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Evaluation of a community-based hypertension improvement program (ComHIP) in Ghana: data from a baseline survey

BMC Public HealthBMC series – open, inclusive and trusted201717:368

https://doi.org/10.1186/s12889-017-4260-5

Received: 29 September 2016

Accepted: 11 April 2017

Published: 28 April 2017

Abstract

Background

Ghana faces an increasing burden of non-communicable disease with rates of hypertension estimated as high as 36% in adults. Despite these high rates, hypertension control remains very poor in Ghana (4%). The current project aims to implement and evaluate a community-based programme to raise awareness, and to improve treatment and control of hypertension in the Eastern Region of Ghana. In this paper, we present the findings of the baseline cross-sectional survey focusing on hypertension prevalence, awareness, treatment, and control.

Methods

To evaluate the ComHIP project, a quasi-experimental design consisted of a before and after evaluations are being implemented in the intervention and comparison districts. A cohort study component is being implemented in the intervention district to assess hypertension control. Background anthropometric and clinical data collected as part of the baseline survey were analyzed in STATA Version 11. We examined the characteristics of individuals, associated with the baseline study outcomes using logistic regression models.

Results

We interviewed 2400 respondents (1200 each from the comparison and intervention districts), although final sample sizes after data cleaning were 1170 participants in the comparison district and 1167 in the intervention district. With the exception of ethnicity, the control and intervention districts compare favorably. Overall 32.4% of the study respondents were hypertensive (31.4% in the control site; and 33.4% in the intervention site); 46.2% of hypertensive individuals were aware of a previous diagnosis of hypertension (44.7% in the control site, and 47.7% in the intervention site), and only around 9% of these were being treated in either arm. Hypertension control was 1.3% overall (0.5% in the comparison site, and 2.1% in the intervention site). Age was a predictor of having hypertension, and so was increasing body mass index (BMI), waist, and hip circumferences. After adjusting for age, the risk factors with the greatest association with hypertension were being overweight (aOR = 2.30; 95% CI 1.53–3.46) or obese (aOR = 3.61; 95% CI 2.37–5.51). Older individuals were more likely to be aware of their hypertension status than younger people. After adjusting for age people with a family history of hypertension or CVD, or having an unhealthy waist hip ratio, were more likely to be aware of their hypertension status.

Conclusions

The high burden of hypertension among the studied population, coupled with high awareness, yet very low level of hypertension treatment and control requires in-depth investigation of the bottlenecks to treatment and control. The low hypertension treatment and control rates despite current and previous general educational programs particularly in the intervention district, may suggest that such programs are not necessarily impactful on the health of the population.

Background

Available evidence shows raised blood pressure to be one of the leading causes of cardiovascular disease (CVD) and deaths globally, with latest estimates at nearly 10.4 million deaths per year worldwide [1]. The level of raised blood pressure for which treatments have been shown to reduce clinical events in randomized trials is generally accepted as ≥140 systolic mmHg or ≥90 diastolic mm Hg. This level is termed ‘hypertension’ [2]. For individuals diagnosed with hypertension, lowering blood pressure with drugs reduces the risk of subsequent cardiovascular events, including a 35–40% reduction in the risk of stroke and a 20–25% reduction in the risk of myocardial infarction and heart failure [35].

Studies show that the current prevalence of hypertension in many low- and middle-income countries (LMICs), particularly in urban societies, is already as high as or higher than in high-income countries [68]. Worldwide the prevalence of hypertension in adults ranges between 32 and 50%, with evidence suggesting that the prevalence is increasing in Sub- Saharan Africa [8].

Like many LMICs, Ghana is facing an increasing burden of non-communicable diseases (NCDs), with hypertension at the forefront. The Ghana healthcare system has traditionally focused on addressing communicable diseases and maternal and child health challenges. There is now a great need to build the capacity of existing public and private healthcare systems to improve hypertension screening and management. A decade old report of the Ghana Ministry of Health (MOH) report showed hypertension as the second leading cause of outpatient morbidity in adults older than 45 years [9]. Recent estimates of prevalence of hypertension in Ghana range from 24 to 28% among women and 20–32% among men [1013]. Of note, the overall rates of hypertension from other local studies [10, 13] are relatively low, in part due to inclusion of younger participants in samples. Hypertension, nonetheless, is a serious health problem in Ghana; common risk factors include increasing body mass index (BMI), increased salt consumption, family history of hypertension and excessive alcohol intake [10, 14].

Studies suggest that the majority of individuals with hypertension are unaware of their status, even fewer are treated for the condition and only a proportion of those have their blood pressure (BP) under control (i.e. blood pressure < 140/90 mmHg) [15, 16]. Awareness of hypertension in Ghana is estimated to range between 16.4 and 54.1% [10, 12, 13, 17] and only 1.7–12.7% in individuals who have their hypertension under control [10, 12, 17]. In the most recent survey involving a nationally representative sample, the level of awareness and treatment status of women and men classified as hypertensive, was alarmingly low. More than 6 in 10 women (63%) and 8 in 10 men (86%) having high blood pressure, reported to be unaware of their condition. Amongst the hypertensive patients, only 17% of the women and 6% of the men were treated and controlled [13].

The context of hypertension control in Ghana

Ghana’s national NCD Control Programme (NCDCP), under the Disease Control Prevention Department, was established in 1992. The Ghana Health Service (GHS) has developed various guidelines for NCDs and prioritized hypertension. The guidelines recommend that all patients with hypertension be referred for further assessment.

