Doreen Busingye

Do the socioeconomic and hypertension gradients in rural populations of low- and middle-income countries differ by geographical region? A systematic review and meta-analysis

BACKGROUND Of the 1 billion people with hypertension globally, two-thirds reside in low- and middle-income countries (LMICs). The risk of hypertension in LMICs is thought to be positively associated with socioeconomic status (SES). However, recent studies have provided data inconsistent with this concept. Thus, we assessed the association between SES and hypertension in rural populations of LMICs. Further, we explored whether this association differs according to geographical region. METHODS Through a search of databases we identified population-based studies that presented risk estimates for the association between SES, or any of its proxies, and hypertension. Meta-analyses were conducted using a random effects model. RESULTS Overall, no association was detected between educational status and hypertension, whereas a positive association was observed with income. Interestingly, educational status was inversely associated with hypertension in East Asia {effect size [ES] 0.82 [95% confidence interval (CI) 0.78, 0.87]} but positively associated in South Asia [ES 1.28 (95% CI 1.14, 1.43)]. Higher income, household assets or social class were positively associated with hypertension in South Asia whereas no association was detected in East Asia and Africa. Compared with other occupations, farmers or manual labourers were associated with a lower risk for hypertension. Further, in regions such as Latin America, few studies were identified that fulfilled our inclusion criteria. CONCLUSIONS We provide evidence that the association between hypertension and SES in rural populations of LMICs in Asia varies according to geographical region. This has important implications for targeting intervention strategies aimed at high-risk populations in different geographical regions.

Association between salt and hypertension in rural and urban populations of low to middle income countries: a systematic review and meta-analysis of population based studies.

BACKGROUND AND OBJECTIVES The prevalence of hypertension, the greatest contributor to mortality globally, is increasing in low-and-middle income countries (LMICs). In urban regions of LMICs, excessive salt intake is associated with increased risk of hypertension. We aimed to determine whether this is the case in rural regions as well. METHODS AND STUDY DESIGN We performed a meta-analysis of studies in rural and urban areas of LMICs in which the association of salt and hypertension were assessed using multivariable models. RESULTS We identified 18 studies with a total of 134,916 participants. The prevalence of high salt intake ranged from 21.3% to 89.5% in rural and urban populations. When salt was analysed as a continuous variable, a greater impact of salt on hypertension was found in urban (n=4) (pooled effect size (ES) 1.42, 95% CI 1.19, 1.69) than in rural populations (n=4) (pooled ES 1.07, 95% CI 1.04, 1.10, p for difference <0.001). In studies where salt was analysed continuously, a greater impact of salt on hypertension was observed in lean rural populations (BMI <23 kg/m2) than in non-lean rural populations (BMI >=23 kg/m2, p for difference <0.001). CONCLUSIONS The prevalence of high salt intake is similar in rural and urban regions. Excessive salt intake has a greater impact on the prevalence of hypertension in urban than rural regions. BMI appears to modify the relationship between salt and hypertension in rural populations.

Rejoinder: Socioeconomic gradients and hypertension in low- and middle-income countries: a straw man and no solutions

Rejoinder: Socioeconomic gradients and hypertension in lowand middle-income countries: a straw man and no solutions From Doreen Busingye,* Roger G Evans, Simin Arabshahi, Asvini K Subasinghe, Michaela A Riddell and Amanda G Thrift Department of Medicine, School of Clinical Sciences, and Department of Physiology, Monash University, Melbourne, VIC, Australia and Stroke Division, Florey Neuroscience Institutes, Heidelberg, VIC, Australia

Development of an electronic health message system to support recovery after stroke: Inspiring Virtual Enabled Resources following Vascular Events (iVERVE)

