Blood pressure screening in Mata Sector, a rural area of Rwanda

doi:10.21203/rs.3.rs-3634712/v1

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Blood pressure screening in Mata Sector, a rural area of Rwanda

https://doi.org/10.21203/rs.3.rs-3634712/v1

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published 24 Apr, 2024

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In rural sub-Saharan Africa, knowledge of non-communicable diseases such as high blood pressure (BP) is rather limited. This report provides information about a BP screening in Mata Sector, a rural region in Southern Province of Rwanda. Community-based, house-to-house screening was performed between February and July 2020 on more than 7,000 inhabitants. The screening was conducted by a local team composed by 20 community health care workers, five community health care supervisors, and one nurse with hypertension surveillance training. BP and heart rate were recorded after 5 minutes of resting, using a validated automated oscillometric OMRON M6 IT-HEM-7322-E monitor with Intelli Wrap Cuff (HEM-FL31-E) technology. The mean of the second and third value was retained. BP was normal (< 140/90 mm Hg) in 6,340 (88%) and elevated in 863 (12%) participants with 95% of unawareness. Grade 1 (140–159/90–99 mm Hg) hypertensive BP readings were detected in 697 (81%), grade 2 (160–179/100–109 mm Hg) in 134 (16%), and grade 3 (≥ 180/≥110 mm Hg) in 32 (3.7%) individuals. The prevalence of hypertensive readings was significantly age-dependent. Additionally, a slightly greater proportion of participants with high BP (14% versus 11%) had a body mass index (BMI) ≥ 25.0 kg/m². Also resting heart rate was higher in individuals with high BP (82 versus 77 beats/min).

Although individuals identified with occasionally elevated BP values need further confirmatory measurements to establish the diagnosis of hypertension, these data suggest that high BP represents an escalating concern within sub-Saharan Africa.

Health sciences/Diseases/Cardiovascular diseases/Hypertension

Health sciences/Health care/Diagnosis

In sub-Saharan Africa, infectious diseases like malaria, tuberculosis, and AIDS have historically been major causes of illness. However, countries within this region, as many low- and middle-income ones worldwide, are experiencing a shift in disease patterns. Communicable and childhood-related diseases are nowadays overshadowed by chronic, non-communicable diseases [1, 2]. Cancer, chronic respiratory diseases, diabetes, mental disorders, and cardiovascular diseases including rheumatic heart disease and arterial hypertension, are becoming increasingly burdensome in several countries in sub-Saharan Africa [3]. Knowledge of these non-communicable diseases in sub-Saharan Africa is rather limited, particularly in remote rural areas. This report provides information about a blood pressure (BP) screening performed in Mata Sector, a rural region in Southern Province of Rwanda.

General Information

Mata Sector is located in Nyaruguru District, Southern Rwanda, approximately 27.5 km west of Huye, the main urban center of this Province. It is a rural region with a population of around 15,000 people (2020: 15,691) spread across an area of 62.2 km² at an elevation of approximately 1900 meters above sea level. It has a subtropical highland climate, characterized by steadily moderate temperatures and rainfall evenly spread throughout the year. Within Mata, there are 16 villages that prioritize sustainable farming methods and community development projects. The Association Mabawa - Wings for Africa (https://en.mabawa.org/chisiamo) in Mata Sector since 2005 has had a profound and transformative role in this region, which was deeply impacted by the 1994 genocide [4]. This association has promoted numerous initiatives that have significantly improved the quality of life in the Region. These initiatives encompass a range of activities, including education and school development, agriculture and livestock programs, beekeeping, housing construction, support for small businesses and microcredit schemes, infrastructure development such as water pipes and aqueducts, and fostering a local Health Care Center.

Among the promoted health care projects, special attention was given to screen for high BP. The BP screening was conducted by a local team, who received a two-day training from a certified European Hypertension Specialist (FM). The team was composed of 20 community health care workers, five community health care supervisors, and one nurse with a Bachelor Degree in General Nursing and a specific education in hypertension surveillance.