The capacity of the GHS workforce to diagnose and manage hypertension is low. For instance, while training on NCD management is incorporated in the basic nurse education curricula, there is no follow-up in-service training or specialist training on NCD management for nurses. Nurses are currently also not expected to manage hypertension and have to learn on-the-job while assisting specialists.

In partnership with the GHS and the Ghana Police Service, FHI 360 developed a facility- and community-based prevention and screening pilot program for cardiovascular diseases (CVD) in 2009. The program included two sites – the Police Hospital, an urban tertiary hospital located in Ghana’s capital city, Accra, and its surrounding community, and Atua Hospital, a district hospital serving a semi-urban community. A population-based Assessment of Biological and Behavioral NCD risk factors within the pilot communities and a Baseline Health Facility Assessment were completed. CVD screening started in mid-August 2011 and included 14,000 patients by May 2012. Counseling and education on healthy eating and lifestyle were provided alongside screening, which was supported through mHealth lifestyle messages, appointment reminders, and treatment adherence support. Baseline findings of this pilot indicate that hypertension was an important health problem in the areas with prevalence of 31.9% among females and 34.1% among males [18].

The current paper presents baseline data from a 2-year hypertension control project, the Community-based Hypertension Improvement Project (ComHIP), which has been introduced in the peri-urban Lower Maya-Krobo district in the Eastern Region of Ghana. ComHIP is a community-based program for hypertension control, based on a public-private partnership, and consisting of three parts: implementation, impact evaluation and a cost-effectiveness evaluation. The private sector is engaged through licensed chemical sellers (LCSs), who are community pharmacists. The program utilizes ICTs and task shifting to enhance the capacity of the Ghana Health Service to improve management and control of hypertension. The various components of ComHIP are presented in Fig. 1.
Fig. 1

Components of ComHIP

ComHIP is also a public-private partnership between the Ghana Health services, FHI360 and the Novartis Foundation, supported by the Ghana School of Public Health and the London School of Hygiene & Tropical Medicine. While the overaching goal of ComHIP is to address the huge burden of hypertension through the deployment of a community-based model that engages the private sector public sector, and utilizes information and communication technologies (ICTs). Such a partnership plus the deployment of innovative technology increases the odds of the project’s success. The current baseline study presents hypertension prevalence, awareness, treatment, as well as knowledge and the risk factors associated with hypertension in two Ghanaian health districts.

Methods

Study design

To evaluate the project, a quasi-experimental study consisting of two parts (cross-sectional surveys, and a cohort study) were employed. The cross-sectional surveys constitute a before and after evaluation at baseline and endline in the intervention and control districts. The cohort study is currently being implemented in the intervention district.

Setting

Intervention district

The community selected for the intervention is Lower Manya-Krobo District in the Eastern Region of Ghana (Fig. 2). This site was selected following the unmet need of hypertension and the existing relationship of FHI360 with the district health authorities and the district authorities’ commitment to address CVD. A recent unpublished situational analysis of hypertension in that same district identified hypertension to be the fourth reason of hospital admissions in 2014 and the eighth cause of mortality. The analysis further showed that four deaths were recorded in hospital for every 100 patients admitted with hypertension [19].
Fig. 2

Map of the Eastern Region of Ghana highlighting the lower Manya Krobo district and Akuapim South municipality

The district has a population of 89,246 of whom 84% lives in urban areas. The population is served by two public hospitals, the Atua Government Hospital and Akuse Hospital, as well as a mission hospital in Agormanya, St. Martin’s. There are four public health centers, serving as primary contact points for health care, referring patients to hospitals. The district includes six sub-districts, 14 Community-based Health Planning and Services (CHPS) zones. There are approximately 75 licensed chemical sellers (LCS) in the district.

Comparison district

The comparison district is Akuapem South Municipality (now Nsawam-Adoagyiri Municipality and Akwapim South District), selected for its relative similarity with the intervention district regarding socio-demographic characteristics (income, employment, education); infrastructure (roads, clinics, hospitals, distance from metropolitan area); baseline health profile (disease prevalence, incidence, morbidity and mortality); development activity (private investment, NGO activity, state demonstrations projects); and level of support from the local health authority.

According to the 2010 Population and Housing Census, Akwapim South Municipality has an estimated population of 123,501, representing 4.7% of the total population of the Eastern Region. Health facilities in the municipality are the District hospital, six Health Centres, two private hospitals, five Functional Community Health Planning and Services (CHPS) compounds; 35 Demarcated CHPS compounds, two Mission Hospitals; and one Orthopedic Centre.