Purpose Worldwide, stroke is a leading cause of disease burden. Many survivors have unmet needs after discharge from hospital. Electronic communication technology to support post-discharge care has not been used for patients with stroke. In this paper, we describe the development of a novel electronic messaging system designed for survivors of stroke to support their goals of recovery and secondary prevention after hospital discharge. Participants and methods This was a formative evaluation study. The design was informed by a literature search, existing data from survivors of stroke, and behavior change theories. We established two working groups; one for developing the electronic infrastructure and the other (comprising researchers, clinical experts and consumer representatives) for establishing the patient-centered program. Following agreement on the categories for the goal-setting menu, we drafted relevant messages to support and educate patients. These messages were then independently reviewed by multiple topic experts. Concurrently, we established an online database to capture participant characteristics and then integrated this database with a purpose-built messaging system. We conducted alpha testing of the approach using the first 60 messages. Results The initial goal-setting menu comprised 26 subcategories. Following expert review, another 8 goal subcategories were added to the secondary prevention category: managing cholesterol; smoking; physical activity; alcohol consumption; weight management; medication management; access to health professionals, and self-care. Initially, 455 health messages were created by members of working group 2. Following refinement and mapping to different goals by the project team, 980 health messages across the health goals and 69 general motivational messages were formulated. Seventeen independent reviewers assessed the messages and suggested adding 73 messages and removing 16 (2%). Overall, 1,233 messages (18 administrative, 69 general motivation and 1,146 health-related) were created. Conclusion This novel electronic self-management support system is ready to be pilot tested in a randomized controlled trial in patients with stroke.

Knowledge of risk factors for diabetes or cardiovascular disease (CVD) is poor among individuals with risk factors for CVD.

Background There is limited evidence on whether having pre-existing cardiovascular disease (CVD) or risk factors for CVD such as diabetes, ensures greater knowledge of risk factors important for motivating preventative behaviours. Our objective was to compare knowledge among the Australian public participating in a health check program and their risk status. Methods Data from the Stroke Foundation ‘Know your numbers’ program were used. Staff in community pharmacies provided opportunistic health checks (measurement of blood pressure and diabetes risk assessment) among their customers. Participants were categorised: 1) CVD ± risk of CVD: history of stroke, heart disease or kidney disease, and may have risk factors; 2) risk of CVD only: reported having high blood pressure, high cholesterol, diabetes or atrial fibrillation; and 3) CVD risk free (no CVD or risk of CVD). Multivariable logistic regression analyses were performed including adjustment for age and sex. Findings Among 4,647 participants, 12% had CVD (55% male, 85% aged 55+ years), 47% were at risk of CVD (40% male, 72% 55+ years) and 41% were CVD risk free (33% male, 27% 55+ years). Participants with CVD (OR: 0.66; 95% CI: 0.55, 0.80) or risk factors for CVD (OR: 0.65; 95% CI: 0.57, 0.73) had poorer knowledge of the risk factors for diabetes/CVD compared to those who were CVD risk free. After adjustment, only participants with risk factors for CVD (OR: 0.80; 95% CI: 0.69, 0.93) had poorer knowledge. Older participants (55+ years) and men had poorer knowledge of diabetes/CVD risk factors and complications of diabetes. Conclusions Participants with poorer knowledge of risk factors were older, more often male or were at risk of developing CVD compared with those who were CVD risk free. Health education in these high risk groups should be a priority, as diabetes and CVD are increasing in prevalence throughout the world.

The Quality of Discharge Care Planning in Acute Stroke Care: Influencing Factors and Association with Postdischarge Outcomes

BACKGROUND Comprehensive discharge planning is important for successful transitions from hospital to home after stroke. The aim of this study was to describe the quality of discharge planning received by patients discharged home from acute care, identify factors associated with a positive discharge experience, and assess the influence of discharge quality on outcomes. METHOD Patients discharged to the community and registered in the Australian Stroke Clinical Registry in 2014 were invited to participate. Patient-perceived discharge quality was evaluated using the Prescriptions, Ready to re-enter community, Education, Placement, Assurance of safety, Realistic expectations, Empowerment, Directed to appropriate services questionnaire (recall at 3-9 months). Factors associated with higher discharge quality scores were identified and associations between quality scores of more than 80% and outcomes were investigated using multivariable, multilevel regression analyses. RESULTS There were 200 of 434 eligible registrants who responded; responders and nonresponders were similar with respect to age, sex, and type of stroke. The average overall quality score was 73% (standard deviation: 21). However, only 18% received all aspects of discharge care planning. Quality scores of more than 80% were independently associated with receiving hospital specific information (odds ratio: 5.7, 95% confidence interval [CI]: 2.7, 12.4), and referral to a local support group (odds ratio: 2.5, 95% CI: 1.1, 5.9). Discharge quality scores of more than 80% were associated with higher European Quality of Life-5 Dimensions EQ-5D scores (coefficient: .1, 95% CI: .04, .2) and a reduction in the rate of unmet needs reported at 3-9 months postdischarge (incidence rate ratio: .5, 95% CI: .3, .7). CONCLUSION We provide new information on the quality of discharge planning from acute care after stroke. Aspects of discharge planning that correlate with quality of care may reduce unmet needs and improve quality of life outcomes.

