Control of Hypertension among Diabetic Patients in a Referral Hospital in Tanzania: A Cross-Sectional Study

Prevalence of and factors associated with uncontrolled hypertension among patients with early chronic kidney disease attending tertiary hospitals in Dodoma, Tanzania: a cross-sectional study

OBJECTIVE

To determine the prevalence of uncontrolled hypertension and its associated factors among patients with early chronic kidney disease (CKD) attending medical outpatient clinics at tertiary hospitals in Dodoma, Tanzania.

DESIGN

Cross-sectional study.

SETTING

Two tertiary hospitals in Dodoma, Tanzania.

PARTICIPANTS

The participants in this study were adult patients (≥18 years) with early CKD stages (1, 2 and 3) who were attending nephrology and medical outpatient clinics from November 2020 to March 2021. Patients who had been attending the clinic for at least 3 months, had baseline clinical data on their files, had estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 and who provided written informed consent were eligible. A total of 352 patients were enrolled, of whom 182 were men and 170 were women.

OUTCOME MEASURE

The dependent variable was uncontrolled hypertension among patients with early CKD, based on blood pressure measurements.

RESULTS

The prevalence of hypertension was 58.5% (206 of 352) and the prevalence of uncontrolled hypertension was 58.3% (120 of 206). Among patients with uncontrolled hypertension, 88.3% (106 of 120) had CKD stage 3, 80.2% (96 of 120) reported non-adherence to antihypertensives, 76.7% (92 of 120) were overweight or obese, 72.5% (87 of 120) reported current alcohol use and 26.7% (32 of 120) had diabetes mellitus. Factors that contributed to higher odds of uncontrolled hypertension were: age ≥50 years (OR=5.17, 95 % CI 2.37 to 13.33, p=0.001), alcohol use (OR=11.21, 95% CI 3.83 to 32.84, p=0.001), non-adherence to antihypertensives (OR=10.19, 95% CI 4.22 to 24.61, p=0.001), overweight/obesity (OR=6.28, 95% CI 2.54 to 15.53, p=0.001) and CKD stage 3 (OR=3.52, 95% CI 1.32 to 9.42, p=0.012).

CONCLUSION

Uncontrolled hypertension was highly prevalent among patients with early CKD in this setting and was associated with age, current alcohol use, non-adherence to antihypertensives, overweight/obesity and declining eGFR.

Regional prevalence of hypertension among people diagnosed with diabetes in Africa, a systematic review and meta-analysis

Hypertension and diabetes comorbidity can increase healthcare expenditure and the risk of coronary heart disease. We conducted a systematic review and meta-analysis to estimate the prevalence of hypertension among people with diabetes in African countries. We searched EMBASE, PubMed and HINARI databases from inception to March 2023. Cross-sectional studies reporting the prevalence of hypertension among people with diabetes and published in English in Africa were eligible for inclusion. The cross-sectional study design component of the mixed method appraisal tool was used to assess the quality of the included studies. We quantified the overall and regional prevalence of hypertension among people with diabetes using random-effects meta-analysis. We assessed heterogeneity and publication bias using I2 statistics and funnel plots. Out of 3815 articles retrieved from the various databases, 41 met the inclusion criteria with sample sizes ranging from 80 to 116726. The mean age was 58 years (± 11) and 56% were women. The pooled prevalence of hypertension in people diagnosed with diabetes was 58.1% [95% CI: 52.0% - 63.2%]. By region, Central Africa had the highest hypertension prevalence; 77.6% [95% CI: 53.0% - 91.4%], Southern Africa 69.1% [95% CI: 59.8% - 77.1%;], North Africa 63.4% [95% CI: 37.1% - 69.1%;], West Africa 51.5% [95% CI: 41.8% - 61.1%] and East Africa 53.0% [95% CI: 45.8% - 59.1%]. Increasing age, being overweight/obese, being employed, longer duration of diabetes, urban residence, and male sex were reported to be associated with a higher likelihood of developing hypertension. The high prevalence of hypertension among people with diabetes in Africa highlights the critical need for an integrated differentiated service delivery to improve and strengthen primary care and prevent cardiovascular disease. Findings from this meta-analysis may inform the delivery of interventions to prevent premature cardiovascular disease deaths among persons in the region.