Sample size, participants sampling and summary of field procedures

For sample size calculations different assumptions about baseline prevalence, and intervention effects on different outcomes can produce different sample sizes. The main expected outcome of the ComHIP study is to reduce the proportion of people with uncontrolled hypertension. The power and sample sizes were thus calculated for reductions of prevalence of uncontrolled hypertension of about 3% in the control group and 10% in the intervention group (and for other values). Table 1 shows the power for the detection of different effect sizes on the reduction of hypertension.
Table 1

Sample size and power calculations for reduction in hypertension under different assumptions of baseline prevalence, intervention effect and sample size (per arm per survey)

Baseline prevalence

30%

30%

30%

35%

35%

35%

Improvement in control (A)

−3.0%

−3.0%

−3.0%

−3.5%

−3.5%

−3.5%

Improvement in intervention (B)

−9.0%

−10.5%

−12.0%

−10.5%

−12.3%

−14%

Intervention effect size (B – A):

-6%

−8%

−9%

−7%

−9%

−11%

Power if sample size = 800

51%

71%

86%

61%

81%

93%

Power if sample size = 900

56%

76%

90%

66%

85%

95%

Power if sample size = 1000

60%

80%

92%

71%

88%

97%

Power if sample size = 1100

64%

84%

94%

75%

91%

98%

Power if sample size = 1200

68%

87%

96%

78%

93%

99%

Using type I error in the analysis: alpha=

0.05

0.05

0.05

0.05

0.05

0.05

Expected baseline prevalence in both groups: A=

30%

30%

30%

35%

35%

35%

Expected improvement in control group: B=

−3.0%

−3.0%

−3.0%

−3.5%

−3.5%

−3.5%

Expected improvement in intervention group: C=

−9.0%

−10.5%

−12.0%

−10.5%

−12.3%

−14.0%

Therefore the effect of Intervention is: C-B =

-6%

−8%

−9%

−7%

−9%

−11%

Sample per group per period

1000

1.2

833

53%

72%

87%

63%

82%

94%

Sample per group per period

1100

1.2

917

57%

76%

90%

67%

86%

96%

Sample per group per period

1200

1.2

1000

60%

80%

92%

71%

88%

97%

Sample per group per period

1000

1.4

714

47%

66%

82%

56%

76%

90%

Sample per group per period

1100

1.4

786

50%

70%

85%

60%

80%

92%

Sample per group per period

1200

1.4

857

54%

74%

88%

64%

83%

94%

 

(A)

(B)

(C)

      

(A) = Number sampled; (B) = Desgin effect; (C) = Efective sample size

Within each of the study districts, a random sample of households was conducted using a four- stage sampling procedure. First, a purposive sampling technique was used to select the intervention and comparison districts; the second stage entailed a systematic selection of Census Enumeration Areas (EAs) from those two districts. That selection was done by the Ghana Statistical Service (GSS). The third stage entailed a simple random selection of households. Households were eligible for inclusion if one or more members were aged 30 years and above and had lived in the district during the last 12 months. All adults meeting the inclusion criteria in a selected household would be interviewed; this number ranged from 1 to 9 adults per household in both districts, with a median of 1 adult per household. There were 30 EAs each in the Intervention and Comparison districts.

Surveys were conducted using an innovative mobile technology: the Open Data Kit software on mobile devices. With this technology, data were collected at the household level. Data collected included demographics, lifestyle factors, knowledge of risk factors and physical measurements.
  • The primary outcomes of the baseline survey are hypertension prevalence, awareness, proportion of patients under treatment, proportion of patients who have their hypertension under control, systolic and diastolic BP values. Secondary outcomes at baseline included knowledge of hypertension risk factors.

Definitions of outcomes:

Primary outcomes
  • Prevalence of hypertension: Number of individuals in district having a SBP ≥ 140 mmHg or DBP ≥90 mmHg or receiving BP-lowering treatment. High BP was further defined as

    Stage one hypertension: SBP ≥ 140 and < 160 mm/Hg, or DBP ≥90 and <100 mm/HG

    Stage two hypertension: SBP ≥ 160- < 180 mm/Hg or DBP ≥100- <110 mm/HG

    Stage three hypertension: SBP ≥ 180 mm/Hg or DBP ≥110 mm/Hg [2]

  • Hypertension awareness: Defined by an individual’s self-reporting a diagnosis of hypertension, and found to be hypertensive, or currently taking anti-hypertensive medication

  • Hypertension treatment: Percent of participants with hypertension currently under treatment.

  • Hypertension control: patients with controlled hypertension: individuals self-reporting taking the medicines for hypertension prescribed by a health professional, and having a BP < 140/90 mmHg.

Secondary outcomes
  • Knowledge of hypertension risk factors;

    The number of risk factors that each respondent was able to correctly identify through their own recall (without having it read to them)
    • having received information on prevention of hypertension was divided into four categories. 1. not received information, 2 received information in community, including from friends/family/traditional healers/street corners) 3. received information through the media, 4. received information from health centres or healthcare providers.

  • Systolic and diastolic blood pressure: baseline levels (mean and median) of BP.

Demographic data
  • To ensure that the two districts were comparable we looked at basic demographics, including age, marital status, religion, ethnicity, and level of education.

Associated risk factors: we analysed risk factors that could have an association with hypertension, according to the World Heart Federation roadmap for hypertension [20].
  • Physical Activity: number of times per week participants reported being physically active

  • Alcohol consumption: due to issues with the survey we were only able to define participants as never consuming alcohol or drinking alcohol at least once a day

  • Salt consumption: as a proxy for salt consumption, we asked whether participants added salt to food at the table and whether salt is added during food preparation. Both of these were divided into the categories: Never; Rarely; Sometimes; Often and Always

  • Sleep apnoea: as a proxy for sleep apnoea we included three questions: choking while sleeping, snoring while sleeping, and snorting or gasping while sleeping

  • History of hypertension

  • Family history of hypertension

  • Being overweight: proxy indicators for being overweight included BMI, mid-upper arm circumference (MUAC), and waist hip ratio.

