Aletta E. Schutte

Angela J. Woodiwiss1

Caitlynd Myburgh

Gavin R. Norton

Ruan Kruger

South East Academic Libraries System (SEALS)

May Measurement Month 2018: an analysis of bloodpressure screening results in South AfricaAngela J. Woodiwiss1*, Ruan Kruger2,3, Gavin R. Norton1, Aletta E. Schutte2,3,Caitlynd Myburgh4, Benedicta Nkeh-Chungag5, Constance R. Sewani-Rusike6,Muhammed Vally7, Erika Jones8, Vernice Peterson1, Justin Marsh1,Lebo F. Gafane-Matemane2,3, Blessing O. Ahiante3, Edith Phalane3,Thomas Beaney9,10, Anca Chis Ster9, Xin Xia9, and Neil R. Poulter91Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences,University of the Witwatersrand, 7 York Road, Parktown, 2193 Johannesburg, South Africa;2MRC Research Unit for Hypertension and Cardiovascular Disease, Faculty of Health Sciences, North-West University,Building C1, 53 Borcherd Street, Potchefstroom, 2531, South Africa;3Hypertension in Africa Research Team, Faculty of Health Sciences, North-West University, 53 Borcherd Street,Potchefstroom, 2531, South Africa;4Department of Life and Consumer Sciences, University of South Africa (UNISA), Science Campus, Roodepoort, 1732,South Africa;5Department of Biological and Environmental Sciences, Faculty of Natural Science, Walter Sisulu University, Unitra,5117, Mthatha, South Africa;6Department of Human Biology, Faculty of Health Sciences, Walter Sisulu University, Unitra, 5117, Mthatha, SouthAfrica;7Pharmacology Division, Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of theWitwatersrand, 7 York Road, Parktown, 2193, Johannesburg, South Africa;8Division of Nephrology and Hypertension, Groote Schuur Hospital, Faculty of Health Sciences, University of CapeTown, Observatory, 7925, Cape Town, South Africa;9Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK; and10Department of Primary Care and Public Health, Imperial College London, St Dunstan’s Road, London W6 8RP, UKKEYWORDSHypertension;Blood pressure;Screening;Treatment;ControlElevated blood pressure (BP) is a growing burden worldwide, leading to over 10 mil-lion deaths each year. May Measurement Month (MMM) is a global initiative of theInternational Society of Hypertension (ISH) aimed at raising awareness of high BP andacting as a temporary solution to the lack of screening programmes worldwide. Aspart of MMM, screening in South Africa in 2017 revealed that 24.5% of adults (meanage ¼ 31 years) have hypertension and only half of those with hypertension had con-trolled BP. These data highlight the need for continued screening and awarenesscampaigns. An opportunistic cross-sectional survey of volunteers aged 18 years wascarried out in May 2018. Blood pressure measurements, the definition of hyperten-sion and statistical analyses followed the MMM protocol. The sites screened weregeneral populations and university campuses in preference to hospitals and clinics,aiming to raise awareness and allow access to screening to those less likely to beaware of their BP. In total, 2965 individuals (age 40.56 18.2 years) were screened.After multiple imputation for missing BP readings, 34.6% had hypertension, only56.7% of those with hypertension were aware, 21.2% of those not receiving*Corresponding author. Tel: þ27 11 717 2363, Email: angela.woodiwiss@wits.ac.zaPublished on behalf of the European Society of Cardiology. VC The Author(s) 2020.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium,provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.comEuropean Heart Journal Supplements (2020) 22 (Supplement H), H115–H118The Heart of the Matterdoi:10.1093/eurheartj/suaa043Downloaded from https://academic.oup.com/eurheartjsupp/article/22/Supplement_H/H115/5898729 by Walter Sisulu University user on 01 July 2021treatment for hypertension were hypertensive, and a large proportion (42.5%) ofindividuals receiving antihypertensive medication had uncontrolled BP. These resultssuggest that opportunistic screening campaigns can identify significant numbers withundiagnosed and uncontrolled hypertension. The high proportions of individuals withundiagnosed and treated uncontrolled hypertension highlight the need for hyperten-sion awareness campaigns and more rigorous management of hypertension.IntroductionIn South Africa, non-communicable diseases, of which hy-pertension is a major contributor, are now leading causesof death and disability.1 In 2012, 43.4% of all deaths inSouth