Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension in Nepal between 2000 and 2025: A Systematic Review and Meta-Analysis

Implications of the dissemination of healthy lifestyle advice for Afghan adults without histories of hypertension diagnosis or treatment

Objectives

This study explored the relationship between receiving healthy lifestyle advice from healthcare providers and hypertension among undiagnosed individuals in Afghanistan, defined as adults with no previous hypertension diagnosis or treatment history.

Materials and Methods

Data were extracted from the 2018-19 Afghanistan National Non-Communicable Diseases Risk Factors Survey, comprising 2,838 participants. Outcomes included hypertension (systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg) and elevated blood pressure (systolic blood pressure 120-129 mmHg and diastolic blood pressure <80 mmHg). Bivariate and multivariable multinomial logistic regression analyses were conducted to assess associated factors.

Results

Among the 2,838 participants, 1,344 (47.4%) had hypertension and 344 (12.1%) had elevated blood pressure. Most participants were aged <40 years (63.8%), male (55.8%), and ever-married (80.2%). Multivariable analysis revealed that not receiving healthy lifestyle advice was significantly associated with hypertension (adjusted relative risk ratio [aRRR]=1.24; 95% confidence interval [CI]: 1.04-1.47) and elevated blood pressure (aRRR=1.40; 95% CI: 1.08-1.81). Sociodemographic and behavioral factors such as age, sex, marital status, education, occupation, fruit consumption, physical activity, and excess weight were significantly associated with hypertension, whereas only sex and excess weight were significantly associated with elevated blood pressure.

Conclusion

Our findings underscore the association between receiving healthy lifestyle advice from healthcare providers and a lower prevalence of hypertension among undiagnosed Afghan adults. Accordingly, healthcare providers should recommend lifestyle changes to help manage hypertension among adults.

Burden and determinants of self-reported high blood pressure among women of reproductive age in Tanzania: Evidence from 2022 Tanzania demographic and health survey

BACKGROUND

High blood pressure, commonly referred to as hypertension, remains a prevalent global health concern characterized by elevated arterial pressure, posing significant risks such as cardiovascular diseases, stroke, and kidney diseases. Therefore, this study aimed to assess the burden and determinants of self-reported high blood pressure among women of reproductive age in Tanzania.

METHODS

We utilized population-based cross-sectional data obtained from the Tanzania Demographic and Health Survey (TDHS) 2022. The analysis involved a weighted sample of 15,254 women aged 15-49 years. Multivariable logistic regression models were employed to examine the independent variables associated with self-reported high blood pressure, and the results were presented as adjusted odds ratios (aOR) with a 95% confidence interval (CI). The significance level was set at p <  0.05 for all analyses.

RESULTS

Overall, the mean age of study participants was 29.3 ±  9.8 years, with a self-reported high blood pressure burden of 6.6% among women of reproductive age in Tanzania. Moreover, increased age correlated with higher odds of high blood pressure compared to women aged 15-19 years. Those with a secondary level of education exhibited a higher likelihood of high blood pressure in contrast to women with no education. Married and widowed individuals were more prone to high blood pressure than those who were never married. Additionally, women in higher wealth groups showed a significantly elevated risk of high blood pressure compared to those in the poorest wealth group. Conversely, self-reported poor health status and recent visits to health facilities were associated with significantly higher odds of high blood pressure.

CONCLUSION

This study highlights the burden of high blood pressure among reproductive-age women, urging heightened awareness and proactive screening measures. These findings prompt targeted interventions, emphasizing the need for collaborative efforts among stakeholders to effectively curb this health burden.

Tackling chronic kidney disease in Nepal: from evidence to action

Chronic kidney disease (CKD) poses a significant burden in Nepal. We reviewed the epidemiology of CKD in Nepal and proposed strategies to mitigate its burden. A nationwide survey of non-communicable diseases in 2019 reported CKD prevalence of 6.2% (95% Confidence Interval [CI]: 5.7-6.6%). Further, we found that the age-standardized prevalence of chronic kidney disease in Nepal grew by 0.11% (95% uncertainty interval, [UI]: 0.10-0.11%) per annum between 1990 and 2021. Despite the high burden (10,887.7 prevalent CKD per 100,000 population), the country only has 56 nephrologists and 60 hemodialysis centers, the majority of which are located in the country's capital, serving only 15% of the population. CKD requires multi-component interventions that address the diverse causes and pathological expressions of the disease. Integrating interventions across the care continuum, such as health education and literacy, screening, lifestyle modifications, and improved access to renal replacement therapies, can enhance effective coverage and scalability of care. Additionally, it is crucial to explore and address disparities in access to CKD treatment, including gender and socioeconomic disparities.

Impact of a community health worker led intervention for improved blood pressure control in urban Nepal: an open-label cluster randomised controlled trial

Background

Effective control of hypertension remains challenging in low and middle-income countries. We tested the effectiveness of comprehensive approaches to hypertension management including six home visits by community health workers with regular follow up by a trained healthcare provider on blood pressure levels in Nepal.