The project was approved by the Rwanda National Ethics Committee (RNEC) as “Study for better Blood Pressure and Cardiovascular Risk Control in a rural area of the District of Nyaruguru” (RNEC Approval Nr 752/RNEC/2019) and was performed in accordance with the Declaration of Helsinki. The project was endorsed by the World Hypertension League. Verbal informed consent in Kinyarwanda, the national spoken language, was obtained from all participants.

Study design

This community-based, house-to-house BP screening was carried out between February and July 2020 in 12 villages of Mata Sector (Cyafurwe, Mata, Matyazo, Murambi, Nyamyumba, Ramba, Rimbanya, Runono, Rwamiko, Rwinanaka, Taba, and Tubururu). The remaining four villages (Gasasa, Mataba, Nyacyondo, and Ruhunga) were not involved in the screening because of distance barriers.

Data collected included demographics, self-reported previous diagnosis and/or treatment of hypertension and/or diabetes, and social history of tobacco smoking. Measurements included anthropometrics, BP, and resting heart rate.

Weight was taken using a digital Pearl® platform scale (PEARL GmbH, Buggingen, Germany) and height using a 300 cm Metrica® measuring tape (Metrica SpA, Milan, Italy). Body mass index (BMI), calculated as ratio between weight in kilogram and height in square meters, was used as a simple surrogate of normal (≤ 24.9 kg/m²) or excessive (≥ 25.0 kg/m²) body fat content.

According to European Society of Hypertension (ESH) Guidelines [5], after resting in seated position for at least five minutes, sitting brachial BP and heart rate were measured three times one minute apart, using a validated, automated, oscillometric OMRON M6 IT-HEM-7322-E BP monitor with Intelli Wrap Cuff (HEM-FL31-E) technology (Omron Healthcare UK Ltd, Milton Keynes, UK) [6]. This pre-formed, expanded coverage BP cuff inflates around the entire upper arm to fit arms with a circumference of 22–42 cm and ensures accurate readings [7]. The mean of the second and third value was calculated and retained. According to the ESH Guidelines [5], BP is classified into four categories: normal (< 140/90 mm Hg); grade 1 (140–159/90–99 mm Hg), grade 2 (160–179/100–109 mm Hg), and grade 3 (≥ 180/≥110 mm Hg) hypertension. We refer to this categorization of BP [5] hereafter. Fast heart rate was defined as resting heart rate > 80 beats/min.

Statistical Analysis

Dichotomous categorical data are expressed as count and were analyzed by means of the 𝜒² test [8]. Ordered categorical data were analyzed by means of the non-parametric Kruskal-Wallis test [9]. The normality D’Agostino-Pearson Omnibus Test [10] disclosed that age (P < 0.0001), weight (P < 0.0001), height (P < 0.0001), BMI (P < 0.0001), resting heart rate (P < 0.0001) and both systolic and diastolic BP (P < 0.0001) do not follow a Gaussian distribution. Consequently, continuous data are presented as median and interquartile range and were analyzed using the non-parametric Mann-Whitney-Wilcoxon U test and the Kruskal-Wallis test [8]. Age, resting heart rate, and BMI are also presented [11] in box-and-whisker plots (the bottom and top of the box represent the 25th and 75th centile, the middle band the median, and the ends of the whiskers the 10th and the 90th centile). Simple regressions were also calculated [12]. Two-sided P values of < 0.05 were considered significant. GraphPad Prism for Macintosh 10.0.2 (GraphPad Software, San Diego, California, United States) was used for statistics.

The number of inhabitants who voluntarily underwent the screening was 7,425. Two hundred and twenty-two individuals were excluded because of young age, missing data, being under treatment for hypertension, and reporting a diagnosis or treatment of diabetes, as depicted in Fig. 1.