Management of chronic conditions in resource limited settings: multi stakeholders' perception and experiences with receiving and providing integrated HIV, diabetes and hypertension services in Tanzania

BACKGROUND

The rising prevalence of non-communicable diseases (NCDs) alongside the continuing high burden of HIV poses a serious challenge to middle- and low-income countries' healthcare systems. Pilot studies of integrated models of service delivery for HIV, hypertension and diabetes have demonstrated that they are feasible and acceptable among patients and care providers. This study assessed multi-stakeholders' perspectives of the delivery and receipt of integrated care in Tanzania.

METHODS

A qualitative process evaluation was conducted in Dar es Salaam region of Tanzania where the integrated service delivery model was implemented from July to November 2021. In-depth interviews were held with seven key informants at the national, regional and district levels, eight healthcare providers, two researchers working at the integrated clinic and forty patients benefiting from integrated services at a large hospital. Three focus group discussions were held with community leaders and residents of the hospital's catchment area, and clinic level observations were conducted. Thematic analysis was conducted followed by the use of Bronfenbrenner's ecological model to identify factors pertinent to sustaining and scaling up of the integrated model.

RESULTS

Participants of the study at all levels were aware of the increased prevalence of NCDs specifically for hypertension and diabetes and were concerned about the trend of increasing co-morbid conditions among people living with HIV (PLHIV). The integrated service delivery model was positively perceived by stakeholders because of its multiple benefits for both patients and the healthcare system. These include stigma and discrimination reduction, improved quality of care, efficient use of limited resources, cost and time saving, reduced duplication of services and fostering of early detection for undiagnosed conditions. The organisation of the clinic was critical in increased satisfaction. Several challenges were observed, which included costs for NCD services relative to free care for HIV and inconsistent availability of NCD medications.

CONCLUSION

Stakeholders reported numerous benefits of the integrated service delivery model that are fundamental in improving the health of many Tanzanians living with NCDs and HIV. These benefits highlight the need for policy and decision-makers to sustain and expand the integrated service delivery model as a solution to many challenges facing the health system especially at the primary care level.

Suboptimal blood pressure control and its associated factors among people living with diabetes mellitus in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Suboptimal blood pressure control among people living with diabetes mellitus (DM) is one of the primary causes of cardiovascular complications and death in sub-Saharan Africa (SSA). However, there is a paucity of evidence on the prevalence and associated factors of suboptimal blood pressure control in SSA. Therefore, this review aimed to estimate its pooled prevalence and associated factors among people living with DM in SSA.  METHODS: We systematically searched PubMed, African Journals OnLine, HINARI, ScienceDirect, Google Scholar, and direct Google to access observational studies conducted in SSA. Microsoft Excel spreadsheet was used to extract the data, which was exported into STATA/MP version 16.0 for further analyses. Heterogeneity across studies was checked using Cochran's Q test statistics and I² test, and small study effect was checked using Funnel plot symmetry and Egger's statistical test at a 5% significant level. A random-effects model was used to estimate the pooled prevalence and associated factors of suboptimal blood pressure control at a 95% confidence interval (CI) and significance level of p < 0.05.

RESULTS

Of the 7329 articles retrieved, 21 articles were eligible for the meta-analysis. After performing random-effects model, the pooled prevalence of suboptimal blood pressure control was 69.8% (95% CI: 63.43, 76.25%). Poor adherence to antihypertensive treatment (OR = 1.7; 95% CI: 1.03-2.80, I² = 0.0%, p = 0.531) and overweight (OR = 2.4, 95% CI: 1.57-3.68, I² = 0.00%, p = 0.47) were significantly associated with suboptimal blood pressure control.

CONCLUSIONS

The prevalence of suboptimal blood pressure control among diabetic patients in SSA was high, and poor adherence to antihypertensive treatment and overweight were significantly associated with suboptimal blood pressure control. Hence, there is an urgent need for initiatives to improve and control hypertension, and preventive measures should concentrate on modifiable risk factors.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020187901.

The acceptability of integrated healthcare services for HIV and non-communicable diseases: experiences from patients and healthcare workers in Tanzania

BACKGROUND

In sub-Saharan Africa, the prevalence of non-communicable diseases (NCDs) has risen sharply amidst a high burden of communicable diseases. An integrated approach to HIV and NCD care offers the potential of strengthening disease control programmes. We used qualitative methods to explore patients' and care-providers' experiences and perspectives on the acceptability of integrated care for HIV-infection, diabetes mellitus (DM), and hypertension (HT) in Tanzania.

