Community burden of hypertension and treatment patterns: An in-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - Nyive Phase I)

James Osei-Yeboah; Ellis Owusu-Dabo; William K B A Owiredu; Sylvester Yao Lokpo; Francis Delali Agode; Beatrice Bella Johnson

doi:10.1371/journal.pone.0252284

. 2021 Aug 12;16(8):e0252284. doi: 10.1371/journal.pone.0252284

Community burden of hypertension and treatment patterns: An in-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - Nyive Phase I)

James Osei-Yeboah ^1,^*, Ellis Owusu-Dabo ¹, William K B A Owiredu ^2,³, Sylvester Yao Lokpo ⁴, Francis Delali Agode ^4,⁵, Beatrice Bella Johnson ⁶

Editor: Sonak D Pastakia⁷

PMCID: PMC8360602 PMID: 34383770

Abstract

Background

This study aimed to describe the burden, treatment patterns and, age threshold for predicting hypertension among rural adults in Nyive in the Ho Municipality of the Volta Region, Ghana.

Methods

A population-based cross-sectional study design was employed. A total of 417 adults aged 20 years and above were randomly selected from households within the Nyive community. The WHO STEPwise approach for non-communicable diseases risk factor surveillance (STEPS) instrument was used to obtain socio-demographic and clinical information including age, gender, educational background, marital status, and occupation as well as hypertension treatment information. Blood pressure was measured using standard methods. The risk of hypertension and the critical age at risk of hypertension was determined using binary logistic regression model and the receiver-operator characteristics (ROC) analysis.

Results

The direct and indirect age-standardized hypertension prevalence was higher in males (562.58/487.34 per 1000 residents) compared to the females (489.42/402.36 per 1000 residents). The risk of hypertension among the study population increased by 4.4% (2.9%-5.9% at 95% CI) for one year increase in age while the critical age at risk of hypertension was >39 years among females and >35 years among males. About 64(46.72%) of the hypertensive participants were not on treatment whereas only 42(30.66%) had their blood pressure controlled.

Conclusion

Rural hypertension is high among adults in Nyive. The critical age at risk of hypertension was lower among males. The estimated annual increase of risk of hypertension was 4.7% for females and 3.1% for males. High levels of undiagnosed and non-treatment of hypertension and low levels of blood pressure control exist among the rural folks.

1. Background

Hypertension is a major risk contributor to stroke, ischaemic heart disease, and kidney failures [1, 2] as well as premature death [3]. Current reports by the World Health Organization (WHO) indicate that an estimated 1.13 billion people have hypertension globally, with two-thirds of the affected people living in low- and middle-income countries [4]. Of all the WHO Regions, sub-Saharan Africa is reported to have the highest prevalence of hypertension (27%) [4]. In Ghana, varied reports of hypertension prevalence have been published, with rates ranging from 22–44.7% over the past years [5–8]. Heavy alcohol consumption [9] overweight and obesity [6], as well as sedentary lifestyles [10] are some factors postulated to contribute to the rising burden of hypertension in sub-Saharan Africa. Moreover, previous studies have suggested a higher burden of hypertension among Ghanaian urban dwellers compared to their rural folks. Over the years, however, the gap in the rates between the two settings appeared to have narrowed. For example, a study conducted by Cappuccio, Micah [7] in the year 2004 revealed hypertension rates among rural and urban dwellers in the Ashanti Region to be 24% and 32%, respectively. While in 2017, Solomon, Adjuik [10] reported rates of 34% and 36% among rural and urban dwellers respectively in the Hohoe Municipality. The results could also indicate a phenomenon of a rising hypertension trend among Ghanaians in rural communities, as reported earlier by Cook-Huynh, Ansong [11]. Besides, earlier studies have suggested an early onset of hypertension among the Ghanaian populace [12, 13].

The Community-Based Health Planning and Services (CHPS) policy is a national strategy rolled out in Ghana to provide primary healthcare services to deprived communities including those in rural areas [14] after a successful pilot study in Navrongo located in Northern Ghana [15]. Since then, studies have explored the possibility of incorporating hypertension care into the CHPS program in a strategy dubbed “the nurse-led task-shifting strategy for hypertension control” (TASSH) yielding a relative success in blood pressure control when combined with the health insurance coverage initiative [16, 17]. However, financial, logistical, and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation, and lack of regular skill development training programs for community health management committees (CHMC) remain barriers to the successful implementation of the CHPS program [18]. Moreover, there is also limited data on the hypertension burden and control in most rural areas of sub-Saharan African countries including Ghana [19]. It is against this backdrop that we designed the current study to investigate the prevalence of hypertension, treatment patterns, and predictive age thresholds for diagnosing hypertension among rural adults in the Nyive community in the Ho Municipality of the Volta Region, Ghana.

2. Materials and methods

2.1 Study area and study site description

Nyive is a rural community found on the left bank of River Tordzie in the northern part of the Ho Municipality. The Nyive community has four CHPS zones providing primary health services to the community. The Municipality has Ho as its capital and also serves as the capital and economic hub of the Volta Region. The Municipality is located between latitudes 6^o20”N and 6^o55”N and longitudes 0^o12’E and 0°53’E. The Municipality shares boundaries with Adaklu and Agotime-Ziope Districts to the South, Ho West District to the North and West, and the Republic of Togo to the East. Its total land area is 2,361 square kilometers thus representing 11.5 percent of the region’s total land area. The population of the district according to the 2010 population and housing census was 177,281, with 83,819 being males and 93,469 females. A total of 110,048 of the population, representing 62.1% live in urban areas while 37.9% live in rural areas.