The characteristics of the remaining 7,203 participants (3,957 females and 3,246 males, aged 32 [21–46]) are presented in Table 1. History of untreated hypertension and tobacco smoking was positive in 1.4% and 10% of the screened population, respectively. Eleven percent had a BMI ≥ 25.0 kg/m². BP was normal in 6,340 (88%) and elevated in 863 (12%) participants. Grade 1 hypertensive blood pressure readings were detected in 697 (81%), grade 2 in 134 (16%), and grade 3 in 32 (3.7%) individuals. Compared to normotensive participants, individuals with hypertensive values were significantly older (46 versus 30 years; P < 0.0001) and more frequently reported a prior diagnosis of untreated hypertension (5.7% versus 0.9%; P < 0.0001) and tobacco smoking habit (16% versus 9.3%; P < 0.0001). Additionally, a slightly greater proportion of participants with high BP readings (14% versus 11%; P = 0.0019) had a BMI ≥ 25.0 kg/m² (Fig. 2, panel B). Lastly, also resting heart rate was higher in the group of individuals with elevated BP values (82 versus 77 beats/min; P < 0.0001). Of note, among those found to have high BP readings, 338 (39%) had isolated systolic (systolic ≥ 140 mm Hg and diastolic < 90 mm Hg) BP values, while 244 (28%) isolated diastolic (systolic < 140 mm Hg and diastolic ≥ 90 mm Hg), and 281 (33%) systo-diastolic (systolic ≥ 140 mm Hg and diastolic ≥ 90 mm Hg).

Table 1

Characteristics of 7,203 individuals undergoing the blood pressure screening in Mata Sector of Nyaruguru District (Rwanda). Participants with and without elevated blood pressure readings were not compared with respect to blood pressure, being statistically significant difference predictable. Data are presented as frequency (with percentage) or as median (with interquartile range).
		All	B l o o d P r e s s u r e
		All	Normal	High	P-value
N (%)		7,203	6,340 (88)	863 (12)
Females : Males, N (%)		3957 (55) : 3246 (45)	3469 (55) : 2871 (45)	488 (57) : 375 (43)	0.2358
Age, years		32 [21–46]	30 [20–44]	46 [32–61]	< 0.0001
Self-reported hypertension*, N (%)		104 (1.4)	55 (0.9)	49 (5.7)	< 0.0001
Tobacco smoking, N (%)		728 (10)	587 (9.3)	141 (16)	< 0.0001
Weight, kg		56 [50–62]	56 [50–62]	58 [51–64]	< 0.0001
Height, m		1.62 [1.56–1.68]	1.62 [1.56–1.68]	1.62 [1.56–1.68]	0.8924
Body mass index, kg/m²
	value	21.2 [19.5–23.1]	21.2 [19.5–23.1]	21.7 [20.0-23.7]	< 0.0001
	≥ 25.0, N (%)	815 (11)	688 (11)	129 (14)	0.0019
Blood pressure, mm Hg
	systolic	118 [110–127]	116 [108–124]	144 [137–153]
	diastolic	75 [68–81]	73 [68–79]	91 [84–95]
Resting heart rate, beats/min		78 [69–87]	77 [69–86]	82 [72–92]	< 0.0001
* untreated

The prevalence of individuals with high BP readings was identical in females and males (12%), as shown in Table 2. Interestingly, while in both sexes, age and resting heart rate were significantly higher (P < 0.0001) among individuals with hypertensive than normotensive readings, BMI was significantly higher in males with hypertensive than normotensive values, but it was not significantly different (P = 0.0748) between females with hypertensive and normotensive values (Table 2 and Fig. 2). Age (Fig. 2, panel A), BMI (Fig. 2, panel B) and resting heart rate (Fig. 2, panel C) were higher in normotensive females than in normotensive males (P < 0.0001). A similar difference was observed also between females and males with elevated BP values (age: P < 0.0001; BMI: P = 0.0015; resting heart rate: P = 0.0036). Furthermore, being aware of their potential hypertensive status and being tobacco smokers were more common in those with high BP measurements, both in females and males (Table 2 and Fig. 2, panel D and E).