METHODS

A qualitative study was conducted in selected health facilities in Dar es Salaam and Coastal regions, which had started to provide integrated care and management for HIV, DM, and HT using a single research clinic for patients with one or more of these conditions. In-depth interviews were held with patients and healthcare providers at three time points: At enrolment (prior to the patient receiving integrated care, at the mid-line and at the study end). A minimum of 16 patients and 12 healthcare providers were sampled for each time point. Observation was also carried out in the respective clinics during pre- and mid-line phases. The Theoretical Framework of Acceptability (TFA) underpinned the structure and interpretation of the combined qualitative and observational data sets.

RESULTS

Patients and healthcare providers revealed a positive attitude towards the integrated care delivery model at the mid-line and at study end-time points. High acceptability was related to increased exposure to service integration in terms of satisfaction with the clinic setup, seating arrangements and the provision of medical care services. Satisfaction also centred on the patients' freedom to move from one service point to another, and to discuss the services and their own health status amongst themselves. Adherence to medication and scheduling of clinic appointments appeared central to the patient-provider relationship as an aspect in the provision of quality services. Multi-condition health education, patient time and cost-saving, and detection of undiagnosed disease conditions emerged as benefits. On the other hand, a few challenges included long waiting times and limited privacy in lower and periphery health facilities due to infrastructural limitations.

CONCLUSION

The study reveals a continued high level of acceptability of the integrated care model among study participants in Tanzania. This calls for evaluation in a larger and a comparative study. Nevertheless, much more concerted efforts are necessary to address structural challenges and maximise privacy and confidentiality.

High prevalence of uncontrolled hypertension among patients with type 2 diabetes mellitus: a hospital-based cross-sectional study in Southwestern Uganda

INTRODUCTION

most patients with diabetes mellitus are prone to uncontrolled blood pressures despite effective medical therapies; only about 30% of hypertensive patients have their blood pressures controlled. Poor control of hypertension is associated with increased risk for cardiovascular mortality and morbidity. We aimed to determine the prevalence and associated factors of uncontrolled hypertension among patients with type 2 diabetes mellitus (T2DM) attending ambulatory care at Mbarara Regional Referral Hospital, Southwestern Uganda.

METHODS

we conducted a cross-sectional study from January to April 2019, among hypertensive T2DM patients. We used a structured questionnaire to obtain data on socio-demographic and clinical characteristics. We defined uncontrolled hypertension in participants with blood pressure ≥140/90mmHg and performed binary logistic regression to determine factors associated with uncontrolled hypertension.

RESULTS

we analyzed data of 206 hypertensive participants with concomitant T2DM, with a median age of 54 (IQR, 49-60) years, and median duration of diabetes of 4 (IQR, 3-8) years; 71% were female. The prevalence of uncontrolled hypertension was 82.5% (170/206). Isolated systolic hypertension (aOR=7.58; 95%CI: 2.18-26.36, P=0.001) and left ventricular hypertrophy (LVH) (aOR=5.38; 95%CI: 1.11-26.10, P=0.037) were significantly associated with uncontrolled hypertension.

CONCLUSION

this study revealed a high prevalence of uncontrolled hypertension among T2DM patients in Southwestern Uganda. Isolated systolic hypertension and LVH were the key factors associated with uncontrolled hypertension. We recommend optimization therapy to reduce the burden of uncontrolled hypertension among patients with T2DM especially in those with isolated systolic hypertension, and left ventricular hypertrophy, who are at higher cardiovascular risk.

Control of hypertension among teachers in schools in Kerala (CHATS-K), India

Objective

We investigated the prevalence, awareness, treatment, control of hypertension and the factors associated with hypertension prevalence and control among school teachers in Kerala, India.

Methods

We surveyed 2216 school teachers in Thiruvananthapuram district of Kerala as part of the control of hypertension among teachers in schools in Kerala (CHATS-K), India. We used World Health Organization STEPS tools for non-communicable diseases risk factor surveillance. Blood pressure, weight and height were measured using standard protocols. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg, or self-reported current antihypertensive medication. Controlled hypertension was defined as SBP<140 and DBP<90 mmHg. Separate multivariate analysis was done for finding the associated factors with prevalence and control of hypertension.