Methods

We implemented a non-blinded, open-label, parallel-group, two-arm cluster randomised controlled trial, with 1:1 allocation ratio in Budhanilakantha municipality, Kathmandu, Nepal. Ten public health facilities and their catchment area were randomly allocated to receive comprehensive intervention or only usual hypertension care. We recruited 1252 individuals aged 18 years and older with hypertension. The primary outcome was systolic blood pressure. Secondary outcomes were diastolic blood pressure, proportion with controlled blood pressure, waist to hip ratio, body mass index, physical activity, diet quality score, daily salt intake, adherence to antihypertensives, hypertension knowledge and perceived social support. Primary analysis was by intention-to-treat using a linear mixed model.

Findings

Participants were, on average 57 years old, 60% females, 84% married, 54% Brahmin/Chettri ethnicity and 33% were illiterate. The decrease in mean systolic blood pressure (1.7 mm Hg, 95% CI -0.1, 3.4) and diastolic blood pressure (1.6 mm Hg, 95% CI 0.5, 2.6) was more in the intervention arm compared to the control. The proportion with blood pressure control (OR 1.5 95% CI 1.0, 2.1) and engaging in adequate physical activity (≥600 Metabolic equivalents of task per week) (OR 2.2, 95% CI 1.6, 3.1) were higher in the intervention arm compared to control. The change in hypertension knowledge score was higher and daily salt intake was lower in the intervention arm compared to control. Waist to hip ratio increased more and global dietary requirement scores decreased more in the intervention group and there was no effect on the body mass index and adherence to antihypertensives.

Interpretation

Community health workers facilitated home support and routine follow-up care by healthcare providers was effective in controlling blood pressure in urban Nepal. These findings suggest comprehensive interventions targeting individual, community and health system barriers are feasible in low resource settings, but larger implementation trials are needed to inform future scale-up.

Funding

This work was supported by Norwegian University of Science and Technology, Trondheim, Norway (Project number 981023100).

Anxiety and depression among hypertensive patients during the COVID-19 pandemic: A cross-sectional study from Kathmandu Metropolitan, Nepal

INTRODUCTION

The outbreak of a global pandemic like COVID-19 has highlighted significant distress around mental health. The burden of mental health issues like anxiety and depression requires evidence-based intervention, especially in low-income settings like Nepal. The study aims to determine the prevalence of anxiety and depression and the factors associated with it among hypertensive patients.

MATERIALS AND METHODS

The quantitative cross-sectional study design was used for this study. The study was conducted among 374 samples from selected wards of Kathmandu Metropolitan using a convenience sampling technique. Face-to-face interviews were conducted using a structured interview schedule. A Chi-square test was used to identify the statistical significance between dependent and independent variables. Binary logistic regression analysis was performed to determine the factors associated with anxiety and depression.

RESULTS

The prevalence of anxiety and depression among hypertensive patients during the COVID-19 pandemic was 27.8% and 24.3% respectively. According to the results of bivariate logistic regression analysis, smoking/tobacco consumption, staying in quarantine, positive COVID-19 test result, history of COVID-19 positive in the family, History of death due to COVID-19 in the family, visiting a hospital during the COVID-19 pandemic appeared as influencing factors of both anxiety and depression.

CONCLUSION

Our findings suggest that COVID-19 has a substantial effect on the mental health of hypertensive patients. This study highlights the need to develop early intervention and coping strategies among this population to minimize the negative impact of COVID-19 on their mental health and well-being.

Exploring ways to support patients with noncommunicable diseases: A pilot study in Nepal during the COVID-19 pandemic

Global healthcare systems have faced unprecedented strain due to the COVID-19 pandemic, with a profound impact on individuals with non-communicable diseases (NCDs), a scenario particularly pronounced in low-income countries like Nepal. This study aimed to understand the experiences of and challenges faced by patients with NCDs in Nepal during the pandemic, focusing on healthcare service availability and identifying factors affecting healthcare use, with the goal of being prepared for future emergencies. This study utilized a telephonic survey of 102 patients with NCDs and 10 qualitative interviews with healthcare providers in the Kavrepalanchok and Nuwakot districts of Nepal. We used mixed methods, with both qualitative and quantitative approaches. Specifically, multiple correspondence analysis, hierarchical cluster analysis, and classification tree analysis were used as exploratory methods. The study revealed that while 69.6% of the participants reported no difficulty in obtaining medication, other questions revealed that 58.8% experienced challenges in accessing routine medical care. Major barriers, such as fear of infection, unavailability of medicine in rural areas, and lack of transportation, were found through the qualitative interviews. Meanwhile, participants identified innovative strategies, such as telemedicine and community-based awareness programs, as potential facilitators for addressing barriers that arise during pandemic situations such as COVID-19. The COVID-19 pandemic exacerbated challenges in accessing healthcare services for patients with NCDs in Nepal. Our findings suggest the need to design and implement telemedicine services for patients with NCDs, as well as community-based programs that aim to improve health literacy, encourage healthy behavior, prevent development of NCDs, and ensure continuity of care during such crises, especially in countries with limited resources.