Factors associated with awareness, treatment and control of hypertension in a disadvantaged rural Indian population

The aim of this study was to identify factors associated with awareness, treatment and control of hypertension in a rural setting in India. Following screening of the population, all individuals with hypertension (blood pressure (BP) ⩾140/90 mm Hg or taking antihypertensive medications) were invited to participate in this study. We measured BP, height, weight, skinfolds, waist and hip circumference, and administered a questionnaire to obtain information regarding socioeconomic and behavioural characteristics. Multivariable logistic regression was used to determine factors associated with awareness, treatment and control of hypertension. We recruited 277 individuals with hypertension. Awareness (43%), treatment (33%) and control (27%) of hypertension were poor. Greater distance to health services (odds ratio (OR) 0.56 (95% confidence interval (CI)) 0.32–0.98) was associated with poor awareness of hypertension while having had BP measured within the previous year (OR 4.72, 95% CI 2.71–8.22), older age and greater per cent body fat were associated with better awareness. Factors associated with treatment of hypertension were having had BP measured within the previous year (OR 6.18, 95% CI 3.23–11.82), age ⩾65 years, physical inactivity and greater per cent body fat. The only factor associated with control of hypertension was greater per cent body fat (OR 1.05, 95% CI 1.01–1.11). Improving geographic access and utilisation of health services should improve awareness and treatment of hypertension in this rural population. Further research is necessary to determine drivers of control.

PS 06-06 ASSOCIATION BETWEEN INFLAMMATION AND HYPERTENSION IN A RURAL, DISADVANTAGED INDIAN POPULATION IS DIFFERENT FOR MEN AND WOMEN

Objective: There is some evidence that low grade inflammation is associated with an increased risk of hypertension, but whether this is the case in disadvantaged populations in India has not been established. We aimed to assess the risk of hypertension associated with high sensitivity C-reactive protein (CRP), a marker of inflammation, in a rural population of Indians living in poverty. Design and Method: In a case-control study in 58 villages in southwestern Andhra Pradesh, we age- and sex-matched 300 cases with hypertension to 300 controls without hypertension. Blood pressure (BP) was measured according to a strict protocol. CRP (Immulite 2000xpi) was categorized into three groups: < 1 mg/L (reference category), 1 to <3 mg/L, and ≥ 3 mg/L. Conditional logistic regression was used to determine associations between CRP and hypertension (BP ≥ 140/90 mmHg), adjusted for income, smoking, central obesity, and residual effects of age. Results: In this population, 34% of participants had CRP levels below 1 mg/L and 31% ≥ 3 mg/L. We were unable to detect an association between hypertension and CRP levels of 1 to < 3 mg/L (Odds Ratio (OR) 1.29, 95% Confidence Interval (95%CI) 0.83 to 2.00) or CRP ≥ 3 mg/L (OR 1.33, 95%CI 0.84 to 2.10). When investigating these associations by sex, there was an association between CRP and hypertension in men (levels of 1 to < 3 mg/L [OR 1.80, 95%CI 1.00 to 3.24] and ≥ 3 mg/L [OR 1.99, 95%CI 1.04 to 3.82]). No similar association was found in women (levels of 1 to < 3 mg/L [OR 0.79, 95%CI 0.39 to 1.60] and ≥ 3 mg/L [OR 0.80, 95%CI 0.41 to 1.56]). Conclusions: We provide evidence of a cross-sectional association between CRP and hypertension in men, but not in women, in this rural disadvantaged population. CRP could add to the prediction of future CVD in rural communities, particularly in men, but this requires further testing.