2.2 Study design, study population, and sampling technique

A population-based cross-sectional study was conducted from August to September 2018. A total population of 3,110 was projected in Nyive based on the enumerated data from the Ghana Universal Long-Lasting Insecticidal Net (LLIN) distribution in a pre-distribution household data validation for 2018. The national LLINs distribution program was carried out between May 2010 and October 2012 in Ghana where about 12.5 million nets were distributed to households. The program involved pre-registration of households and their sleeping places, door-to-door distribution of LLINs by volunteers, and post-distribution behaviour change communication activities to encourage high and sustained use [20]. A projected eligible population of 1,840 with 999 females and 841 males (20 years and above) was estimated using the age and sex distribution from the 2010 population and housing census for the area. Out of a total of 425 eligible adults aged 20 years and above, 417 consented to participate in this study constituting an acceptance rate of 98.12%. Participants who were randomly selected from households based on the population density of the four CHPS zones are part of an ongoing study of the Rural Community Risk of Non-Communicable Disease Study-(Nyive Phase I) Cohort. The Rural Community Risk of Non-Communicable Disease Study is a baseline study aimed at understanding the burden of non-communicable diseases including type 2 diabetes, hypertension, and co-morbid conditions as well as the risk drivers within a rural context using Nyive as the study community in the Ho Municipality of the Volta Region.

2.3 Data collection techniques and tools

The WHO STEPwise approach for non-communicable diseases risk factor surveillance (NCD) instrument was used to collect data for this study. In brief, the instrument covers three different levels or ’steps’ of risk factor assessment: Step 1 (demographic information), Step 2 (physical measurements), and Step 3 (biochemical measurements). Step 1 captures information related to socio-demography (age, gender, educational level, marital status, employment status, income) and behavourial or lifestyle parameters (tobacco use, alcohol consumption, dietary characteristics, physical activity, history raised blood pressure, and diabetes). Step 2 captures information related to physical measurements (weight, height, waist circumference, blood pressure, hip circumference, and heart rate). Step 3 captures information related to biochemical measurements (blood glucose, blood lipids (total cholesterol), triglyceride, and high-density lipoprotein cholesterol) [21].

2.4 Blood pressure measurements

After resting for 3–5 minutes, blood pressure was measured in the non-dominant arm using fully automated blood pressure monitor (OMRON Healthcare, Intelli-sense BP785, HEM-7222, USA) in the sitting position and at arm’s level during the time they were fasting 10–12 hours. A qualified health practitioner performed the blood pressure measurements and the average of three consecutive readings taken about 2 minutes apart was recorded.

2.5 Definition of hypertension and haemodynamic presentations

Hypertension was defined as a self-report of a previous diagnosis of hypertension and/or being on antihypertensive medication. Haemodynamic presentations among the undiagnosed participants were assessed using the Seventh Report of the Joint National Committee (JNC VII) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure criteria. This criterion remain the hypertension diagnosis guidelines in used the jurisdiction, as stated in the 7^th edition of the Standard Treatment Guidelines of the Ghana Ministry of Health [22]. Normotensives were classified as systolic blood pressure (SBP) < 120 mmHg and diastolic blood pressure (DBP) < 80 mmHg, prehypertension (SBP 120–129 mmHg or DBP 80–89 mmHg), hypertension stage 1 (SBP 140–159 mmHg or DBP 90–99 mmHg), and hypertension stage 2 (SBP ≥ 160 mmHg or DBP ≥ 100 mmHg) [23]. Age at diagnosis was defined as the age of participants at the time of diagnosis for self-reported or previously diagnosed participants and the current age for newly diagnosed participants.

2.6 Sample size calculation

A minimum sample size of 318 was calculated from the community’s expected population of 1,840, at a 95% confidence interval, an acceptable margin of error of 5%, and a response rate of 50%. The Online Raosoft sample size calculator was used (www.raosoft.com.14). A total of 417 participants were used in this study.

2.7 Statistical analysis

A continuous variable was expressed as mean ± standard deviation and categorical variables were expressed as frequency and proportion. The difference between proportions was tested with Fisher exact and at all times an alpha of less than 0.05 was considered statistically significant. Crude incidence and age-standardized incidence were calculated using data from the 2010 Population and Housing Census for the study area and 2018 LLIN pre-distribution household data validation as the base population. Population weights were calculated as the total number of people who fell within a specific age group (n) divided by the total eligible population (N). A binary logistic model was used to assess the predictability of hypertension by age. The Youden index was computed to identify population-specific age cut-off points for the optimal differentiation between hypertension and non-hypertension. The Youden Index was derived from (sensitivity + specificity) - 1. Using the area under the curve (AUC) of a receiver-operator characteristic curve (ROC), the gender-specific predictive threshold for identifying hypertension cases (discrimination) was estimated. IBM Statistical Package for the Social Sciences version 22.00 (SPSS Inc, Chicago, USA (http://www.spss.com)) and MedCalc version 12.3.2 for windows (MedCalc Software bvba, Acacialaan 22, B-8400 Ostend, Belgium, (www.medcalc.org) were used for data analysis.

2.8 Ethical consideration

Ethical clearance was sought, and ethical approval was given by the Ethical and Protocol Review Committee of the University of Health and Allied Sciences, Ho, Ghana with protocol number UHAS-REC A.4 [192] 18–19]. Signed written informed consent was obtained from the participants who could read and write. The aim and processes of the research were fully explained to the participants who could not read, and a thumbprint was obtained. Participation was voluntary and confidentiality of data was guaranteed.

3. Results

The average age of the respondents was 50.62 ranging from a minimum of 20 years to a maximum of 85 years. Per the age categorization, 44.13% of the respondents were below 50 years. The proportion of female participants was higher (81.29%). The majority of the participants (74.59%) had attained not more than basic education at the time of the survey. Most of the respondents had ever married and were employed in the informal sector (Table 1).

Table 1. Demographic characteristics of residents of the Nyive community.