Global prevalence of cardiovascular risk factors based on the Life's Essential 8 score: an overview of systematic reviews and meta-analysis

Cardiovascular health (CVH) is a critical issue for global health. However, no previous study has determined the prevalence of cardiovascular risk factors based on the American Heart Association's (AHA) Life's Essential 8 (LE8). Therefore, we aimed to estimate the global prevalence of the eight cardiovascular risk factors identified in the LE8. A systematic search of systematic reviews with meta-analysis on cardiovascular risk factors covering data reported between 2000 and 2019 was conducted on PubMed, Epistemonikos, and the Cochrane Library until 1 May 2023. After applying exclusion criteria, 79 studies remained in the final selection for the narrative synthesis in the systematic review, of which 33 of them were used in the meta-analysis which included 2 555 639 participants from 104 countries. The overall pooled prevalence of cardiovascular risk factors was as follows: insufficient physical activity, 26.3% (95% CI 2.3%-63.4%), no adherence to a healthy diet, 34.1% (95% CI 5.8%-71.2%), nicotine exposure, 15.4% (95% CI 10.4%-21.2%), insufficient sleep quality, 38.5% (95% CI 14.0%-66.7%), obesity, 17.3% (95% CI 6.1%-32.6%), dyslipidemia, 34.1% (95% CI 33.8%-34.4%), diabetes, 12.0% (95% CI 7.0%-18.2%), and hypertension, 29.4% (95% CI 23.3%-35.8%). These results warrant prevention strategies aimed at reducing insufficient sleep quality, and no adherence to a healthy diet as leading cardiovascular risk factors worldwide. The high prevalence of hypertension among children and adults is concerning and should also be adequately addressed through global policies.

Social determinants of health and cardiometabolic risk factors in Nepal: A scoping review

AIMS

Cardiometabolic risk factors are modifiable contributors to cardiometabolic disease and adverse outcomes. Cardiometabolic risk factors are emerging health concerns among adults in low and middle-income countries. The role of social determinants of health on cardiometa gaps.

DATA SYNTHESIS

A comprehensive search was conducted in multiple databases: PubMed (MEDLINE), Web of Science (Clarivate), and CINAHL (EBSCO). Joanna Briggs Institute's (JBI) Scoping Review methodology and PRISMA extension for scoping reviews-SCRA guided this review. Forty-four cross-sectional studies published between 2010 and 2022 were eligible for this review. Men were more likely to have hypertension, while women were more likely to have obesity and abdominal obesity. Participants from marginalized caste/ethnicity, urban regions, and those with lower education, and greater wealth index had a greater likelihood of hypertension, dyslipidemia, and hyperglycemia; however, differences across these sociodemographic subgroups are narrowing. Smoking, harmful alcohol use, high salt intake, low fruit and vegetable intake, and sedentary lifestyles were associated with one or more cardiometabolic risk factors. Finally, one cardiometabolic risk factor increased the risk of others.

CONCLUSIONS

Findings reflect that Nepal is at the intersection of rapid urbanization, nutritional transition, and socioeconomic shift. Future studies should take a multilevel approach to investigate the role of social determinants in increasing the cardiometabolic risk burden in Nepal.

Factors associated with self-care behaviours among people with hypertension residing in Kathmandu: a cross-sectional study

OBJECTIVE

To determine the prevalence and associated factors of self-care behaviours among people with hypertension in the Kathmandu district of Nepal.

DESIGN

Cross-sectional study.

SETTING

Municipalities of Kathmandu district, Nepal.

PARTICIPANTS

We enrolled 375 adults aged ≥18 years with a minimum 1-year duration of hypertension using multistage sampling.

OUTCOME MEASURES

We used the Hypertension Self-care Activity Level Effects to assess self-care behaviours and collected data through face-to-face interviews. We conducted univariate and multivariable logistic regression analyses to determine the factors associated with self-care behaviours. The results were summarised as crude and adjusted ORs (AORs) with 95% CIs.