Blood pressure measurement

Blood pressure was measured a minimum of three times by survey interviewers, using as fully automated, digital devices, the OMRON digital sphygmomanometer. Interviewers were trained to use the device according to the manufacturer’s recommended protocol, using recommended methods and categories from standard guidelines the World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension [21].

Anthropometric measurements

The anthropometric measurements of weight, height, mid-upper arm circumference, waist and hip circumference were measured according to standard procedures [22].

Data analysis

Categorical variables were described with proportions and continuous variables are summarised with medians, means, and standard deviations. All baseline data were recorded per comparison or intervention district, as well as overall.

Association of variables with outcomes

We examined what characteristics of the individuals were associated with the primary and secondary outcome variables of the survey. For each potential explanatory variable we created a separate logistic regression model against the outcomes “hypertension status” and “hypertension awareness” separately. Each model was repeated unadjusted by other variables and adjusted by age, sex and district. The models for the outcome “hypertension awareness” were restricted to people with hypertension only. P value less than 0.05 denotes statistical significance.

Results

Participant characteristics

We interviewed 1200 respondents each from the comparison and intervention districts. However, after cleaning, 1170 and 1167 surveys respectively from the comparison district and the intervention district had complete data for analysis. Demographic data are presented in Table 2. Other than ethnicity, baseline characteristics were similar between districts. Participants were overwhelmingly Christian (96.0%), had a mean age of 49 years; 66.0% being between 30 and 54 years. Only 10.0% had never been married, and 25.0% had no formal education.
Table 2

Knowledge of risk factors of hypertension in intervention and comparison districts

Knowledge of risk factors

 

Comparison district

Intervention district

Overall

Number of risk factors respondent knows

 0

585

63.2%

479

58.4%

1064

60.1%

 1

172

18.6%

129

15.7%

301

17.3%

 2

115

12.4%

141

17.2%

256

14.7%

 3

35

3.8%

51

6.2%

86

4.9%

 4

12

1.3%

14

1.7%

26

4.9%

 5

3

0.3%

4

0.5%

26

1.5%

 6

2

0.2%

1

0.1%

7

0.4%

 7

0

0.0%

0

0.0%

3

0.2%

 8

1

0.1%

1

0.1%

2

0.1%

Knows alcohol as a risk factor

Comparison

Intervention

 

Overall

  

 No

779

66.6%

666

57.1%

1445

61.8%

 Yes

146

12.5%

154

13.2%

300

12.8%

 N/A

245

20.9%

347

29.7%

592

25.3%

Knows lack of exercise as a risk factor

 No

891

76.1%

775

66.4%

1666

71.3%

 Yes

34

2.9%

45

3.9%

79

3.4%

 N/A

245

20.9%

347

29.7%

592

25.3%

Knows lack of fruit as a risk factor

 No

917

78.4%

806

69.1%

1723

73.7%

 Yes

8

0.7%

14

1.2%

22

0.9%

 N/A

245

20.9%

347

29.7%

592

25.3%

Knows lack of vegetable as a risk factor

 No

917

78.4%

805

69.0%

1722

73.7%

 Yes

8

0.7%

15

1.3%

23

1.0%

 N/A

245

20.9%

347

29.7%

592

25.3%

Knows salt as a risk factor

 No

830

70.9%

719

61.6%

1549

66.3%

 Yes

95

8.1%

101

8.7%

196

8.4%

 N/A

245

20.9%

347

29.7%

592

25.3%

Knows obesity as a risk factor

 No

896

76.6%

794

68.0%

1690

72.3%

 Yes

29

2.5%

26

2.2%

55

2.4%

 N/A

245

20.9%

347

29.7%

592

25.3%

Received messages about heart health

 Received none

320

34.7%

336

41.9%

656

38.0%

 In community

108

11.7%

92

11.5%

200

11.6%

 Through media

319

34.6%

207

25.8%

526

30.5%

 Health centre or doctor

176

19.1%

167

20.8%

343

19.9%

How important to you is lowering the salt/sodium in your diet

 Not at all important

111

9.5%

134

11.5%

245

10.5%

 Somewhat important

217

18.6%

260

22.4%

477

20.5%

 Very important

836

71.8%

769

66.1%

1605

69.0%

Prevalence of hypertension

Table 3 summarizes the prevalence, awareness, treatment and control of hypertension in the intervention and comparison districts. The prevalence of hypertension was 32.0% among women and 33.0% among men (not presented in Table 3). Overall 32.4% of the 2337 individuals were hypertensive: 18.9% of them presented with stage one hypertension, 8.2% with stage two and 4.9% with stage three. Two individuals for whom DBP was recorded to be higher than SBP were excluded.
Table 3

Hypertension prevalence, awareness, treatment and control in the intervention and comparison districts

 

Comparison

Intervention

Total

N

%

95% CI

N

%

95% CI

N

%

95% CI

Examined

1170

100%

 

1167

100%

 

2337

100%

 

Normal

805

68.8%

(66% – 71.4%)

785

67.3%

(64.5% – 69.9%)

1590

68.0%

(66.1% – 69.9%)

Stage 1

232

19.8%

(17.6% – 22.3%)

210

18.0%

(15.9% – 20.3%)

442

18.9%

(17.4% – 20.6%)

Stage 2

86

7.4%

(6% – 9%)

105

9.0%

(7.4% – 10.8%)

191

8.2%

(7.1% – 9.4%)

Stage 3

47

4.0%

(3% – 5.3%)