Parameter	Frequency	Percentage
Total	417	100
Age of Participants (years)
Mean Age	50.62±15.39^*	(20–85)^*
20–29	40	9.59
30–39	71	17.03
40–49	73	17.51
50–59	108	25.90
60–69	63	15.11
70–79	47	11.27
80–89	15	3.60
Gender
Female	339	81.29
Male	78	18.71
Educational Background
None	77	18.47
Basic	234	56.12
Secondary	79	18.94
Tertiary	27	6.47
Marital Status
Single	36	8.63
Married	254	60.91
Divorce	54	12.95
Widowed	73	17.51
Occupation
None	12	2.88
Informal	381	91.37
Formal	24	5.76

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Data is presented as frequency and proportion.

* Data is presents as mean±standard deviation with minimum and maximum in parenthesis.

Out of the 417 participants, 402 representing 96.40% attested ever having their blood pressure measured for hypertension. Among those ever tested, 32.85% affirmed been diagnosed with hypertension. Among these known hypertensive participants, 64(46.72%) were not on treatment, 73(53.28%) had ever taken medication for hypertension (orthodox, herbal or both), 38.69% had ever consulted a traditional healer on hypertension and 19.71% were on herbal medication for the management of hypertension. While 12.41% combined both orthodox and herbal medications for hypertension management, 7.30% and 33.58% either used herbal medication and orthodox medication for hypertension management respectively. The level of controlled blood pressure recorded among known hypertension was 30.66% overall, 29.91% among the female subgroup, and 35.00% among the males (Table 2).

Table 2. Prevalence of known hypertension and treatment options among residents of Nyive community.

Parameter	Total	Female	Male	p value
Ever had BP Measured	402(96.40)	331(97.64)	71(91.03)	0.011
Diagnosed of Hypertension	137(32.85)	117(34.51)	20(25.64)	0.143
Diagnosed of Hypertension within the last 12 months	92(67.15)	78(66.67)	14(70.00)	1
Controlled Blood Pressure	42(30.66)	35(29.91)	7(35.00)	0.793
*Medication Profile*
Not on Treatment	64(46.72)	53(45.30)	11(55.00)
Hypertension Medication within 2 Weeks	63(45.99)	55(47.01)	8(40.00)	0.632
Consulted Traditional Healer on Hypertension	53(38.69)	47(40.17)	6(30.00)	0.463
Herbal Medication for Hypertension	27(19.71)	25(21.37)	2(10.00)	0.364
Herbal Medication only	10(7.30)	9(7.69)	1(5.00)
Orthodox Medication only	46(33.58)	39(33.33)	7(35.00)
Both Herbal & Orthodox	17(12.41)	16(13.68)	1(5.00)

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Data are presented as the frequency with the corresponding percentage in parenthesis. p is significant at 0.05. BP- Blood pressure.

Among the participants who had not been diagnosed with hypertension, 75 out of 280 were diagnosed of having high blood pressure. The percentage burden of newly diagnosed hypertension was significantly higher among the male subpopulation (41.38%) compared to their female counterparts (22.79%). Among the newly diagnosed hypertensive participants, 34.67% were classified as stage two hypertension, 46.67% presented with isolated high systolic blood pressure (SBP), 26.67% with isolated high diastolic blood pressure, and the rest with both high SBP and DBP (26.67%) (Table 3).

Table 3. Prevalence of undiagnosed hypertension and haemodynamic presentation of community residents in Nyive.

Parameter	Total (280)	Female (222)	Male (58)	p value
Normotensive	109(38.93)	91(40.99)	18(31.03)
(SBP<120 and DBP<80)
Prehypertension	96(34.29)	80(36.04)	16(27.59)
(SBP 120–139 or DBP 80–89)
Hypertension	75(26.79)	51(22.97)	24(41.38)	0.0019
(SBP ≥140 or DBP ≥90)
*Stages of Hypertension*
Stage 1 Hypertension	49(65.33)	31(60.78)	18(75.00)	0.3011
(SBP 140–159 or DBP 90–99)
Stage 2 Hypertension	26(34.67)	20(39.22)	6(25.00)
(SBP ≥160 or DBP ≥100)
*Pattern of Hypertension*
Isolated SBP Hypertension	35(46.67)	26(50.98)	9(37.50)	0.2621
(SBP ≥140 and DBP < 90)
Isolated DBP Hypertension	20(26.67)	11(21.57)	9(37.50)	0.0052
(SBP < 140 and DBP ≥90)
Both SBP & DBP Hypertension	20(26.67)	14(27.45)	6(25.00)	0.2341
(SBP ≥140 and DBP ≥90)

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Data are presented as the frequency with the corresponding percentage in parenthesis. p is significant at 0.05. SBP-Systolic blood pressure, DBP-Diastolic blood pressure.

The crude prevalence of hypertension among the study population was estimated at 508.39 per 1000 residents, 495.58 per 1000 female, and 564.10 per 1000 male subpopulations respectively. Upon a direct age-adjustment using the total surveyed population, the direct age standardized prevalence of hypertension was estimated at 489.42 and 562.58 per 1000 residents among the female and the male subpopulations respectively. After an indirect age adjustment using the actual population of the study area in 2018, the age-standardized prevalence of Nyive was estimated at 402.36 per 1000 female residents for the female group and 487.34 per 1000 male residents for the male group. In general, the prevalence of age group-specific hypertension recorded a rise from 20 to 49 years before a decline with older year groups (Table 4).

Table 4. Crude and age standardized prevalence rate of hypertension among dwellers of the Nyive community.