Table 2

Characteristics of 3,957 female and 3,246 male individuals undergoing the blood pressure screening in Mata Sector of Nyaruguru District (Rwanda). Participants with and without elevated blood pressure readings were not compared with respect to blood pressure, being statistically significant difference predictable. Data are presented as frequency (with percentage) or as median and interquartile range.
		All	Blood Pressure
		All	Normal	High	P-value
Females
	NN	3975	3468	507
N (%)		3,957	3,469 (88)	488 (12)
Age, years		34 [22–48]	32 [21–45]	52 [39–63]	< 0.0001
Self-reported hypertension*, N (%)		79 (2.0)	42 (1.2)	37 (7.6)	< 0.0001
Tobacco smoking, N (%)		211 (5.3)	146 (4.2)	65 (13)	< 0.0001
Weight, kg		56 [50–62]	56 [50–62]	56 [49–62]	0.4163
Height, m		1.59 [1.55–1.64]	1.60 [1.55–1.64]	1.59 [1.54–1.63]	0.2980
Body mass index, kg/m²
	value	21.8 [20.0-23.8]	21.8 [19.9–23.8]	21.9 [20.2–24.1]	0.0748
	≥ 25.0, N (%)	629 (16)	542 (16)	87 (18)	0.3288
Blood pressure, mm Hg
	systolic	116 [108–126]	114 [107–122]	145 [136–155]
	diastolic	75 [69–81]	74 [69–79]	91 [86–95]
Resting heart rate, beats/min		80 [72–88]	80 [72–88]	82 [74–93]	< 0.0001
Males
N (%)		3246	2871 (88)	375 (12)
Age, years		30 [20–43]	28 [20–42]	37 [28–55]	< 0.0001
Self-reported hypertension*, N (%)		25 (0.8)	13 (0.5)	12 (3.2)	< 0.0001
Tobacco smoking, N (%)		517 (16)	441 (15)	76 (20)	0.0215
Weight, kg		57 [51–62]	57 [51–62]	60 [54–66]	< 0.0001
Height, m		1.66 [1.60–1.71]	1.66 [1.60–1.71]	1.67 [1.61–1.72]	0.1052
Body mass index, kg/m²
	value	20.6 [19.0-22.2]	20.5 [18.9–22.1]	21.4 [19.8–23.2]	< 0.0001
	≥ 25.0, N (%)	186 (5.7)	146 (5.1)	40 (11)	< 0.0001
Blood pressure, mm Hg
	systolic	120 [112–129]	118 [111–125]	143 [139–150]
	diastolic	74 [67–80]	72 [67–78]	90 [82–94]
Resting heart rate, beats/min		75 [66–84]	74 [66–83]	81 [70–90]	< 0.0001
* untreated

The characteristics of the 7,203 screening participants according to age groups are presented in Table 3. Weight and BMI were on average significantly higher in participants with 35–44 years of age as compared to the remaining age groups. Resting heart rate and the prevalence of resting heart rate > 80 beats/min were age independent. On the contrary, both systolic and diastolic BP and the prevalence of hypertensive readings were significantly age-dependent. Similarly, hypertensive grade 2 and grade 3 values were uncommon (< 10%) in participants ≤ 34 years of age but more common (> 10%) in individuals ≥ 35 years of age (P < 0.0001).