Africa were attributed to non-communicable dis-eases, compared with 33.6% due to HIV/AIDS and tubercu-losis.2 Moreover, deaths due to non-communicable diseasesshowed a steady increase from 1997 to 2012; whereasdeaths due to HIV/AIDS and tuberculosis decreased.2 Thedoubling of the prevalence of hypertension (from 24% in1998 to 45% in 2016)3,4 plays a major role in the burden ofcardiovascular disease in South Africa. Despite the highprevalence of hypertension in South Africa, a large propor-tion of individuals remains untreated or has uncontrolledblood pressure (BP). Indeed, a previous South African com-munity surveillance study conducted in 2016 revealed thatonly 6% of men and 9% of womenwere taking antihyperten-sive medication and had normal BP.4 Although limited ac-cess to treatment for hypertension plays a role, other keyfactors include low awareness and lack of adequate hyper-tension screening facilities.5,6 Hence, in 2017 South Africajoined May Measurement Month (MMM), a global initiativeof the International Society of Hypertension (ISH) aimed atraising awareness of high BPand to act as a temporary solu-tion to the lack of screening programmes worldwide. In2017, 3250 adults were screened, 24.5% were found tohave hypertension, 57.7% of those with hypertension wereuntreated, and 46.9% of individuals receiving antihyperten-sive medication had uncontrolled BP.7 The 2017 resultshighlighted the need for repeated screening programmesin South Africa to increase awareness and education as wellas to allow access to BP measurements for those who havenever been screened before.MethodsStudy groupThe study was approved by the Ethics Committees for eachsite (see Supplementary material online). Participantsgave written informed consent. In total, 2965 participantsaged 18years and older were screened at various sites (seeSupplementarymaterial online).Blood pressure, demographic, andanthropometric measurementsBefore the commencement of data collection, volunteerswere trained in accurate BPmeasurement techniques usingvalidated automated devices (Omron MIT5 Connect andOmron M6 Comfort devices, donated by OmronHealthcare). Screening was primarily on weekdays for theduration of May. At least three seated BP and heart raterecordings were taken on the left arm (preferably) after atleast 5min rest with 1-min interval. A questionnaire wasused to collect limited clinical and demographic data aspreviously described.8 The data were either entered di-rectly onto a bespoke mobile application or entered onto astudy-specific worksheet (Excel). The data were cleanedby each of the site principal investigators (PIs) before sub-mitting to MMM centrally.Data analysisHypertension was defined as BP 140/90mmHg or thoseon antihypertensive treatment, and BP control asBP< 140/90mmHg. The data were analysed centrally bythe MMM project team.8 Crude analyses were done usingthe mean of the 2nd and 3rd BP readings where available.For comparisons of BP between all individuals, multiple im-putation was used to estimate the average of the 2nd and3rd readings where either reading was not documented(n¼ 115). Linear regression models were run separately forsystolic and diastolic BP to look for the strength of associa-tions with BP.ResultsThe characteristics of those individuals screened are shownin Supplementary material online, Table S1. The partici-pants were aged 40.56 18.2 years on average, includedmore women than men, and were predominantly of blackor white ethnicity. 54.4% of the study population was over-weight or obese. The proportions of participants with dia-betes or prior cardiovascular events were low.In total, 1025 (34.6%) participants were found to havehypertension. Only 581 (56.7%) of those with hypertensionwere aware that they had hypertension. 