Parameter	Crude Rate / 1000		Direct Age Standardized Rate/1000			Weight Community^*		Indirect Age Standardized Rate / 1000
Age Group	Female	Male	Survey Weight^*	Female	Male	Female	Male	Female	Male
20–29 years	71.43	333.33	0.1	6.85	31.97	0.26	0.28	18.45	92.75
30–39 years	288.14	250	0.17	49.06	42.57	0.2	0.21	57.11	52.02
40–49 years	569.23	750	0.18	99.65	131.29	0.19	0.18	105.98	132.88
50–59 years	566.67	666.67	0.26	146.76	172.66	0.14	0.14	81.11	92.75
60–69 years	574.47	750	0.15	86.79	113.31	0.09	0.09	54.05	69.56
70–79 years	690.48	400	0.11	77.82	45.08	0.09	0.07	58.75	26.16
80–89 years	625	714.29	0.04	22.48	25.69	0.04	0.03	26.9	21.23
Total	495.58	564.10	1	489.42	562.58	1	1	402.36	487.34

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*Survey Weight: Based on the total eligible population.

Using a population pyramid of hypertension over a single year of the age distribution for the general population, a distribution with a heavy base cluster with a mean age of 45.83±15.62 and mode of 46.00 was observed for the non-hypertension population. On the other hand, a flat base distribution with a heavy cluster from the middle to the top at a mean age of 55.26±13.69 and a modal mark of 55.00 was observed for the hypertension population. A significant average age difference tilted towards the hypertension population was observed (p <0.0001) (Fig 1).

The non-hypertension female group was found to cluster at the lower base of the pyramid leaving a flat top with a median age of 46 and an age mean of 45.87±14.98 which was significantly lower (p<0.0001) compared to an age mean of 55.21±13.25 for the hypertension group. The hypertension group was found to cluster heavily from the middle (≥40) to the top of the pyramid with a flat base (Fig 2).

In the male subpopulation, the non-hypertension group was distributed around a population mean of 45.65±18.74, significantly lower (p = 0.0133) compared to the age mean of 55.45±15.48 for the hypertension group. As seen in Fig 3, the population density for the non-hypertension group was heaviest below 40 years while the population density bulges after 40 years among the hypertension group (Fig 3).

Using a binary logistic model adjusted for education, it was observed that, for a one year increase in age, the risk of hypertension among the population increases by 4.4% (2.9%-5.9% at 95% CI), this odds was 4.7% (3.0%-6.5% at 95% CI), among the female subpopulation and 3.1% (0.2%-6.0% at 95% CI), among the male subpopulation. The model correctly classified 60.67% of the population, 60.49% of the non-hypertension population, and 60.85% of the hypertension population.

As seen in Table 5, the critical age threshold of >39 years with a discriminating power of 0.679 for hypertension was observed among the female subpopulation using receiver operating characteristics curve analysis. In the male subpopulation, the critical at-risk age for hypertension (i.e. the age cutoff at which a person have a risk of developing hypertension) was >35 with a discriminating power of 0.658, a sensitivity of 86.36, and specificity of 50.00 (Table 5).

Table 5. Binary logistic age prediction of hypertension and critical age cutoff for hypertension among residents of Nyive.

Parameter	Total	Female	Male
Exp(B)(Odds Ratio)	1.044	1.047	1.031
Lower 95% CI of Exp(B)	1.029	1.030	1.002
Upper 95% CI of Exp(B)	1.059	1.065	1.060
Significance	<0.0001	<0.0001	0.016
Percentage Correct Classification by Model
Non-Hypertension	60.49	60.82	50.00
Hypertension	60.85	60.12	77.27
Overall	60.67	60.47	65.3
Age Predictive Threshold
Associated criterion	>39	>39	>35
ROC curve (AUC)	0.676	0.679	0.658
Sensitivity	87.74	88.69	86.36
Specificity	41.46	39.77	50.00
p value	<0.0001	<0.0001	0.0153

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CI: Confidence Interval, ROC: Receiver Operating Characteristic, AUC: Area Under the Curve.

4. Discussion

Hypertension contributes to a major disease burden in Ghanaian adults, with variable rates documented among urban and rural dwellers [5, 8]. To date, there is no comprehensive literature on the burden, treatment patterns, and the critical age predicting hypertension among rural folks in the Volta Region of Ghana. Hence, we aimed to fill this knowledge gap by designing the current study. Among a total of 417 rural community dwellers recruited into this study, we observed that the majority [402 (96.40%)] had been tested for hypertension, with more than half presenting with hypertension [212(50.84%)]. The rates of hypertension were 49.56% (168 participants) among females and 56.41% (44 participants) among males, with [137(32.85%)] previously diagnosed hypertension. The variation in the burden of rural hypertension (persons living with hypertension in rural areas) across various geographical areas are said to be attributed to the heterogeneity of hypertension studies including varying study methodologies, measurement techniques, study settings, the definition of hypertension, time study was conducted and the presence of hypertension risk factors [5, 7, 24]. The current finding, however, contributes to the growing evidence of increasing hypertension burden among Ghanaian rural dwellers over the years. Estimates from previous studies between 2004 and 2017 ranged from 24.1% to 44.7% [5–7, 10, 11]. In other studies, rural hypertension rates were reported to range from 32.3% in India [25] to 43% in Nigeria [26].

The crude prevalence of hypertension among the study population was estimated at 508.39 per 1000 residents. After age standardization, the male preponderance to hypertension observed in the current study was in line with an earlier report by Tuoyire and Ayetey [27] in the Ghana demographic and health survey, but opposite to that reported by Agyemang, Nyaaba [8] in the RODAM study. It is not quite apparent from this study what could be responsible for the male preponderance to hypertension. However, Bello [28] suggested that the phenomenon could be due to the high risk assumed by rural men owing to higher rates of alcohol and tobacco usage, as well as their socio-economic responsibility in providing for the family’s upkeep. There are also assertions of male predilection for cardiovascular morbidity in middle-age which is mitigated in advancing years [29, 30].