67

5.7%

(4.5% – 7.3%)

114

4.9%

(4.1% – 5.9%)

Examined

1170

  

1167

  

2337

  

Hypertensive (1)

367

31.4%

(28.7% – 34.1%)

390

33.4%

(30.7% – 36.2%)

757

32.4%

(30.5% – 34.3%)

Aware (2)

164

44.7%

(39.5% – 49.9%)

186

47.7%

(42.7% – 52.8%)

350

46.2%

(42.6% – 49.9%)

Treated (2)

14

3.8%

(2.2% – 6.5%)

17

4.4%

(2.6% – 7%)

31

4.1%

(2.8% – 5.8%)

% of Aware

 

8.5%

(4.9% – 14.2%)

 

9.1%

(5.6% – 14.5%)

 

8.9%

(6.2% – 12.5%)

Controlled (2)

2

0.5%

(0.1% – 2.2%)

8

2.1%

(1% – 4.2%)

10

1.3%

(0.7% – 2.5%)

% Treated

 

14.3%

(2.5% – 43.8%)

 

47.1%

(23.9% – 71.5%)

 

32.3%

(17.3% – 51.5%)

Comparison districts: (1) % over examined individuals, (2) % over hypertensive individuals

Hypertension awareness

Participants aware of their hypertension are represented in Table 3. A total of 46.2% of the hypertensive individuals were aware of their condition (44.7% in the comparison district and 47.7% in the intervention district) (Table 3).

Hypertension treatment and control

The proportion of patients with hypertension who were under treatment is alarmingly low: only between 5 and 14% of hypertension patients in the comparison district, and between 5.6 and 14.5% in the intervention district reported to be treated for hypertension. Of those, the individuals who had their hypertension under control was 1.3% (95% CI 0.7% - 2.5%), with only 0.5% of the patients in the comparison district (0.1–2.2%) and 2.1% of the patients in the intervention district (1–4.2%) controlled for hypertension. For those patients who reported to be currently treated, hypertension control was higher at 32.3% (14.3% in the comparison site, and 47.1% in the intervention site). However, the number of patients under treatment was very low, while the 95% confidence intervals are wide and overlapping (Table 3).

Knowledge and prevalence of biological and behavioural risk factors for hypertension

Tables 2 3, and 4 present knowledge and prevalence of risk factors for hypertension, prevalence of selected behavioral and biological risk factors of hypertension, as well as other variables. Only 5.7% of the participants from the comparison district, and 8.6% in the intervention district knew three or more of the eight known risk factors. The proportion of people who were aware of one risk factor was 19% in the comparison district, and 16% in the intervention district, while 63% in the comparison and 58% in the intervention district unfortunately knew none of the risk factors (Table 3). Participants’ knowledge of alcohol consumption, lack of exercise, and insufficient fruit and vegetables as risk factors for hypertension are presented in Table 3. Participants from both intervention and comparison districts demonstrated similarly low knowledge of the behavioural risk factors for hypertension.
Table 4

Prevalence of selected behavioral and biological risk factors of hypertension

Physical activity

Times per week

Comparison

 

Intervention

 

Overall

 

 0

711

62.2%

679

61.1%

1390

61.6%

 1

56

4.9%

46

4.1%

102

4.5%

 2

60

5.2%

41

3.7%

101

4.5%

 3

65

5.7%

76

6.8%

141

6.3%

 4

43

3.8%

28

2.5%

71

3.2%

 5

61

5.3%

61

5.5%

122

5.4%

 6

36

3.2%

40

3.6%

76

3.4%

 7

112

9.8%

140

12.6%

252

11.2%

Alcohol consumption

 Never Drink

1032

88.7%

1029

90.1%

2061

89.5%

 Drink once a day+

131

11.3%

112

9.8%

243

10.6%

Salt

Do you add salt to food at table

 Never

805

68.8%

581

49.8%

1386

59.3%

 Rarely

54

4.6%

94

8.1%

148

6.3%

 Sometimes

196

16.8%

297

25.5%

493

21.1%

 Often

72

6.2%

120

10.3%

192

8.2%

 Always

43

3.7%

75

6.4%

118

5.1%

Is salt added during food preparation

 Never

59

5.0%

18

1.5%

77

3.3%

 Rarely

17

1.5%

11

0.9%

28

1.2%

 Sometimes

47

4.0%

42

3.6%

89

3.8%

 Often

247

21.1%

200

17.1%

447

19.1%

 Always

800

68.4%

896

76.8%

1696

72.6%

Snoring while sleeping

 Rarely or never

947

82.4%

908

80.2%

1855

81.3%

 More than once a week

202

17.6%

224

19.8%

426

18.7%

*Total 2281

Snorting or gasping while sleeping

 Rarely or never

1027

89.1%

971

86.5%

1998

87.8%

 More than once a week

126

10.9%

152

13.5%

278

12.2%

*total 2276

Any sleep problem

 Rarely or never

928

80.0%

891

77.8%

1819

78.9%

 More than once a week

232

20.0%

254

22.2%

486

21.1%

Previous history

Any previous diagnosis of hypertension

 None

869

74.3%

71.2%

1700

72.7%

 

 Previous diagnosis

275

23.5%

27.4%

595

25.5%

 

 Do not know

24

2.1%

1.3%

39

1.7%

 

 No response

2

0.2%

0.1%

3

0.1%

 