RESULTS

The adherence to antihypertensive medication, Dietary Approach to Stop Hypertension (DASH) diet, physical activity, weight management, alcohol moderation, and non-smoking were 61.3%, 9.3%, 59.2%, 14.1%, 90.9%, and 72.8%, respectively. Secondary or higher education (AOR: 4.42, 95% CI: 1.11 to 17.62), Brahmin and Chhetri ethnic groups (AOR: 3.30, 95% CI: 1.26 to 8.59) and good to very good perceived health (AOR: 3.96, 95% CI: 1.60 to 9.79) were positively associated with DASH diet adherence. Males (AOR: 2.05, 95% CI: 1.19 to 3.55) had higher odds of physical activity. Brahmin and Chhetri ethnic groups (AOR: 3.44, 95% CI: 1.63 to 7.26) and secondary or higher education (AOR: 4.70, 95% CI: 1.62 to 13.63) were correlates of weight management. Secondary or higher education (AOR: 2.47, 95% CI: 1.16 to 5.29), body mass index ≥25 kg/m² (AOR: 1.83, 95% CI: 1.04 to 3.22) and income above the poverty line (AOR: 2.24, 95% CI: 1.08 to 4.63) were positively associated with non-smoking. Furthermore, Brahmin and Chhetri ethnic groups (AOR: 4.51, 95% CI: 1.64 to 12.40), males (AOR: 0.17, 95% CI: 0.06 to 0.50) and primary education (AOR: 0.26, 95% CI: 0.08 to 0.85) were associated with alcohol moderation.

CONCLUSION

The adherence to the DASH diet and weight management was particularly low. Healthcare providers and policymakers should focus on improving self-care by designing simple and affordable interventions for all patients with hypertension.

Stakeholder's perspectives on acceptable interventions for promoting hypertension medication adherence in Namibia: nominal group technique

OBJECTIVE

To determine the most acceptable hypertension intervention package to promote hypertension adherence based on stakeholders' perspectives.

DESIGN

We employed the nominal group technique method and purposively sampled and invited key stakeholders offering hypertension services and patients with hypertension. Phase 1 was focused on determining barriers to hypertension adherence, phase 2 on enablers and phase 3 on the strategies. We employed the ranking method based on a maximum of 60 scores to establish consensus regarding hypertension adherence barriers, enablers and proposed strategies.

SETTING AND PARTICIPANTS

12 key stakeholders were identified and invited to participate in the workshop in Khomas region. Key stakeholders included subject matter experts in non-communicable diseases, family medicine and representatives of our target population (hypertensive patients).

RESULTS

The stakeholders reported 14 factors as barriers and enablers to hypertension adherence. The most important barriers were: lack of knowledge on hypertension (57 scores), unavailability of drugs (55 scores) and lack of social support (49 scores). Patient education emerged as the most important enabler (57 scores), availability of drugs emerged second (53 scores) and third having a support system (47 scores). Strategies were 17 and ranked as follows: continuous patient education as the most desirable (54 scores) strategy to help promote hypertension adherence, followed by developing a national dashboard to primarily monitor stock (52 scores) and community support groups for peer counselling (49 scores).

CONCLUSIONS

Multifaceted educational intervention package targeting patient and healthcare system factors may be considered in implementing Namibia's most acceptable hypertension package. These findings will offer an opportunity to promote adherence to hypertension therapy and reduce cardiovascular outcomes. We recommend a follow-up study to evaluate the proposed adherence package's feasibility.

Cluster randomised trial to evaluate comprehensive approach to hypertension management in Nepal: a study protocol

INTRODUCTION

Despite having effective approaches for hypertension management including use of antihypertensive medication, monitoring of blood pressure and lifestyle modification many people with hypertension in Nepal remain undetected and untreated. A comprehensive intervention which provides personalised counselling on lifestyle modification, medication adherence together with support for regular monitoring of blood pressure is expected to achieve well controlled blood pressure.

METHODS AND ANALYSIS

This is a community-based, non-blinded, parallel group, two-arm cluster randomised controlled trial, with an allocation ratio of 1:1, conducted in Budhanilkantha municipality, Nepal. Ten health facilities and their catchment area are randomly allocated to either of the two arms. 1250 individuals aged 18 years and older with an established diagnosis of hypertension will be recruited. The intervention arm receives a comprehensive hypertension management package that includes blood pressure audit by health workers, home-based patient support by community health workers to engage patient and family members in providing tailored educational counselling on behavioural and lifestyle changes in addition to routine care. The control arm includes routine hypertension care. Trained enumerators will ensure consent and collect data. Outcome data on blood pressure, weight, waist and hip circumference will be measured and self-reported data on diet, lifestyle, medication adherence and hypertension knowledge will be registered at 11 months' follow-up. The change in outcome measures will be compared by intention to treat, using a generalised linear mixed model. A formative assessment will be conducted using semistructured interviews and focus group discussions to explore factors affecting hypertension management. A mix-method approach will be applied for process evaluation to explore acceptability, adoption, fidelity, feasibility and coverage.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Nepal Health Research Council (682/2021) and Regional Committee for Medical and Health Research Ethics, Norway (399479). The findings will be disseminated in peer-reviewed journal articles and with decision makers in Nepal.