We observed significantly increasing numbers of participants with hypertension who clustered at advanced ages in the hypertension group while a greater proportion of normotensives clustered at lower ages (Figs 1–3). A direct association between age and hypertension prevalence exists, often attributable to age-related structural changes in blood vessels potentially causing narrowing of the vascular lumen, and consequently increasing blood pressure [31–34]. Notably, the crude and age-standardized prevalence of age-group specific hypertension rose initially from 20 to 49 years before declining to the 70–79 years group (Table 4). The decline in the hypertension prevalence among the older age groups could be due to the phenomenon of excess mortality among the elderly with hypertension, a view Abdulle [35] held from a previous study. Moreover, the finding of a higher prevalence of hypertension among females, particularly those within the 60–79 years age categories compared to the menopausal age of 49 years could be explained by the effect of reduced oestrogen levels known to potentiate hypertension in advancing years [36, 37].

In this study, we found the risk of hypertension to increase by 4.4% (2.9%-5.9% at 95% CI) in the study population; a higher risk among females [4.7% (3.0%-6.5% at 95% CI)] compared to males [3.1% (0.2%-6.0% at 95% CI)] for a one year increase in age. The critical age of developing hypertension among the rural dwellers was >39 years, with a discriminating power of 0.679, similar to what was observed among females but lower in males (critical risk age was >35; discriminating power of 0.658) (Table 5). The observed age predicting hypertension (>39 years) in our study could suggest an early onset of hypertension among rural dwellers in Nyive; the onset was found to be even earlier among the male sub-population (>35 years). A similar age threshold for hypertension diagnosis was previously reported among urban dwellers in Kumasi and other parts of the country suggesting that the phenomenon is not limited to only rural dwellers in Nyive [12, 13, 38–40]. The earlier on-set of hypertension among men in this study may be explained by the lower oestrogen levels [37], but increased activities of the sympathetic nervous system and endothelin-1 leading to increased vasoconstriction and high blood pressure levels [41] compared to premenopausal women.

Standard treatment guidelines for hypertension recommend early diagnosis and commencement of treatment, in addition to making certain lifestyle changes to achieve optimal blood pressure control and prevent complications [42, 43]. Although pills and injectables are forms of antihypertensive medications widely in use [8], there are reports of patronage for alternative management with traditional healing and herbal preparations in Sub-Saharan Africa [44]. At the time of this study, 27(19.71%) previously diagnosed hypertensives were using herbal medications, while 17(12.41%) combined orthodox and herbal treatments (Table 2). Though the choice of herbal medication did not significantly differ by demographic strata among the population, people with no education who also formed the majority of workers in the informal sector had higher percentage patronage of herbal medication (S1 Table). In the RODAM study, the age-standardized hypertension treatment for Ghanaian rural men and women was found to be 19% and 32% respectively [8]. In our study, the proportion of hypertensives with a preference to both orthodox and herbal treatments is, however, comparable to the previous reports of Kretchy, Sarkodie [45] in Accra and Kumasi (19.5%) and Ameade, Ibrahim [46] in Tamale (17.9%). While it is unclear why people would prefer alternative medication to orthodox treatment, or even combine both forms of treatment as observed in sub-Saharan Africa, the perceived failure of allopathic medications, traditional beliefs, health systems deficiencies, low socioeconomic status, and non-health insurance policy uptake was previously suggested as attributed factors [47, 48]. However, the simultaneous use of orthodox and herbal medicines can potentially result in therapeutic interactions leading to altered drug metabolism, exaggerated hypotensive effect, or decreased hypertension control with serious implications on the cardiovascular system and blood pressure control [49–52]. Approximately, only a third of previously diagnosed hypertensive participants [42 (30.66%)] had optimal blood pressure control, with similar proportions observed in both gender populations (male vs female; 35.00% vs 29.91%) (Table 2). The results suggest poor blood pressure control in the majority of hypertensives on treatment at the time of this study. Uncontrolled hypertension accounts for a greater proportion of stroke and heart failure cases among Ghanaians [53]. A wide range of factors have been proposed to contribute to the high rates of uncontrolled hypertension in less developed countries including lack of access to appropriate health care, cost, inadequate healthcare personnel to population ratio, and non-adherence to treatment and follow-up [24, 54, 55].

An important observation that equally merits attention is the high rate of prehypertension [96(34.29%)] and undiagnosed hypertension [75(26.79%)] among the rural dwellers. Among the newly diagnosed hypertensive participants, we observed 26(34.67%) presenting with stage two hypertension (Table 3). The results are, probably, the reaffirmation of the low awareness of hypertension status among populations in sub-Sahara Africa and rural dwellers in particular [56–58].

A potential limitation to the findings of this study is the inclusion of subjective definitions of hypertension and treatment patterns which could result from a recall bias on the part of the study participants.

5. Conclusion

Hypertension is high among rural adults in Nyive. The critical age at risk of hypertension and the estimated annual increased risk of hypertension were lower in males compared to females. High levels of undiagnosed hypertension and low levels of blood pressure control exist among the rural dwellers.

Supporting information

S1 Table. Treatment options among known hypertension residents of Nyive community stratified by demography.

(DOCX)

Click here for additional data file.^{(17KB, docx)}

S1 Data

(SAV)

Click here for additional data file.^{(16.9KB, sav)}

Data Availability

All relevant data are in the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0252284.r001

Decision Letter 0

Sonak D Pastakia

14 Sep 2020

PONE-D-20-24599

The Community Burden of Hypertension and Treatment Patterns: An In-depth age predictor analysis: The Rural Community Risk of Non-Communicable Disease Study - (Nyive Phase I)

PLOS ONE

Dear Dr. Osei-Yeboah,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I found this paper to be a potentially valuable addition to the literature. Similar to the comments from the other reviewers, I believe that if you provide additional context for some of your statements, the paper will become more clear and understandable for readers who aren't familiar with the region you are studying in Ghana.