Family history High Blood Pressure

 No

669

57.2%

570

48.8%

1239

53.0%

 Yes

364

31.1%

460

39.4%

824

35.3%

 Not Sure

137

11.7%

137

11.7%

274

11.7%

BMI

 Mean

25.4

(25.1, 25.8)

25.5

(25.2, 25.9)

25.5

 

 Median

24.57

 

24.54

 

24.6

 

 Underweight

85

7.3%

85

7.3%

170

7.3%

 Normal

529

45.2%

540

46.3%

1069

45.7%

 Overweight

336

28.7%

321

27.5%

657

28.1%

 Obese

220

18.8%

221

18.9%

441

18.9%

In Table 2, prevalence of behavioral and biological risk factors for hypertension are summarized. The majority of the participants was identified as non- alcohol users (88.7% in the intervention district and 90.1% in the control district). BMI was normal in 45.2% of the participants in the intervention district and 46.3% in the comparison district, while 7.3% of the respondents from both sites was underweight and 19.0% obese.

Biological and behavioural risk factors for hypertension

Figures 3, 4 and 5 represent the different factors associated with hypertension. Bivariate/unadjusted regression estimates are presented together with measures adjusted for age, gender and district. Age was a predictor of having hypertension; similarly, the odds of being hypertensive tended to increase with increasing BMI and waist- and hip circumference. Those with a family history of hypertension or NCD and participants who smoked also had higher odds of being hypertensive. The multiple logistic regression model examined predictors of hypertension after adjusting for a number of covariates. When adjusted for age, risk factors with the greatest association with hypertension were being overweight (aOR = 2.30; 95% CI 1.53–3.46) or obese (aOR = 3.61; 95% CI 2.37–5.51), although significant associations were also observed with increased waist/hip ratio (aOR = 1.43; 95% CI 1.30–157), MUAC (aOR = 1.47; 95%CI 1.34–1.62), high waist circumference (aOR = 1.47; 95% CI 1.34–1.61), and having some sort of sleep disturbance (aOR = 1.51; 95% CI 1.21–1.87) (Fig. 3).
Fig. 3

Factors associated with hypertension status, adjusted for age, sex and district

Fig. 4

Associations between hypertension risk factors and hypertension awareness, adjusted by age, sex and district

Fig. 5

Factors associated with hypertension awareness, adjusted by age and sex divided by district

Figure 4 presents factors associated with hypertension awareness, adjusted for age. In unadjusted models, older individuals were more likely to be aware of their hypertension status than younger people. When adjusted for age, sex, and district people with a family history of hypertension (aOR = 2.98; 95% CI 1.20–7.40), or CVD (aOR = 1.71; 95% CI 1.17–2.52), or with a high waist hip ratio (aOR = 1.94; 95% CI 1.44–2.63), were more likely to be aware of their hypertension status. Figure 5 compares the primary outcome of hypertension awareness, adjusted by age. There were no significant differences for the primary outcome hypertension awareness by study site.

Discussion and conclusions

This baseline survey aimed to assess the prevalence, awareness, and risk factors of hypertension in two Ghanaian districts prior to the implementation of a community-based intervention to improve the management of hypertension. Prevalence of hypertension in the comparison district was 31.4% (95% CI 28.7.0–34.1) and 33.4% (95% CI 30.7–36.2) in the intervention district. Less than 50% of the patients with hypertension were aware of their condition and the proportion of patients under treatment was alarmingly low. Both the level of hypertension control and in-depth knowledge of the risk factors for hypertension were very low (Tables 2 and 3).

Study site differences

Overall the findings in our two study sites were very similar. Descriptive analysis suggested that individuals in the intervention district may have had more exposure to educational information about heart health, and an overall greater awareness of risk factors. This may be because of FHI 360 s previous efforts in the area as in 2009 a facility- and community-based CVD prevention and screening project was implemented in the district hospital aiming to strengthen the capacity of facilities to manage CVD. The project also implemented facility and community-based primary and secondary prevention activities, and engaged policy makers in the prevention of CVD and NCDs in general. mHealth technology provided patients with information on healthy lifestyles and adherence to NCD treatment [18].

The largest demographic difference between the comparison and intervention sites was ethnic group, with the majority in the comparison district defining themselves as Akan, and of the majority in the intervention group as Krobo/Ga/Dangbe. Although belonging to two distinct ethnic groups, both are located within the same ecological zone and do not differ significantly in their health seeking behaviour or practices [23, 24].