PS 15-17 KNOWLEDGE ABOUT RISK FACTORS FOR HYPERTENSION IN RURAL INDIA IS EVEN POOR IN PEOPLE AWARE OF THEIR HYPERTENSIVE STATUS

Objective: The prevalence of hypertension in rural populations in India is increasing, but little is known about awareness of hypertensive status or knowledge of risk factors for hypertension. We aimed to determine knowledge about risk factors for hypertension in individuals with and without hypertension, and to identify factors associated with better knowledge. Design and Method: Residents of randomised rural villages (n = 58) were invited to participate in a study of hypertension. We measured blood pressure (BP), height, weight, waist and hip circumference and administered a questionnaire to obtain information on sociodemographic and behavioural characteristics, and knowledge of hypertension. Multivariable logistic regression analyses were conducted to determine factors associated with knowledge of more than one risk factor (median) for hypertension. Results: The study included 626 individuals. Knowledge about risk factors for hypertension was poor in both those with hypertension who were aware (74/117; 63%) and unaware of the condition (169/209; 81%); as well as those without hypertension (247/300; 82%). Only 13% of women and 29% of men were aware of more than one risk factor for hypertension. Factors associated with knowledge about risk factors for hypertension were younger age (Odds Ratio (OR) 0.98, 95% Confidence Interval (95% CI) 0.96–0.97), being male (OR 2.32, 95% CI 1.36–3.98), higher educational attainment (OR 1.86, 95% CI 1.11–3.14), being overweight or obese (OR 2.91, 95% CI 1.75–4.84), and being aware of ones hypertensive status (OR 2.72, 95% CI 1.61–4.60). Conclusions: Our findings highlight poor knowledge about risk factors for hypertension in a disadvantaged Indian population. Targeting educational interventions to the identified high risk groups should be a priority, as this may improve knowledge of hypertension as well as promote healthy lifestyle behavioural changes in this rural population.

PS 06-09 SEX DIFFERENCES IN THE ASSOCIATION BETWEEN ADIPOSITY AND HYPERTENSION IN A DISADVANTAGED RURAL INDIAN POPULATION

Objective: Obesity is associated with hypertension in high income countries, but less is known about this association in rural regions of low- to middle-income countries. We aimed to assess the risk of hypertension associated with obesity in a disadvantaged region of rural South India. Design and Method: We undertook a case-control study in 58 villages in southwestern Andhra Pradesh. Three hundred cases with hypertension were age- and sex-matched to 300 controls without hypertension. Blood pressure (BP), waist circumference, waist-hip ratio (WHR), and body mass index (BMI) were measured according to strict protocols. Percent body fat was estimated using skinfold thickness measured at the biceps, triceps, subscapular and supra-iliac regions. Conditional logistic regression was used to determine associations between each measurement of body fat and hypertension (BP ≥ 140/90 mmHg), adjusted for age and disadvantage. Linear regression was used to determine the relationship between continuous measurements of adiposity and systolic and diastolic BP. Results: Overall, mean BMI was 20.5 kg/m2, 29% of people were underweight, 9% were overweight and 14% were obese. Hypertension was positively associated with obesity, as defined by a BMI ≥ 23 kg/m2 (Odds Ratio (OR) 1.8, 95% Confidence Interval (CI) 1.1–3.0), waist circumference (OR 2.2, 95% CI 1.3–3.8) and WHR (OR 2.1, 95% CI 1.4–3.0), but not percent body fat. WHR was a better predictor of hypertension in women (OR 3.3, 95% CI 1.8–6.0) than men (OR 1.5, 95% CI 0.92–2.4, p for difference 0.04). All measures of adiposity were associated with diastolic BP (p < 0.05), but not systolic BP. Similar patterns were observed in men and women. Conclusions: Our findings confirm that even in this relatively thin rural sample in India, BMI, waist circumference and WHR are strongly associated with hypertension. Central adiposity may play a greater role in the pathogenesis of hypertension in women in these populations. Those with high waist circumference, particularly women, should be screened for hypertension.