Within the comments provided by the other reviewers, please ensure that you incorporate all the major or mandatory comments I've highlighted in parentheses. We believe that once you incorporate these suggestions, the paper will be significantly improved and suitable for publication.

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We look forward to receiving your revised manuscript.

Kind regards,

Sonak D. Pastakia

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PLOS ONE

Additional Editor Comments:

The authors describe an interesting study describing their teams efforts to describe of hypertension amongst rural community members. My comments mirror the comments of the reviewers and would request that you address these comments to provide additional clarity on the issues they mention.

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Reviewer #1: Partly

Reviewer #2: Yes

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Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #1: Recommendation | The Community Burden of Hypertension and Treatment Patterns: An In-depth age

predictor analysis: The Rural Community Risk of Non-Communicable Disease Study -

(Nyive Phase I)

The manuscript talks about a health condition that is certainly of interest to healthcare and may contribute to literature. Hence, understanding risk factors to hypertension such as age and the effect of the condition on a community in addition to the "treatment patterns" available may help to improve care for hypertensive patients.

This manuscript shows strengths in its introduction and clear lay out of the table of results. Authors random selection of participants is an additional strength.

Under discussion, it seems the authors are suggesting that the time period within which the study was done could be one of the factors contributing to the variation in the burden of hypertension. Not sure if I missed it but authors should consider indicating months/year data was collected to help readers connect to the above implication. Furthermore, the manuscript could benefit from an elaborate discussion on bridging the numbers from the results with the aims. What gap in literature will this fill? (mandatory)

Under methods, authors should consider disclosing the number of all the participants contacted and those who opted out of the study. Did all eligible participants contacted by investigators consent to participate in the study? Kindly indicate the response rate and if the recorded number is small, consider indicating that as a limitation of the study. (mandatory if possible)

Authors should also consider describing the parts of the WHO STEPwise approach used since the study does not report on all the three steps. For example, There are other variables worth mentioning such as diet, smoking and exercise that affect hypertension but were not reported as part of the data collected. Did the questionnaire include all the variables in the WHO STEPwise approach? Consider stating this as potential limitation. (optional)

Again, it is indicated in the manuscript that there were objective and subjective measures of hypertension by definition. The subjective report could also be a potential limitation.

"Rural hypertension" may not be a term that is widely known. Therefore, it will be appropriate to define what the term mean in the study at first mention. That is, please define "rural hypertension". (Please make this more clear)

Other consideration:

Title: Consider revising the title, for instance, "Community Burden of Hypertension and Treatment Patterns - The Rural Community Risk of Non-Communicable Disease Study (Nyive Phase I): An In-depth age predictor analysis"

Abstract:

* Under methods; Sentence 2: Suggestion, "WHO STEPS Instrument... OR ..."The WHO STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) instrument...." as stated on the WHO website instead of "The WHO STEPS wise approach for non-communicable diseases risk (NCD) instrument..." (minor)

Introduction:

* Review of literature seems fair although authors could consider information from more recent literature. Generally the review includes literature from Ghana and Sub-Saharan Africa. Almost half of the reference is 10 or more years. I suggest adding current literature such as: (major)

Methods:

*Line 33 & 34; revise the wording for the WHO instrument used as suggested under "Abstract" above.

* Line 100; Consider revising, "...is was the tool used to the collect data and ..."

* Line 115; Consider revising, "...Committee (JNC VII) on Prevention, Detection,..." NOT line 116 "...(JNC VII) criteria for blood pressure..."

*If data was collected before JNC VIII became available, then authors can ignore this recommendation. If not, JNC VIII guidelines have been available since December 2013. Consider adding a reason why JNC VII was preferred as reference for this study instead of the recent JNC VIII guidelines.

Results/Findings:

*Line 157, 162, 163 and 165; Consider revising, "... ever...". Are you trying to state "never"?

Discussion:

*Line 241; Consider revising, "...ever..."

*Line 243, Suggest, ".This rate of hypertension was...." and Line 244 to 245, "...with previously diagnosed hypertension."

*Line 296, Optimal BP control may differ based on individual patient condition and BP goal. Consider adding more information to clarify this assertion from the referenced literature.

Thank you for the opportunity to review this manuscript.

Reviewer #2: This paper is a significant contribution to the under-studied field of hypertension (HTN) control in Ghana. Although I recommend some significant revisions for clarity and context, I think it is an important analysis that merits publication. My comments by section follow below.

Introduction

There are a few typos and style issues to address - for instance the word "indicates" in line 53, and the use of "Africa" in line 55 when I presume "sub-Saharan Africa" would be more accurate. More broadly, however - the section could incorporate some additional context (space permitting) to make the paper's contribution clearer and stronger. For instance, the section makes reference to the Community Based Health Planning and Services (CHPS) program without citing or explaining it - consider detailing how this program works via, say, Phillips 2006 or other references. Similarly, the paper does not reference recent efforts to incorporate HTN care into CHPS, such as per Ogedegbe, 2018 and the TASSH study, or Haykin, 2020. There is also some limited data on HTN in Ghana in rural areas worth noting (e.g. Gomez-Olive, 2017). Detailing further what we currently know about attempts to measure and address the rural HTN burden in Ghana would make it easier for the reader to see why this new paper is noteworthy. (mandatory)

Methods

The study area section might benefit from a map, so persons unfamiliar with Ghana's geography can appreciate where the site is. Further explaining the features of the LLIN dataset would also help orient the reader, as would some more details on exactly how the current work builds on the Rural Community Risk of Non-Communicable Disease Study. (mandatory)

It is laudable that the study ensured that blood pressure was measured only after 3-5 minutes' rest, in a seated position, and documented this fact. Ideally, BP should be measured at arm's level, and the subject told not to eat or hold their urine prior to the BP check. Was this done? (mandatory)