Participant characteristics

In line with the Ghana National Strategy for the Management, Prevention and Control of Chronic Non-Communicable Diseases 2012–2016, this study focused on adults aged 30 years or more. The PURE study included a comparable age group between 35 and 70 years [15] coming from both high and low-and middle income countries. Other previous studies [1012] all involved Ghanaian men and women aged between 25 and 102 years. The 2014 Ghana Demographic and Health Survey (DHS) was a representative survey looking at hypertension [13]: although the survey is focusing on 15–49 year olds, the age band 30–49 years permits comparisons with our study. Our prevalence findings of 20.1/19.6% males/females with hypertension is similar to that found in the DHS of 23.5/20.1% males/females. The estimated hypertension prevalence in our baseline survey is comparable with that of previous local and international studies. The PURE study [15] reported an overall prevalence of 40.8% (40.7% for HICs, 49.7% for UMICs, 39.9% for LMICs, and 32.2% for LICs), while hypertension prevalence from local studies involving men and women in similar age groups were comparable with our findings (Table 3). Our prevalence estimates are substantially higher than the most recent DHS (2014) survey and lower than those found by Lloyd-Sherlock [17]. This is, however, not surprising given that the DHS survey included individuals for 15–49 and the Lloyd-Sherlock [17] only included adults over 50. Our data compare with those of a 2009 facility- and community-based CVD prevention and screening project implemented in the intervention district: about one-in-five (22%) of those screened were pre-hypertensive (systolic 120–139, diastolic 80–89) and 33% were hypertensive (systolic ≥140, diastolic ≥90) [18]). Our estimated prevalence of hypertension is consistent with reported prevalence in other parts of Africa [8, 25], such as in the neighboring cities of Abidjan in 2005 and Cotonou in 2007, the prevalence was 21.7% and 27.3% respectively [26]. Higher prevalence was however reported in semi-urban Nigeria (37%) [25], Burkina Faso (40%) [27] and Niger (42%) [26].

We estimated that only between 42.6 and 50% of the people with hypertension were aware of their condition, while PURE reported an overall awareness of 46.5% (49.0% for HICs, 52.5% for UMICs, 43.6% for LMICs, and 40.8% for LICs). The level of awareness in our study was higher than in most previous studies in Ghana (Table 5), but disparity in age, as well as setting peculiarity may explain the differences.
Table 5

Demographic characteristics of participants in intervention and comparison districts

 

Comparison

Intervention

Overall

Demographics

1170

1167

2337

Numbers in survey

Age

 

std dev

 

std dev

 

std dev

 Mean

49.6

14.9

49.4

15.5

49.5

15.2

 Median

47

 

46

 

46

 

Number of adults per age category

 30–44

508

43.4%

518

44.4%

1026

43.9%

 45–54

264

22.6%

239

20.5%

503

21.5%

 55–64

186

15.9%

193

16.5%

379

16.2%

 65+

212

18.1%

217

18.6%

429

18.4%

# Adults per HH

 Range

1, 9

 

1, 9

 

1,9

 

 Mean

1.6

 

1.3

 

1.4

 

 Median

1

 

1

 

1

 

Sex

 % male

35.5%

 

36.5%

 

36.0%

 

Marital status

 Never married

117

10.0%

152

13.0%

269

11.5%

 Living together

59

5.0%

72

6.2%

131

5.6%

 Married

647

55.3%

641

54.9%

1288

55.1%

 Widowed

166

14.2%

179

15.3%

345

14.8%

 Divorced/separated

181

15.5%

123

10.5%

304

13.0%

Religion

 Christian

1120

95.7%

1119

95.6%

2239

95.8%

 Muslim

12

1.0%

21

1.8%

33

1.4%

 Traditional/Spiritualist

13

1.1%

15

1.3%

28

1.2%

 No religion

18

1.5%

9

0.8%

27

1.2%

 Other

7

0.6%

3

0.3%

10

40.0%

Ethnicity

 Akan

945

80.8%

47

4.0%

992

42.5%

 Krobo/Ga/Dangbe

78

6.7%

882

75.6%

960

41.1%

 Ewe

113

9.7%

218

18.7%

331

14.2%

 Grussi

13

1.1%

2

0.2%

15

0.6%

 Mole-Dagbani

3

0.3%

3

0.3%

6

0.3%

 Hausa

5

0.4%

8

0.7%

13

0.6%

 Other

13

1.1%

7

0.6%

20

0.9%

Level of education

 No formal education

285

24.4%

314

26.9%

599

25.6%

 Less than Primary

202

17.3%

182

15.6%

384

16.4%

 Completed primary

210

18.0%

196

16.8%

406

17.4%

 Some secondary

315

26.9%

283

24.3%

598

25.6%

 Completed secondary

105

9.0%

117

10.0%

222

9.5%

 Tertiary Completed post- graduate

50

4.3%

73

6.3%

123

5.3%

 Not sure

2

0.2%

0

0.0%

2

0.1%

Compared to PURE, the overall self-reported treatment and control rates in our study were only 31 of 757 hypertensive individuals (14 from the comparison district, and 17 from the intervention district). Among the treated hypertension patients, the control rate was 9% overall, with 14.3% in the control arm and 47.1% in the intervention. In the Ghana DHS only 11.5% of hypertensives under treatment were reported to have their hypertension under control [13].

Associations with risk factors

Supportive of previous studies [1012, 28], our study showed that age, BMI, and biological factors were positively associated with both hypertension status and awareness of the condition. Older individuals, females, people with a family history of CVD and with unhealthy hip/waist ratios were more likely to be aware of their hypertension status. Age, increasing BMI and waist hip circumference were predictors of having hypertension.

This was a community-based study with a sample size of over 2000 individuals, one of the largest studies of its kind in the region. This study is part of a larger, mixed-methods evaluation of community based hypertension control project, and will be followed up with a second similar sized cross sectional survey. However, as with any survey there are some potential limitations of the data collected. Due to safety issues data collectors were only able to visit households during daylight hours, and as a result some adults were at work when they visited the house. To minimize this, collectors would come back to houses on multiple occasions. This issue seems however to be similar in both the comparison and intervention districts.