Table 3

Characteristics of 7,203 individuals undergoing the blood pressure screening according to age groups. Data are presented as frequency (with percentage) or as median (with interquartile range).
			A g e (y e a r s)						P-values
			15–24	25–34	35–44	45–54	55–64	> 65
N			2,465	1,467	1,294	833	663	481
Females : Males, N			1,199 : 1,266	792 : 675	762 : 532	516 : 317	400 : 263	288 : 193
Weight, kg			55 [49–60]	58 [53–63]	59 [53–65]	57 [51–63]	55 [50–60]	51 [46–58]	< 0.0001
Height, m			1.61 [1.55–1.67]	1.62 [1.57–1.69]	1.62 [1.58–1.68]	1.62 [1.57–1.68]	1.62 [1.57–1.68]	1.60 [1.54–1.65]	< 0.0001
Body mass index, kg/m²
	Value		20.8 [19.1–22.6]	21.7 [20.2–23.4]	22.0 [20.3–24.0]	21.4 [19.6–23.2]	20.7 [18.9–22.7]	20.2 [18.4–22.1]	< 0.0001
	≥ 25.0, N		172 (7.0)	198 (13)	231 (18)	108 (13)	67 (10)	39 (8.1)	< 0.0001
Resting heart rate, beats/min
	Value		78 [69–87]	77 [68–86]	78 [70–87]	78 [70–86]	78 [69–86]	78 [70–86]	0.0575
	> 80, N (%)		1,046 (42)	570 (39)	562 (43)	337 (40)	280 (42)	188 (39)	0.1594
Blood pressure, mm Hg
	Systolic		115 [107–122]	117 [109–126]	119 [110–128]	121 [113–131]	124 [113–136]	129 [118–146]	< 0.0001
	Diastolic		71 [65–77]	74 [68–80]	77 [71–83]	78 [73–84]	78 [72–84]	77 [71–84]	< 0.0001
	High blood pressure, N (%)		112 (4.5)	131 (9.0)	162 (13)	137 (16)	153 (23)	168 (35)	< 0.0001
	Hypertension grade*								< 0.0001
		Grade 1	105	119	139	111	115	108
		Grade 2	7	10	21	23	30	43
		Grade 3	0	2	2	3	8	17
*classification of the European Society of Hypertension [5]

This community-based BP screening was performed among more than 7,000 individuals, i.e. approximately 50% of the inhabitants of Mata Sector, a rural area in Southern Province of Rwanda. Our field study provides evidence that in such population hypertensive readings prevalence was 12% (without relevant differences between sexes) with a strong age dependence. Moreover, 95% of the individuals with elevated BP values were unaware of their potential hypertensive status.

Between 2000 and 2022, 14 articles, encompassing 15 community-based BP screenings performed in rural East sub-Saharan Africa, were published [13–26]. The size of the screened population varied from 211 to 6,678 and the mean age between 35 and 64 years. The overall prevalence of high BP ranged between 15 and 70% and was therefore higher than in our population (12%), which was on average rather young (mean age 36 years). Taking together the published studies and our data, a tendency towards an age-dependent increase in the prevalence of elevated BP appears supported by sufficient evidence (Fig. 3, lower panel). A relationship was observed also between age (when considering the six different age groups included in our study) and the prevalence of increased BP (Table 3 and Fig. 3, upper panel). Taken together, this analysis supports the notion that the increase in arterial BP is similar in Mata Sector and in the aforementioned studies carried out in East sub-Saharan Africa.

In high income countries, excessive body weight is strongly associated with arterial hypertension. The population included in our study was rather lean, as indicated by the fact that a BMI ≥ 25.0 kg/m² was present in 11% of the participants. Nonetheless, in individuals with high BP values, the BMI and the prevalence of BMI ≥ 25.0 kg/m² were slightly but significantly higher. Similar observations were reported by other studies in hypertensive populations in sub-Saharan Africa [27, 28].

Tobacco smoking significantly contributes to cardiovascular morbidity and mortality [5, 29]. The vast majority (90%) of the individuals who participated in our study were non smokers. Nevertheless, tobacco smoking was more prevalent among participants with high BP values than those with normal BP.

Fast resting heart rate predisposes to an increased cardiovascular morbidity and mortality, as recently reviewed [30]. In our study, individuals with high BP readings had a higher resting heart rate (by 5 beats/min) than the normotensive counterpart. Resting heart rate was not assessed in the previously mentioned screening studies conducted in East sub-Saharan Africa except for one of them. However, the latter study failed to report resting heart rate values in the hypertensive and in the normotensive population separately considered [14].