The definitions of HTN use JNC 7 criteria rather than the 2017 ACC/AHA criteria. If possible, I would prefer the analysis be done using these cutoffs (if only as a sensitivity analysis), as they better reflect an updated understanding of the risk of elevated BP between 120 and 139 mm Hg systolic. (optional)

Results

These are generally clear and straightforward, with a few typos (e.g., divorce vs divorced in table 1, and "having been" diagnosed with HTN in lines 163-164). I would suggest however rewording the paragraph in lines 162-171 for readability - I found it hard to follow what relative fraction of patients were using orthodox versus herbal medications versus both, as a proportion of all persons on treatment. These results are shown in table 2 but remain a bit confusing to me: for instance, how the bottom 3 rows (adding up to 73 persons) overlap with those treated in the last 2 weeks (63 persons) - were the other 10 persons off medicine for the last two weeks? I'd suggest making clearer the denominators (e.g., the 73 persons on treatment) relative to the numerators and percentages (e.g., 10, 46, and 17 persons on herbal versus orthodox versus both treatments). (optional)

I'd also be keen to see if age, education level, and occupation (if not marital status) corresponds with tendency to take herbal versus non-herbal (orthodox) medication - the results are displayed only as a function of gender. Can this analysis also be added? (optional)

Lastly - the finding that >35 and >39 are important age thresholds for HTN in men and women respectively is notable. However I was unable to follow the discriminating power calculation, and this does not seem to be discussed in the methods section. Can you kindly clarify? (please clarify)

Discussion

This section is generally well-written, though I would be interested to hear more about the findings regarding herbal medication use (especially if we have more data as above on predictors of same). Are there other findings on this question besides Liwa and Smart's papers (references 36-38 - one is listed twice?) How much do these findings focus on Ghana and/or rural areas in particular? (optional)

I would be happy to review a revised version.

**********

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Reviewer #1: No

Reviewer #2: Yes: David J. Heller MD MPH

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PLoS One. 2021 Aug 12;16(8):e0252284. doi: 10.1371/journal.pone.0252284.r002

Author response to Decision Letter 0

19 Mar 2021

Reviewer 1

Comment:

Response:

Authors have provided the time period within which the study was carried out. We have included it in the methodology which can be found in the statement in lines 108-109 of the revised version of the manuscript.

Comment:

Furthermore, the manuscript could benefit from an elaborate discussion on bridging the numbers from the results with the aims. What gap in literature will this fill?

Response:

Authors have included statements in the discussion as suggested.

Comment:

Response:

Authors have included all information requested above by the reviewer and these can be traced to the statement in lines 118-120. However, we wish to state that there was an overwhelming acceptance rate of 98.12%, hence, this cannot be considered as a limitation for this study.

Comment:

Response:

Authors have included a detailed description of the instrument as suggested by the reviewer. The changes to this manuscript can be found in statements in lines 133-140. However, since the focus of this paper is clearly spelt out (to determine hypertension burden, treatment patterns and possible age predicting hypertension), it is the considered opinion of the authors that the exclusion of other parameters in the instrument for this study cannot be stated as a limitation.

Comment:

Again, it is indicated in the manuscript that there were objective and subjective measures of hypertension by definition. The subjective report could also be a potential limitation.

Response:

Authors have stated that the subjective measurement of hypertension included in this study is a potential limitation. The addition of this statement to the manuscript can be found in statements in lines 382-384.

Comment:

Response:

Authors have included the definition of “rural hypertension” at first mention in the manuscript as suggested by the reviewer. The change can be found in lines 285-286

Other Considerations

Comment:

Response:

Authors have amended the title.

Comment:

Abstract:

Response:

Authors have amended the sentence to reflect the reviewer’s suggestion

Comment:

Introduction:

Response:

While every effort was made to include citations from more recent literature, authors wish to maintain the references- Cappuccio et al. (2004) and Bosu, 2010 for purposes of different time point analyses or comparisons.

Comment:

Methods:

*Line 33 & 34; revise the wording for the WHO instrument used as suggested under "Abstract" above.

* Line 100; Consider revising, "...is was the tool used to the collect data and ..."

Response:

Authors have revised the wordings as suggested.

Comment:

Line 115; Consider revising, "...Committee (JNC VII) on Prevention, Detection," NOT line 116 "...(JNC VII) criteria for blood pressure..."

Response:

The definition of hypertension as used in the current analysis were based on the blood pressure cut-offs for different hypertension stages, this did not differ in the updated guideline, which is also the cut-off in use in the setting.

Comment:

Results/Findings:

*Line 157, 162, 163 and 165; Consider revising, "... ever...". Are you trying to state "never"?

Response:

Author wish that the word “ever” is maintained in lines 157, 162, 163 and 165 since changing it to “never” as suggested will change the meaning of the statements where they appear

Comment:

Discussion:

*Line 241; Consider revising, "...ever..."

*Line 243, Suggest, ".This rate of hypertension was...." and Line 244 to 245, "...with previously diagnosed hypertension."

*Line 296, Optimal BP control may differ based on individual patient condition and BP goal. Consider adding more information to clarify this assertion from the referenced literature.

Response:

Authors have made changes to statements as suggested by the reviewer in lines 283-285.

Concerning issues in line 296 in the previous version of the manuscript, authors addressed the issues by taking out the blood pressure cut-offs “140/90” to make the statement more appropriate

Reviewer 2

Comment:

Introduction

Response:

Authors have addressed the typo and style issues. We have also included additional information on the CHPS program explaining how attempts have been made to incorporate hypertension care into CHPS to address the issue of rural hypertension and the associated challenges. The changes made as suggested by the reviewer can be traced to statements in lines 75-89.

Comment:

Response:

Authors have included the map and the explanation of the LLIN based dataset which was used to determine the projected population as suggested.

