Blood pressure and CVD risk reduction
Cardiovascular disease (CVD) is the primary cause of death worldwide, and in underdeveloped countries such as Haiti. It’s also found that among cardiovascular problems, hypertension is the leading risk factor. In this study, the researcher’s goal was to identify gaps in the hypertension continuum of screening, diagnosis, treatment, and blood pressure (BP) control.
Hypertension
Hypertension (HTN) is the most prevalent risk factor for CVD in low-and middle-income countries (LMICs) with increased BP resulting in life expectancy reductions of 2.6 years for men and 2.9 years for women. High systolic blood pressure (SBP) accounted for 10.4 million deaths in 2019 with two-thirds of the burden occurring in LMICs.
Lowering BP has been shown to substantially reduce CVD mortality and morbidity, however, a large proportion of individuals living in LMICs lack access to HTN screening and management. LMICs have approximately half the proportion of awareness and treatment and a quarter of the control rate, compared to high-income countries.
In Haiti, HTN is the leading CVD risk factor, with an age-adjusted prevalence of 28.5%, with an estimated risk as high as 49% in women and 40% in men ages 35–64. Additionally, HTN may occur earlier in Haitians, with HTN among Haitians aged 18–30 years being two to four times higher than similarly aged Black Americans.
Higher BP in Haitians may in part be due to environmental stressors such as earthquakes and other natural disasters, which put additional strain on the health care system. Non-communicable diseases (NCDs) such as CVD are the leading cause of morbidity and mortality globally and are increasing rapidly in LMICs.
HTN management is a growing challenge in Haiti due to limited access to primary care services, economic constraints, and poor public health infrastructure, with the cost of medications an important barrier.
NCD care continua are theoretical frameworks used to monitor public health system performance by measuring steps of screening, diagnosis, treatment, and ultimately control of chronic diseases.
They are useful to benchmark the coverage or unmet need of primary and secondary prevention interventions for BP in a community. While population-level estimates of HTN for Haiti have been reported in the 2016–2017 Demographic Health Survey(DHS), the survey focuses only on adults 35–64 and may not be representative of the wider population.
Overview of the Study
We present a population-based study with research-grade BP measurements to describe the HTN care continuum in Port-au-Prince(PAP) to identify areas of need for HTN management in this under-served population.
The goal of this analysis is to quantify HTN prevalence and the rates of achieving each step of the care continuum. Another goal is to determine the factors associated with attaining HTN diagnosis, treatment, and control, in a population-based sample from urban Haiti.
Study Population
This analysis includes baseline cross‐sectional data from participants enrolled in the Haiti CVD Cohort Study, a longitudinal observational study of adults ≥18 years in PAP. 19 The study was conducted at the Groupe Haitien d’Etude de Sarcome de Kaposi et de Infections Opportunistes (GHESKIO), research, treatment, and training clinic located in downtown PAP. The aims of the parent study are to estimate the prevalence and incidence of CVD risk factors and examine the role of poverty‐related social determinants. Participants were recruited using multistage random sampling from metropolitan PAP which includes an estimated 1.4 million people.
For this analysis, the research included participants enrolled from March 19, 2019, to April 30, 2021. The analysis was restricted to participants with information on sex, SBP, diastolic blood pressure (DBP), and responses to questions regarding the previous diagnosis of HTN and the use of antihypertensives.
Measurements
Sociodemographic data, health behaviors, and clinical data were collected at the time of study enrollment at GHESKIO. Education was categorized as having completed no education, primary, secondary, or higher than secondary school. Income was categorized from self‐reported data as ≤1 USD per day or >1 USD per day.
Self‐reported smoking status was categorized as never smokers or current/former smokers. Physical activity was determined using questions about vigorous activity for longer than 75 min per week, or moderate activity for longer than 150 min per week.
Participants were categorized as having low physical activity versus moderate to high physical activity. Participants were categorized into groups based on WHO guidelines for BMI, where less than 18.5 kg/m2 was underweight, 18.5–25 kg/m2 was normal weight, 25–30 kg/m2 was overweight, and over 30 kg/m2 was obese.
BP was measured by study staff following WHO and AHA guidelines. The OMRON HEM-907 automatic BP machine was used to measure BP with appropriate cuff sizes that encircled at least 80% of the arm. Participants were seated for 5 min prior to measurement, with both feet on the ground and arms at heart level. Three measurements were taken in the left arm 1 min apart. For this analysis, BP was determined by averaging the last two of three BP measurements. HTN was defined as SBP ≥ 140 mmHg, DBP ≥ 90 mmHg, or the use of self‐reported antihypertensive medication.
Methods
From March 2019 to April 2021, sociodemographic and clinical data were collected from a population-based sample of adults ≥18 years. HTN was defined as systolic BP≥140mmHg, diastolic BP ≥90 mmHg, or use of antihypertensive medication.
The screening was defined as ever having had a BP measurement; diagnosis as previously being informed of any diagnosis; treatment as having taken antihypertensives in the past 2 weeks, and controlled staking antihypertensive and having BP<140/90mmHg. Factors associated with attaining each step in the continuum were assessed using Poisson multivariable regressions.
Results
Among 2737 participants, 810 (29% age-standardized) had HTN, of whom 97% had been screened, 72% diagnosed, 45% treated, and 13% controlled. There were no significant differences across age groups or sex. Obesity (BMI≥30) was a significant factor associated with receiving treatment compared to normal weight (BMI<25), with a prevalence ratio(PR) of 1.5 (95%CI1.1–2.0).
Having secondary or higher education was associated with a higher likelihood of controlled BP (PR1.9[95%CI1.1–3.3]). In this urban Haitian population, the greatest gaps in HTN care are treatment and control. Targeted interventions are needed to improve these steps, including broader access to affordable treatment, timely distribution of medications, and patient adherence to HTN medication.
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