Arterial hypertension and its covariates among nomadic Raute hunter-gatherers of Western Nepal: a mixed-method study

OBJECTIVES

To determine the prevalence of, and understand the factors associated with, hypertension among the nomadic Raute hunter-gatherers of Western Nepal.

DESIGN

A mixed-method study.

SETTING

The study was carried out at Raute temporary campsites in the Surkhet District of Karnali Province between May and September 2021.

PARTICIPANTS

The questionnaire-based survey included all males and non-pregnant females of the nomadic Raute group aged 15 years and above. In-depth interviews were conducted among purposively selected 15 Raute participants and four non-Raute key informants to help explain and enrich the quantitative findings.

OUTCOME MEASURES

The prevalence of hypertension (defined as brachial artery blood pressure of systolic ≥140 mm Hg and/or diastolic ≥90 mm Hg) and its sociodemographic, anthropometric and behavioural covariates.

RESULTS

Of the 85 eligible participants, 81 (median age 35 years (IQR: 26-51), 46.9% female) were included in the final analysis. Hypertension was found in 10.5% of females, 48.8% of males and 30.9% of the total population. Current alcohol and tobacco use were high (91.4% and 70.4%, respectively), with concerning high rates among youths. Males, older people, current drinkers and current tobacco users were more likely to have hypertension. Our qualitative analysis suggests that the traditional forest-based Raute economy is gradually transitioning into a cash-based one that heavily relies on government incentives. Consumption of commercial foods, drinks and tobacco products is increasing as their market involvement grows.

CONCLUSION

This study found a high burden of hypertension, alcohol and tobacco use among nomadic Raute hunter-gatherers facing socioeconomic and dietary transitions. Further research is needed to assess the long-term impact of these changes on their health. This study is expected to help appraise concerned policymakers of an emerging health concern and formulate context-specific and culturally sensitive interventions to limit hypertension-related morbidities and mortalities in this endangered population.

Hypertension control rate in India: systematic review and meta-analysis of population-level non-interventional studies, 2001-2022

Background

Hypertension is a significant contributor to mortality in India. Achieving better hypertension control rate at the population level is critical in reducing cardiovascular morbidity and mortality.

Methods

Hypertension control rate was defined as the proportion of patients with their blood pressure under control (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg). We conducted a systematic review and meta-analysis of community-based, non-interventional studies published after 2001 that reported hypertension control rates. We searched PubMed, Embase, and Web of Science databases, and grey literature, and extracted data using a common framework, and summarized the study characteristics. We conducted random-effects meta-analysis using untransformed hypertension control rates and reported the overall summary estimates and subgroup estimates of control rates as percentages and 95% confidence intervals. We also conducted mixed-effects meta-regression with sex, region, and study period as covariates. The risk of bias was assessed, and level of evidence was summarized using SIGN-50 methodology. The protocol was pre-registered with PROSPERO, CRD42021267973.

Findings

The systematic review included 51 studies (n = 338,313 hypertensive patients). 21 studies (41%) reported poorer control rates among males than females, and six studies (12%) reported poorer control rates among rural patients. The pooled hypertension control rate in India during 2001-2020 was 17.5% (95% CI: 14.3%-20.6%)-with significant increase over the years, reaching 22.5% (CI: 16.9-28.0%) in 2016-2020. Sub-group analysis showed significantly better control rates in the South and West regions, and significantly poorer control rates among males. Very few studies reported data on social determinants or lifestyle risk factors.

Interpretation

Less than one-fourth of hypertensive patients in India had their blood pressure under control during 2016-2020. Although the control rate has improved compared to previous years, substantial differences exist across regions. Very few studies have examined the lifestyle risk factors and social determinants relevant to hypertension control in India. The country needs to develop and evaluate sustainable, community-based strategies and programs to improve hypertension control rates.

Funding

Not applicable.

Ethnicity Disparities in the Prevalence, Awareness, Treatment, and Control Rates of Hypertension in China

Objectives

Previous studies reported that there were disparities in hypertension management among different ethnic groups, and this study aimed to systematically determine the prevalence, awareness, treatment, and control rates of hypertension in multiple Chinese ethnic groups.

Methods

We searched Embase, PubMed, and Web of Science for articles up to 25 October, 2022. The pooled prevalence, awareness, treatment, and control rates of hypertension were estimated with 95% confidence intervals (CI). The heterogeneity of estimates among studies was assessed by the Cochran Q test and I ² statistic. Meta-regression analyses were conducted to identify the factors influencing the heterogeneity of the pooled prevalence, awareness, treatment, and control rate of hypertension.

Results

In total, 45 publications including 193,788 cases and 587,826 subjects were eligible for the analyses. The lowest prevalence was found in the Han group (27.0%), and the highest prevalence was in the Mongolian population (39.8%). The awareness rates ranged from 24.4% to 58.0% in the four ethnic groups. Both the highest treatment and control rates were found in the Mongolian population (50.6% and 16.0%, respectively), whereas the Yi group had the lowest control rate (8.0%). In addition, the study year, the mean age of subjects, mean body mass index of subjects, tobacco use (%), alcohol use (%), residence (urban%), and education (primary school%) had varied effects on heterogeneity.