Comment:

Ideally, BP should be measured at arm's level, and the subject told not to eat or hold their urine prior to the BP check. Was this done? (mandatory).

Response:

Participants’ blood pressure was measured at an arm’s level during the time they were fasting and this statement have been included in the statement in lines 144-145.

Comment:

Response:

Authors adopted the JNC 7 criteria for hypertension definition because the criteria was still in use by the Ghana Health Service in the diagnosis and management of hypertension.

Comment:

Response:

The scheme of analysis in table 2, was to profile or tell a story among participants who knew they were hypertensive and evaluate their practices (thus questions were answerable only when you answer yes of ever being diagnosed of hypertension). Since it obvious these questions would not be applicable to a non-hypertensive person, the denominator was 137 for the total, 117 for female and 20 for the male (representing self-reported known hypertensives).

Comment:

Response:

Authors appreciate the possible additional information in describing the treatment pattern as a function of age, educational attainment and occupation, we have added that part of the analysis as a supplementary information in Table S1.

Comment:

Response:

The method used for determining the discriminating power of the age cutoff points [the area under the curve (AUC) of the receiver -operator characteristic (ROC)] was stated in the materials and methods under the statistical analysis section.

Comment:

Discussion

Response:

Authors have included local findings in the discussion as suggested.

Attachment

Submitted filename: Response to reviewer comments.docx

Click here for additional data file.^{(21.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0252284.r003

Decision Letter 1

Sonak D Pastakia

14 May 2021

Community Burden of Hypertension and Treatment Patterns: An In-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - (Nyive Phase I)

PONE-D-20-24599R1

Dear Dr. Osei-Yeboah,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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Kind regards,

Sonak D. Pastakia

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

This version is considerable improvement from the last version. I would correct a couple of the editorial typos mentioned by the reviewers prior to publication.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: Thanks again for the opportunity to review this manuscript and for considering reviewers suggestions.

Overall, great improvement in clarity, detail and cohesiveness. I recognize the attempt to connect the findings in this study to previous study, however, Doumas et al., 2013 does not seem to fit the statement made (page 24, line 334-337). The need for cardio-protection for premenopausal women on certain therapies may be beneficial but the point on how that can help explain early on-set of hypertension in men is not clear? Please clarify or elaborate so that readers understand how the statement supports the claim.

Reviewer #2: I am satisfied by the thoughtful revisions provided by the authors. These include adding key context to the introduction section; a helpful map of the target area; and clarifying how blood pressure was checked.

I am fine with using the JNC-7 guidelines given these are still used by the Ghana Health Service. I also found the clarifications helpful (in the table and the text) regarding orthodox versus herbal medication.

I propose the paper be accepted essentially as-is, but I propose some minor edits beforehand:

1. Ideally please add a reference in/around line 152 indicating that JNC7 remains the hypertension guideline of choice for the Ghana Health Service;

2. Please indicate in line 205 that the numbers for the three categories of medications used (orthodox, herbal, or both) add up to 53.28% (the total who are on medication)

3. Please proof the paper once more for typos that spell check might have missed (e.g., thumb instead of tomb, line 188).

4. Lastly, forgive any methodological ignorance on my part, but I don’t quite understand what is meant (at a practical level) by the critical at risk age of 35 for men and 29 for women. Can the authors add a line explaining expressly what this means for the clinician?

I have no further comments and thank the reviewers for their edits.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Akua A. Appiah-Num, PharmD, MS

Reviewer #2: No

PLoS One. doi: 10.1371/journal.pone.0252284.r004

Acceptance letter

Sonak D Pastakia

31 May 2021

PONE-D-20-24599R1

Community Burden of Hypertension and Treatment Patterns: An In-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - Nyive Phase I)

Dear Dr. Osei-Yeboah:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Sonak D. Pastakia

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Table. Treatment options among known hypertension residents of Nyive community stratified by demography.

(DOCX)

Click here for additional data file.^{(17KB, docx)}

S1 Data

(SAV)

Click here for additional data file.^{(16.9KB, sav)}

Attachment

Submitted filename: Response to reviewer comments.docx

Click here for additional data file.^{(21.4KB, docx)}

Data Availability Statement

All relevant data are in the paper and its Supporting Information files.

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PERMALINK

Community burden of hypertension and treatment patterns: An in-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - Nyive Phase I)

James Osei-Yeboah

Ellis Owusu-Dabo

William K B A Owiredu

Sylvester Yao Lokpo

Francis Delali Agode

Beatrice Bella Johnson

Roles

Abstract

Background

Methods

Results

Conclusion

1. Background

2. Materials and methods

2.1 Study area and study site description

2.2 Study design, study population, and sampling technique

2.3 Data collection techniques and tools

2.4 Blood pressure measurements

2.5 Definition of hypertension and haemodynamic presentations

2.6 Sample size calculation

2.7 Statistical analysis

2.8 Ethical consideration

3. Results

Table 1. Demographic characteristics of residents of the Nyive community.

Table 2. Prevalence of known hypertension and treatment options among residents of Nyive community.

Table 3. Prevalence of undiagnosed hypertension and haemodynamic presentation of community residents in Nyive.

Table 4. Crude and age standardized prevalence rate of hypertension among dwellers of the Nyive community.

Fig 1. Age distribution population pyramid over hypertension among residents of Nyive.

Fig 2. Age distribution population pyramid over hypertension among female residents of Nyive.

Fig 3. Age distribution population pyramid over hypertension among male residents of Nyive.

Table 5. Binary logistic age prediction of hypertension and critical age cutoff for hypertension among residents of Nyive.

4. Discussion

5. Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Sonak D Pastakia

Roles

Author response to Decision Letter 0

Decision Letter 1

Sonak D Pastakia

Roles

Acceptance letter

Sonak D Pastakia

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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