We have to acknowledge few limitations of our study. First, the results of our population screening, which considered BP values obtained in one visit only, are not sufficient for the diagnosis of arterial hypertension. Indeed, individuals identified with occasionally elevated BP values need further confirmatory measurements over repeated visits to establish the diagnosis of arterial hypertension [5]. Second, sedentary lifestyle, excessive alcohol consumption and adding extra salt to food, three further major modulators of BP levels, were not evaluated in our study [5, 29, 31, 32].

On the other hand, our screening has various strengths. To the best of our knowledge, this is the largest community-based BP screening ever conducted in rural sub-Saharan Africa. Despite being voluntary, the massive participation in this rather small geographical area ended up being accurately representative of the local adult population. Furthermore, it was conducted in a short time frame with the involvement of local community health care workers, who had been carefully trained and were supervised throughout the data collection. Finally, the measurement of BP was carried out strictly adhering to recently available guidelines [5], and was performed by means of a clinically validated, automated, oscillometric device, thus resulting in a reliable and accurate estimate of BP levels.

In conclusion, these data substantiate that high BP, which is the leading preventable cardiovascular risk factor [3, 5, 29], and the main cause of mortality worldwide [3] represents a noteworthy and escalating reason of concern within sub-Saharan Africa, particularly considering the rising life expectancy in this geographical area [1–3]. Thus, as recently stated by the World Hypertension League in a call to action [3], there is an imperative need to enhance diagnosis, treatment (both lifestyle and pharmacological interventions), and control of arterial hypertension also in sub-Saharan Africa.

Acknowledgments

We would like to thank the association Mabawa - Wings for Africa for its logistic support, and the tremendous effort and commitment of our data collectors and field supervisors. The authors would like to express their deepest appreciation to the participants in the screening for giving their time in our project.

Author Contributions

All authors have made substantive intellectual contributions to this project. FM, GP, PS, AU conceptualized the screening and developed the research tools and methodology. FM acquired the funding for this screening. FM, BM, EN, AU collected the data. IH, MGB, GPM, DR conducted the formal data analysis. IH, MGB wrote the original draft of the manuscript. All authors reviewed and edited the draft and agreed to submit the final manuscript for publication.

Funding

This study was supported by an unrestricted grant from the SHK Stiftung für Herz und Kreislaufkrankheiten, Hergiswil Switzerland.

Competing Interests

The authors declare no competing interests.

The project was endorsed by the World Hypertension League.

Ethical Approval

The project was approved by the Rwanda National Ethics Committee (RNEC) as “Study for better Blood Pressure and Cardiovascular Risk Control in a rural area of the District of Nyaruguru” (RNEC Approval Nr 752/RNEC/2019). It was conducted in accordance with the Declaration of Helsinki of 1964 and its later amendments.

Additional Information

Informed Consent Statement

Verbal informed consent in Kinyarwanda, the national spoken language, was obtained from all participants.

Summary Table

What is known about the topic

Hypertension is a newly recognized killer in Africa.
Substantial evidence suggests that westernization of lifestyle is strongly related to the development of hypertension in urban Africa.
Data on blood pressure values and related modulators in rural sub-Saharan Africa are scarce.

What this study adds

In Mata Sector, a rural region in Southern Rwanda, blood pressure is elevated in 12% of the inhabitants.
Blood pressure correlates with age, body mass index, and resting heart rate.
A decentralized, nurse-led blood pressure surveillance is feasible in rural sub-Saharan Africa.

Data Availability

De-identified participant data will be made available, upon reasonable request. Please contact Prof. Gianfranco Parati at [email protected].

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There is NO conflict of interest to disclose.

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published 24 Apr, 2024

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Blood pressure screening in Mata Sector, a rural area of Rwanda

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