Conclusions

These findings highlight the disparities in prevalence, awareness, treatment, and control rates of hypertension in a different ethnic population of China, which could provide suggestions for making targeted prevention measures.

Hypertension screening, awareness, treatment, and control: a study of their prevalence and associated factors in a nationally representative sample from Nepal

Background

The growing burden of hypertension is emerging as one of the major healthcare challenges in low- and middle-income countries (LMICs), such as Nepal. Given that they are struggling to deliver adequate health services, some LMICs have significant gaps in the cascade of hypertension care (including screening, awareness, treatment, and control). This results in uncontrolled hypertension, placing a high burden on both patients and healthcare providers.

Objective

The objective of this study was to quantify the gaps in hypertension screening, awareness, treatment, and control in the Nepalese population.

Methods

We used the data from a pooled sample of 9682 participants collected through two consecutive STEPwise approach to Surveillance (STEPS) surveys conducted in Nepal in 2013 and 2019. A multistage cluster sampling method was applied in the surveys, to select nationally representative samples of 15- to 69-year-old Nepalese individuals. Prevalence ratios were calculated using multivariable Poisson regression.

Results

Among the hypertensive participants, the prevalence of hypertension screening was 65.9% (95% CI: 62.2, 69.5), the prevalence of hypertension awareness was 20% (95% CI: 18.1, 22.1), the prevalence of hypertension treatment was 10.3% (95% CI: 8.8, 12.0), and the prevalence of hypertension control was 3.8% (95% CI: 2.9, 4.9). The unmet need of hypertension treatment and control was highest amongst the poorest individuals, the participants from Lumbini and Sudurpaschim provinces, those who received treatment in public hospitals, the uninsured, and those under the age of 30 years.

Conclusions

The gaps in the cascade of hypertension care in Nepal are large. These gaps are particularly pronounced among the poor, persons living in Lumbini and Sudurpaschim provinces, those who sought treatment in public hospitals, those who did not have health insurance, and young people. National- and local-level public health interventions are needed to improve hypertension screening, awareness, treatment, and control in Nepal.

Particulate air pollution and metabolic risk factors: Which are more prone to cardiac mortality

This study explored multiplex, country-level connections between a wide range of cardiac risk factors and associated mortality within the South Asian Association for Regional Cooperation (SAARC) countries. The grey relational analysis (GRA) methodology is used to evaluate data from 2001 to 2018 to compute scores and rank countries based on cardiac mortality. Subsequently, we used the conservative (Min-Max) technique to determine which South Asian country contributes the most to cardiac mortality. The Hurwicz criterion is further applied for optimization by highlighting the risk factors with the highest impact on cardiac mortality. Empirical findings revealed that India and Nepal are the leading drivers of cardiovascular disease (CVD) mortality among all SAARC nations based on the results of the GRA methodology. Moreover, the outcomes based on the Hurwicz criterion and the conservative criterion indicated that CVD mortality is considerably impacted by household air pollution from the combustion of solid fuel, with India as a potential contributor in the SAARC region. The outcomes of this research may enable international organizations and public health policymakers to make better decisions and investments within the SAARC region to minimize the burden of CVD while also strengthening environmentally sustainable healthcare practices.

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

Background

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

Methods

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

Results

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

Conclusion

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

Blood Pressure and Stroke: A Review of Sex- and Ethnic/Racial-Specific Attributes to the Epidemiology, Pathophysiology, and Management of Raised Blood Pressure

Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strong association with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.

Prevalence of diabetes mellitus and associated risk factors in Nepal: findings from a nationwide population-based survey

OBJECTIVES

The burden of diabetes mellitus (DM) has increased globally, particularly in low-income and middle-income countries, including Nepal. Population-based nationally representative data on the prevalence of DM is limited. This paper presents the prevalence of DM and its associated risk factors in Nepal.

RESEARCH DESIGNS AND METHODS

This population-based study sampled 13 200 participants aged 20 years and above in 400 clusters of 72 districts of Nepal. The study used a standardised questionnaire adapted from the WHO STEPwise approach to non-communicable disease risk factor surveillance instrument and digitalised in Android-compatible mobile phones. Fasting and 2 hours postprandial blood samples were taken to test various biochemical parameters. Descriptive followed by multivariate analyses were done to assess the association between explanatory variables and the outcome variable.

PRIMARY OUTCOME MEASURES

Prevalence of DM.