Results

Age adjusted hypertension prevalence was 14.6%. Men, those with self-reported diabetes, having family history of hypertension and overweight were more likely to have higher prevalence of hypertension compared to their counterparts. Among hypertensives 62% were aware, 49% on treatment and 34% achieved adequate control. Hypertension control was significantly higher among women, diabetics and overweight individuals compared to their counterparts.

Conclusions

A higher level of hypertension control among school teachers in this study indicates an attainable level of hypertension control in the general population of the state. Teachers, with their highly regarded place in the social construct of the country and the state, could thus be used as role models for hypertension control for the general population in the state.

Factors Associated with Untreated Depression Among Type 2 Diabetic Patients at Halaba Kulito Hospital, South Ethiopia: A Cross-Sectional Study

BACKGROUND

Depressed type 2 diabetes mellitus patients (T2DM) show poorer compliance with treatment and self-care recommendations than non-depressed T2DM patients. This contributes to poor prognosis and accelerates diabetic-related complications including poor glucose regulation, diabetic retinopathy, neuropathy, nephropathy, and escalated healthcare expenditure.

OBJECTIVE

This study aimed to determine the magnitude of untreated depression and associated factors among people living with T2DM at outpatient diabetic clinic in Halaba Kulito General Hospital, Southern Ethiopia.

METHODS

Institution-based cross-sectional study was conducted from November 1 to December 15, 2019 at Halaba Kulito Hospital, Southern Ethiopia. We collected data by face-to-face interview with patient record review. A total of 418 type 2 diabetic patients were systematically selected and interviewed using a pretested structured questionnaire. We used a composite score of nine-items Patient Health Questionnaire (PHQ-9) to assess depression status. Descriptive statistics was used to summarize respondents' background characteristics. Logistic regression analysis was done to identify associated factors with the outcome variable. Levels of significance were set at 5% (P<0.05).

RESULTS

The finding depicted that 120 (29.3% with 95% Confidence interval (CI) = 25.0%, 34.0%) study participants satisfied diagnostic criteria for depression disorder. After controlling for confounding effect, we identified being hypertensive (Adjusted Odds Ratio (AOR) = 5.66; 95% CI: 3.24, 9.86), having no child (AOR = 3.32; 95% CI: 1.88, 5.86), and poor glycemic control (AOR = 6.23; 95% CI: 3.65, 10.54) as risk factors for untreated depression among people with type 2 diabetes.

CONCLUSION

Findings of this study indicate that untreated depression among type 2 diabetic patients is high. Poor glycemic control, not having a child and having hypertension were among significantly associated factors with depression. These results suggest much need for interventions, including strong medication adherence and self-care activities such as exercise or healthful diet for optimal glycemic control.

Improving the assessment of medication adherence: Challenges and considerations with a focus on low-resource settings

Improving patient survival and quality of life in chronic diseases requires prolonged and often lifelong medication intake. Less than half of patients with chronic diseases globally are adherent to their prescribed medications which preclude the full benefit of treatment, worsens therapeutic outcomes, accelerates disease progression, and causes enormous economic losses. The accurate assessment of medication adherence is pivotal for both researchers and clinicians. Medication adherence can be assessed through both direct and indirect measures. Indirect measures include both subjective (self-report measures such as questionnaire and interview) and objective (pill count and secondary database analysis) measures and constitute the mainstay of assessing medication adherence. However, the lack of an inexpensive, ubiquitous, universal gold standard for assessment of medication adherence emphasizes the need to utilize a combination of measures to differentiate adherent and nonadherent patients. The global heterogeneity in health systems precludes the development of a universal guideline for evaluating medication adherence. Methods based on the secondary database analysis are mostly ineffectual in low-resource settings lacking electronic pharmacy and insurance databases and allowing refills without updated, valid prescriptions from private pharmacies. This significantly restricts the choices for assessing adherence until digitization of medical data takes root in much of the developing world. Nevertheless, there is ample scope for improving self-report measures of adherence. Effective interview techniques, especially accounting for suboptimal patient health literacy, validation of adherence questionnaires, and avoiding conceptual fallacies in reporting adherence can improve the assessment of medication adherence and promote understanding of its causal factors.