Study implications and future research

The results of this baseline survey have implications for the intervention being implemented and for future research. The high burden of hypertension among the studied population, coupled to the relatively high level of awareness yet very low levels of hypertension treatment and control requires in-depth investigation of the bottlenecks to treatment and control. Secondly, the low treatment and control rates despite current and previous general educational programs in the intervention district, are suggestive that such programs are not really impactful health service delivery strategies. The RODAM study reported hypertension prevalence among rural Ghanaian women/men to be 32.1% 25.5% respectively, and higher among urbanized populations (37.9% 38.2% respectively) [29]. The progressive rise of hypertension as Ghanaians become more urbanized in Berlin, London and Amsterdam, even in the presence of more sophisticated health care, show that Ghanaians continue to be at risk of uncontrolled hypertension. It may therefore be argued that attitude/behaviour is as important as access, if not more so.

These are important findings for the ongoing intervention. The lack of in-depth knowledge of hypertension risk factors and the high burden of biological risk factors of hypertension, particularly obesity, will be notable challenges for the intervention to have its desired impact.

The project’s next steps include an in-depth mapping of individuals with hypertension by census enumeration areas. The key findings of the survey have been shared with the program Technical and Steering Committees, to optimize targeting of interventions. The implementation of the program is currently being carried out. The endline survey will be conducted in 2017, to evaluate the change in hypertension prevalence, awareness, treatment and control between the two districts. Using individual patient data, we will apply logistic regressions for each of these outcomes including the district and survey period baseline / endline variables and look at their interaction; we will also adjust for age. Given that the observed awareness at baseline in either group was about 46%, a sample size of 1150 individuals in each group in the end line survey will provide about a 85% power to detect a difference of 10% between groups. It will also provide a more than 90% power to detect a difference of 7% in treatment coverage in people aware of hypertension (versus a baseline of about 9%), and a 87% power to detect a difference of 10% in the proportion of patients under treatment who have their BP under control (versus a baseline of about 32%).

Abbreviations

BMI: 

Body mass index

CHO: 

Community health officer

CHPS: 

Community-based health planning and services

ComHIP: 

Community-based hypertension improvement programme

CVD: 

Cardiovascular disease

DBP: 

Diastolic blood pressure

DSS: 

Decision support system

EAs: 

Census enumeration areas

FHI360: 

Family Health International 360

GHS: 

Ghana Health Service

GSS: 

Ghana Statistical Service

HPT: 

Hypertension/high blood pressure

ICC: 

Intra class correlation

ICT: 

Information and communication technologies

IRBs: 

Institutional Review Boards

LCS: 

Licensed chemical seller

LMIC: 

Low- and middle-income countries

LMK: 

Lower Manya Krobo

LSHTM: 

London School of Hygiene and Tropical Medicine

MIC: 

Middle income country

MOH: 

Ministry of health

MUAC: 

Mid upper arm circumference

NCDCP: 

NCD Control Programme

NCDs: 

Non-communicable diseases

ODK: 

Open Data Kit

PURE: 

The prospective urban rural epidemiology study

SBP: 

Systolic blood pressure

UIC: 

Upper income country

WHO: 

World Health Organization

Declarations

Acknowledgements

We are grateful to all the households, the 24 field research assistants, and the data management team. The leadership and political support of the Ghana Health Service (both from the national and district levels) deserve mention. As a partner on this project, the Lower Manya Municipal Health Directorate played a critical and important role in its implementation. 

Funding

Funds for the project was made available by Novartis Foundation, Basel, Swtizerland.

Availability of data and materials

The authors agree that the dataset on which the conclusions of this manuscript rely be deposited in publicly available repositories, and have included it as Additional files 1 and 2.

Authors’ contributions

PL conceived of the project and PL and RD designed the interventions. PL, PP, and NP designed the research component. AL supervised the implementation of the field research and data management. AJA and DP performed the statistical analyses. AJA and AL drafted the manuscript, with inputs from PL, PP, RD, AC, DP, AA, and NP. All authors read and approved the final version of the manuscript.

Competing interests

The co-authors PL, AL, PP, AJA, NP and DP-M worked on the ComHIP Programme for which their institutions (LSHTM and UGSPH) have received grants from the Novartis Foundation. The co-authors AA and AC are staff of the Novartis Foundation.

Consent for publication

Participants’ consent was also obtained for the purposes of publishing the results from the study. All the authors also consented to the study results to be published in the form presented in the final version of this manuscript.

Ethics approval and consent to participate

The evaluation protocol was reviewed and approved by the Institutional Review Boards (IRBs) of LSHTM (LSHTM Ethics Ref: 10,152), the Ghana Health Service (ID NO. GHS-ERC 04/01/15), and the University of Ghana at Noguchi Memorial Institute for Medical Research (Ethics clearance # IRB00001276). Written informed consent was obtained from all participants. Prior to data collection, appropriate community entry procedures were followed. Key stakeholders and institutions were notified using introductory letters. Two community volunteers were recruited (one in each district) to facilitate fieldwork in the intervention and comparison districts.

All participants whose SBP was greater than or equal to 140 mmHg or DBP > = 90 mmHg, were verbally referred to the nearest health facility for confirmation of diagnosis and management. The participants consented to the publication of this data.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine
(2)
Department of Population, Family, & Reproductive Health, School of Public Health, University of Ghana
(3)
Family Health International 360
(4)
Novartis Foundation
(5)
Applied Statistical Methods Research Group, Universidad Catolica San Antonio de Murcia (UCAM)

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Copyright

© The Author(s). 2017

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