RESULTS

The prevalence of DM was found to be 8.5% (95% CI 7.8% to 9.3%). The odds of DM occurrence were higher in the upper age groups (40-59 years at adjusted OR (AOR) 3.1 (95% CI2.3 to 4.2) and 60+ years at AOR 4.7 (95% CI 3.3 to 6.6)), compared with the group aged 20-39 years. Men were found to have higher odds of DM (AOR 1.3, 95% CI 1.1 to 1.6) compared with women. Urban residents had almost twice higher odds of DM (AOR 1.7, 95% CI 1.4 to 2.2) compared with rural residents. Participants with raised blood pressure (BP) (AOR 2.2, 95% CI 1.8 to 2.7), those who were overweight and obese (AOR 2.0, 95% CI 1.6 to 2.4) and those who had high triglycride level (≥150 mg/dL) (AOR 2.1, 95% CI 1.8 to 2.6) also had twice higher odds of DM compared with those with normal BP, an average body mass index and normal triglyceride level, respectively.

CONCLUSIONS

Targeted interventions to higher risk groups as well as prevention and control of other associated biological risk factors might help to reduce the prevalence of DM in Nepal.

Translation, Cultural Adaptation and Validation of the Hill Bone Compliance to High Blood Pressure Therapy Scale to Nepalese Language

BACKGROUND

Control of high blood pressure and prevention of cardiovascular complications among hypertensive patients depends on patients' adherence to therapy. The Hill-Bone Compliance to High Blood Pressure Therapy Scale (HBCTS) is one of the most popular scale to assess hypertensive patients' adherence behaviour. Unfortunately, no questionnaire in the Nepalese language is available to date to assess adherence to anti-hypertensive therapy.

AIM

To translate, culturally adapt and validate the English original version of the HBCTS into Nepalese language to measure treatment adherence of Nepalese hypertensive patients.

METHODS

The cross-sectional study was conducted to translate, culturally adapt and validate the HBCTS into Nepalese version. The standard translation process was followed and was evaluated among 282 hypertensive patients visiting selected primary healthcare centers (PHCCs) of Kathmandu district, Nepal. Cronbach's alpha was measured to assess the reliability of the tool. Exploratory factor analysis using principal component analysis with varimax rotation was used to evaluate structural validity.

RESULTS

The mean±SD age of 282 participants was 58.49±12.44 years. Majority of participants were literate (75.2%), and consumed at least one anti-hypertensive medication per day (85.5%). Nearly half (42.2%) of the participants had a family history of hypertension, and almost half (48%) of them had comorbid conditions. Mean ±SD score for overall adherence was 17.85±3.87 while those of medication taking, reduced salt taking, and appointment keeping subscales were 10.63±2.55, 4.16±1.12 and 3.06±1.07, respectively. Kaiser Meyer Olkin (KMO) was found to be 0.877. Exploratory factor analysis revealed a three-component structure; however, the loading of components into medication adherence, reduced salt intake and appointment keeping constructs were not identical to the original tool. Cronbach's alpha score for the entire HBCTS scale was 0.846.

CONCLUSION

The translated Nepali version of the HBCTS demonstrated acceptable reliability and validity to measure adherence to antihypertensive therapy among hypertensive patients in clinical and community settings in Nepal.

Acceptability of a mHealth strategy for hypertension management in a low-income and middle-income country setting: a formative qualitative study among patients and healthcare providers

BACKGROUND

Understanding contextual needs and preferences is important for a successful design and effective outcome of a mHealth strategy.

OBJECTIVES

This formative study aimed to explore the perspectives of patients and providers on the acceptability of a mHealth (text message) strategy and elicit preferred features of a mHealth strategy for hypertension management.

DESIGN

A qualitative study was conducted using in-depth interviews and focus group discussions guided by the technology acceptance model.

SETTING

The study was conducted at primary healthcare facilities and at a tertiary level referral hospital in Kathmandu, Nepal.

PARTICIPANTS

A total of 61 participants, patients with hypertension (n=41), their family members (n=5), healthcare workers (n=11) and key informants (n=4) were included. We purposively recruited patients with hypertension aged 30-70 who attended the selected healthcare facilities to obtain maximum variation based on their age, sex and literacy.

RESULTS

The respondents perceived the mHealth strategy to be useful as it would reinforce medication compliance and behaviour change. Participants valued the trustworthiness of information from health authorities that could be delivered privately. Some implementation challenges were identified including a lack of technical manpower, resources for software development, gaps in recording a patient's essential information and digital illiteracy. Solutions proposed were having system-level preparedness for recording the patient's details, establishing a separate technical department in the hospital and involving a family member to assist illiterate/elderly patients. In addition, participants preferred text messages in the local language, containing comprehensive contextual content (disease, treatment, cultural foods and misconceptions) delivered at regular intervals (2-3 times/week) preferably in the morning or evening.

CONCLUSIONS

We found that a simple text messaging strategy was acceptable for hypertension management in this low/middle-income country setting. However, meticulous planning must address the needs of a diverse range of participants to ensure the mHealth strategy is acceptable to wider groups.

