays.

INTERPRETATION

Inexpensive global screening of blood pressure is achievable using volunteers and convenience sampling. Pending the set-up of systematic surveillance systems worldwide, MMM will be repeated annually to raise awareness of blood pressure.

FUNDING

International Society of Hypertension, Centers for Disease Control and Prevention, Servier Pharmaceutical Co.

Hypertension in Developing Countries: A Major Challenge for the Future

PURPOSE OF REVIEW

Outline recent epidemiologic data regarding hypertension in developing countries, distinguish differences from developed countries, and identify challenges in management and future perspectives.

RECENT FINDINGS

Increased sugar intake, air and noise pollution, and low birth weight are emerging hypertension risk factors. The major challenges in management are difficulties in accurate diagnosis of hypertension and adequate blood pressure control. In contrast to developed countries, hypertension prevalence rates are on the rise in developing countries with no improvement in awareness or control rates. The increasing burden of hypertension is largely attributable to behavioral factors, urbanization, unhealthy diet, obesity, social stress, and inactivity. Health authorities, medical societies, and drug industry can collaborate to improve hypertension control through education programs, public awareness campaigns, legislation to limit salt intake, encourage generic drugs, development and dissemination of national guidelines, and involving nurses and pharmacists in hypertension management. More epidemiologic data are needed in the future to identify reasons behind increased prevalence and poor blood pressure control and examine trends in prevalence, awareness, treatment, and control. National programs for better hypertension control based on local culture, economic characteristics, and available resources in the population are needed. The role of new tools for hypertension management should be tested in developing world.

Cardiovascular Disease Risk Assessment in the United States and Low- and Middle-Income Countries Using Predicted Heart/Vascular Age

Almost 80% of the global burden of cardiovascular disease (CVD) occurs in low- and middle-income countries (LMICs). However, LMICs do not have well-established, low-technology ways to quantify and communicate CVD risk at population or individual levels. We examined predicted heart/vascular age (PHA) in six LMICs and the United States. Data were from CVD-free adults in World Health Organization Study on Global Aging and Adult Health (n = 29094) and US National Health and Nutritional Examination Survey (n = 6726). PHA was calculated using the non-laboratory Framingham CVD risk equation. High excess PHA (HEPHA) was defined as the differences between PHA and chronological age >5 years. Logistic regression models were used to identify factors associated with HEPHA. Age-standardized prevalence of HEPHA was higher in Russia 52%; China 56%; Mexico 59%; and South Africa 65% compared to the US 45%, Ghana 36%; and India 38%. In LMICs, higher income, being divorced/widowed, alcohol intake and abdominal obesity had higher odds of HEPHA; higher education, fruit intake and physical activity had lower odds of HEPHA. The use of PHA may offer a useful avenue to communicate CVD risk. Interventions tailored at socioeconomic and cultural factors that influence CVD risk factors may be necessary to prevent CVD in LMICs.

Hypertension in low and middle-income countries: Challenges, gaps and limited resources specific strategies

In this article we aim to discuss the burden of hypertension in middle-income countries, the challenges and opportunities, identify some implementation gaps in some of the published initiatives and propose a few pillars that could benefit an upstream population health and health promotion. One billion people suffer from hypertension worldwide; however, the prevalence of hypertension in low and middle-income countries is higher than that in the industrialized countries. Hypertension affects 45% of African adults aged 25 and above, compared to the 36% North American prevalence rate; moreover, the death rate from hypertension in LMICs is higher the than that of the European countries (141 vs 93 per 10000, respectively). The association between increased systolic blood pressure and income reversed between the early 80s and the first decade of the 20^th century; the higher the per capita income the lower the risk of hypertension. Hence, unless an effective interventions, such as improving diagnosis and treatment, lowering salt intake, enhancing access and availability of fresh fruit and vegetable, and increasing leisure time physical activities are implemented, then low income countries epidemic is inevitable. In this article we aim to discuss the global burden of hypertension in low and middle-income countries, the gaps and challenges, identify the high-risk groups and propose a prevention and cost effective treatment strategic framework.

Medical screening in dental settings: a qualitative study of the views of authorities and organizations

Background

The practice of identifying individuals with undiagnosed diabetes mellitus type II or undiagnosed hypertension by medical screening in dental settings has been received positively by both patients and dentistry professionals. This identification has also shown to be cost-effective by achieving savings and health benefits, but no investigation has been made of the attitudes of authorities and organizations. The aim of this study was to describe the views of authorities and organizations.

Results

Thirteen authorities and organizations were interviewed of the sample of 20 requested. Seven approached authorities and organizations did not believe it was relevant to participate in the study. The manifest analysis resulted in four categories: medical screening ought to be established in the society; dentistry must have relevant competence to perform medical screening; medical screening requires cooperation between dentistry and health care; and dentistry is not the only context where medical screening could be performed. The latent analysis resulted in an emerging theme: positive to, but uncertain about, the concept of medical screening in dental settings. The spokespersons for the approached authorities and organizations had a positive view of medical screening but the respondents experienced a lack of facts concerning the scientific communities’ position, guidelines and procedures in the topic.

Conclusions and implications

Approached authorities and organizations generally had a positive view of medical screening in dental settings but were uncertain about the concept. Further scientific knowledge and guidelines concerning the topic are needed before it can be commonly introduced and additional research on implementation strategies and long-term follow-up of medical screening are needed.