521 (21.2%) ofthose not receiving antihypertensive medication had hy-pertension. Only 49.2% of hypertensives were receiving an-tihypertensive medication, and only 57.5% of individualsreceiving antihypertensive mediation had controlled BP.The proportion of all hypertensives with controlled BP wasonly 28.3%.Based on a linear regression model, in those who werenot receiving antihypertensive medication, both systolicand diastolic BP showed an increase with age. In women,BP was lower than in men (Supplementary material online,Figure S1). The increase in systolic BP with advancing ageup to the age of 60 years was steeper in women.However, the increase in diastolic BP with advancing ageH116 A.J. Woodiwiss et al.Downloaded from https://academic.oup.com/eurheartjsupp/article/22/Supplement_H/H115/5898729 by Walter Sisulu University user on 01 July 2021paralleled that of men. Systolic and diastolic BP werehigher in obese (7.26 0.8 and 5.36 0.5mmHg, respec-tively, P< 0.0001) or overweight subjects (4.46 0.7 and2.96 0.5mmHg, respectively, P< 0.0001) than in normalweight. Systolic and diastolic BP were higher (6.6 and4.1mmHg, respectively, P< 0.0001) in treated thanuntreated subjects (Supplementary material online,Figure S2). Systolic but not diastolic BP was marginallyhigher in those reporting regular alcohol intake(1.5mmHg, P< 0.05); whereas neither systolic nor dia-stolic BP differed between smokers and non-smokers(Supplementary material online, Figure S2). Diastolic BPbut not systolic BP was significantly lower in pregnantwomen (5.6mmHg, P< 0.01) (Supplementary material on-line, Figure S2).DiscussionThe MMM18 programme in South Africa detected that morethan a third of screenees had hypertension, and only 56.7%of hypertensives were aware that they had hypertension.Only one in two hypertensives received treatment for hy-pertension, and the vast majority (71.7%) had uncontrolledBP. Although a similar number of participants werescreened as compared with 2017, importantly only 8.7% ofthe participants had participated in MMM17. The majority(87.7%) of those screened in 2018 reported having had theirBPmeasured previously. Moreover, 67.8% had their BP mea-sured within the past 12months. Hence, although two-third of individuals are having their BP checked annually,plans to improve awareness and BP control in hypertensivesare urgently required.Although, one-third of participants had hypertension,this proportion is marginally lower than the prevalence ofhypertension (women: 43%; men: 51%) previously reportedfor those aged 35–44years in 2016,4 and in a cohort with asimilar mean age (43 years) from a community-based study(40.4%).9 That only half of hypertensives were receivingtreatment for hypertension also confirms previous reportsfrom a community-based study (52.7%),10 in rural and urbanresearch sites (21.6–55.8%),11 and in a cohort study of hy-pertensive nurse practitioners (59%).12 Similarly, the lowproportion with controlled BP is in keeping with low propor-tions with controlled BP on medication (women: 6.7%; men:2.5%) previously reported for those aged 35–44years inSouth Africa in 2016,4 and in data from a community-basedstudy,10 a cohort study12 and in rural and urban researchsites11 where 77.4%, 61.9%, and 67.7–92.2% of hypertensiveshad uncontrolled BP, respectively. The proportions of SouthAfricans with hypertension, aware that they have hyperten-sion, receiving antihypertensive treatment and havinguncontrolled BP are comparable with the worldwide datareported for screening in 2018.13 The relatively high propor-tions with hypertension and uncontrolled BP, and low pro-portion receiving medication, highlight the urgent need forimproved healthcare systems for better detection andman-agement of hypertension in South Africa.In keeping withworldwide data, increased BPwas associ-ated with advancing age, and systolic BP showed a greaterincrease with age in women compared with men.8,13Although BP was higher in those with increased bodyweight, similar to data worldwide (only 7 and 4mmHghigher systolic and diastolic BP, respectively in obese com-pared to underweight),8,13 and data from screening inSouth Africa in 2017,7 the clinical impact at an individuallevel appears relatively small.The marginal associations between BP and regular alco-hol intake and tobacco use, possibly reflect the relativelylow percentages of individuals reporting regular alcohol in-take and tobacco use. Indeed, the proportion of individualsreporting regular alcohol intake (19.8%) was lower thanthat reported in the 2017 screening campaign (36.2%), andthe percentage reporting tobacco use (12.4%) was slightlylower than previously reported (14.2%).7 It is possible thatthe introduction of taxes and policies by the South Africangovernment to reduce the use of tobacco and alcohol, mayhave had some effect. As reported in 2017,7 the lack ofstrong relationships between previous myocardial infarc-tion, previous stroke or diabetes and BP is most likely dueto the low proportions of