BMI, waist to height ratio and waist circumference as a screening tool for hypertension in hospital outpatients: a cross-sectional, non-inferiority study

OBJECTIVE

This non-inferiority study aimed to determine the burden of obesity in a hospital outpatient setting of a developing country, using three commonly employed metrics as predictors of hypertension (HTN).

DESIGN

A cross-sectional study design was adopted.

SETTING

This study was conducted in Health Promotion and Risk Factor Screening Services of a tertiary hospital for eye and ear, nose, throat in a semiurban area of Nepal.

PARTICIPANTS

2256 randomly selected outpatients between 40 and 69 years old.

OUTCOME MEASURES

The three obesity metrics and HTN were analysed for association using correlation, the area under the receiver operating characteristic (ROC) curve and ORs.

RESULTS

The prevalence of obesity or overweight by body mass index (BMI) was 58.29%; by waist-to-height ratio (WHtR) was 85.95%, high waist circumference (WC) was observed among 66.76% of participants. Female participants had a greater prevalence of high WC (77.46%) than males (53.73%) (p<0.001). Prevalence of HTN and pre-HTN were 40.67% and 36.77%, respectively. The areas under the ROC curve were significantly higher than 0.5 for BMI (0.593), WHtR (0.602) and WC (0.610).

CONCLUSION

This study showed that WHtR and WC measured were not inferior to BMI as a metric for obesity detection and HTN prediction. Because of its low cost, simplicity of measurement and better ability to predict HTN, it may become a more usable metric in health facilities of low-income and middle-income countries.

Effectiveness of community-based health education and home support program to reduce blood pressure among patients with uncontrolled hypertension in Nepal: A cluster-randomized trial

BACKGROUND

Hypertension is a major global public health problem. Elevated blood pressure can cause cardiovascular and kidney diseases. We assessed the effectiveness of health education sessions and home support programs in reducing blood pressure among patients with uncontrolled hypertension in a suburban community of Nepal.

METHODS

We conducted a community-based, open-level, parallel-group, cluster randomized controlled trial in Birendranagar municipality of Surkhet, Nepal. We randomly assigned four clusters (wards) into intervention and control arms. We provided four health education sessions, frequent home and usual care for intervention groups over six months. The participants of the control arm received only usual care from health facilities. The primary outcome of this study was the proportion of controlled systolic blood pressure (SBP). The analysis included all participants who completed follow-up at six months.

RESULTS

125 participants were assigned to either the intervention (n = 63) or the control (n = 62) group. Of them, 60 participants in each group completed six months follow-up. The proportion of controlled SBP was significantly higher among the intervention participants compared to the control (58.3% vs. 40%). Odds ratio of this was 2.1 with 95% CI: 1.01-4.35 (p = 0.046) and that of controlled diastolic blood pressure (DBP) was 1.31 (0.63-2.72) (p = 0.600). The mean change (follow-up minus baseline) in SBP was significantly higher in the intervention than in the usual care (-18.7 mmHg vs. -11.2 mmHg, p = 0.041). Such mean change of DBP was also higher in the intervention (-10.95 mmHg vs. -5.53 mmHg, p = 0.065). The knowledge score on hypertension improved by 2.38 (SD 2.4) in the intervention arm, which was significantly different from that of the control group, 0.13 (1.8) (p<0.001).

CONCLUSIONS

Multiple health education sessions complemented by frequent household visits by health volunteers can effectively improve knowledge on hypertension and reduce blood pressure among uncontrolled hypertensive patients at the community level in Nepal.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT02981251.

Relationship between cigarette smoking and blood pressure in adults in Nepal: A population-based cross-sectional study

Smoking and hypertension are two major risk factors for cardiovascular disease, the leading cause of death in Nepal. The relationship between cigarette smoking and blood pressure (BP) in Nepal is unclear. This study analysed the data from the 2016 Nepal Demographic and Health Survey to explore the differences in systolic BP (SBP) and diastolic BP (DBP) between current daily cigarette smokers and non-smokers in Nepali adults aged 18 to 49 years. A total of 5518 women and 3420 men with valid BP measurements were included. Age, body mass index, wealth quintile (socio-economic status) and agricultural occupation (proxy for physical activity) were included as potential confounders in multivariable linear regression analysis. Women smokers were found to have significantly lower SBP (mean difference 2.8 mm, 95% CI 0.7-4.8 mm) and DBP (mean difference 2.2 mm, 95% CI 0.9-3.6 mm) than non-smokers after adjustment. There were no significant differences in BP between smokers and non-smokers in males, either before or after adjustment. The lower BP in female cigarette smokers in Nepal may be explained by the physiological effect of daily cigarette smoking per se in women, or unmeasured confounders associated with a traditional lifestyle that may lower BP (for example, diet and physical activity). In this nationally representative survey, daily cigarette smoking was not associated with increased BP in males or females in Nepal.