individuals with these conditions.The limitations of the present study include the volun-tary nature of the programme, and therefore, the partici-pation of only a limited number of regions of South Africa.Hence, the data are unlikely to be representative of allprovinces in South Africa. Indeed, the sample is an oppor-tunistic sample and not a random sample. The low numbersof individuals with previous cardiovascular events or diabe-tes precluded meaningful analyses on the relationshipswith BP, and there is a possibility of false-positive diagnosisof hypertension, due to screening on only one occasion.In conclusion, the results of the present study again high-light the need for repeated screening programmes to in-crease awareness and education; but moreover, emphasizethe urgency to introduce plans to improve BP control in hy-pertensive individuals.AcknowledgementsThe present study would not have been possible withoutthe voluntary collaboration of the participants. We arevery grateful for the excellent technical assistance of allthe volunteers who participated in the screening.FundingThis work was supported by the International Society ofHypertension, Centers for Disease Control and Prevention,Servier Pharmaceutical Co., Omron Healthcare, SouthernAfrican Hypertension Society, Cardiovascular Pathophysiologyand Genomics Research Unit and Hypertension in AfricaResearch Team.Conflict of interest: none declared.References1. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D.The burden of noncommunicable diseases in South Africa. Lancet2009;374:934–947.MMM18 South Africa H117Downloaded from https://academic.oup.com/eurheartjsupp/article/22/Supplement_H/H115/5898729 by Walter Sisulu University user on 01 July 20212. Pillay-van Wyk V, Msemburi W, Laubscher R, Dorrington RE,Groenewald P, Glass T, Nojilana B, Joubert JD, Matzopoulos R,Prinsloo M, Nannan N, Gwebushe N, Vos T, Somdyala N, Sithole N,Neethling I, Nicol E, Rossouw A, Bradshaw D. Mortality trends anddifferentials in South Africa from 1997 to 2012: second NationalBurden of Disease Study. Lancet Glob Health 2016;4:e642–e653.3. Steyn K, Gaziano T, Bradshaw D, Laubscher R, Fourie J; SouthAfrican Demographic and Health Coordinating Team. Hypertension inSouth African adults: results from the Demographic and HealthSurvey, 1998. J Hypertens 2001;19:1717–1725.4. National Department of Health (NDoH), Statistics South Africa (StatsSA), South African Medical Research Council (SAMRC), ICF. 2017.South Africa Demographic and Health Survey 2016: key indicators.Pretoria, South Africa and Rockville, MD, USA: NDoH, Stats SA,SAMRC, and ICF.5. Adler AJ, Prabhakaran D, Bovet P, Kazi DS, Mancia G, Mungal-Singh V,Poulter N. Reducing cardiovascularmortality through prevention andmanagement of raised blood pressure: a World Heart Federationroadmap. Glob Heart 2015;10:111–122.6. Olsen MH, Angell SY, Asma S, Boutouyrie P, Burger D, Chirinos JA,Damasceno A, Delles C, Gimenez-Roqueplo A-P, Hering D, López-Jaramillo P, Martinez F, Perkovic V, Rietzschel ER, Schillaci G,Schutte AE, Scuteri A, Sharman JE, Wachtell K, Wang JG. A call toaction and a life course strategy to address the global burden ofraised blood pressure on current and future generations: the LancetCommission on hypertension. Lancet 2016;388:2665–2712.7. Woodiwiss AJ, Kruger R, Norton GR, Schutte AE, Vally M, Da SilvaFernandes D, Masiu M, Kolkenbeck-Ruh A, Gafane-Matemane LF,Ahiante BO, Phalane E, Crouch SH, Beaney T, Xia X, Poulter NR. MayMeasurement Month 2017: an analysis of blood pressure screeningresults in South Africa—Sub-Saharan Africa. Eur Heart J Supp 2019;21:D104–D106.8. Beaney T, Burrell LM, Castillo RR, Charchar FJ, Cro S, Damasceno A,Kruger R, Nilsson PM, Prabhakaran D, Ramirez AJ, Schlaich MP,Schutte AE, Tomaszewski M, Touyz R, Wang JG, Weber MA, PoulterNR, MMM Investigators. May Measurement Month 2018 A, PragmaticGlobal Screening Campaign To Raise Awareness Of Blood Pressure ByThe International Society Of Hypertension. Eur Heart J, 2019 4,2006–20179. Woodiwiss AJ, Molebatsi N, Maseko MJ, Libhaber E, Libhaber C,Majane OHI, Paiker J, Dessein P, Brooksbank R, Sareli P, Norton GR.Nurse-recorded auscultatory blood pressure at a single visit predictstarget organ changes as well as ambulatory blood pressure. JHypertens 2009;27:287–297.10. Hodson B, Norton GR, Ballim I, Libhaber CD, Sareli P, Woodiwiss AJ.Impact of aortic rather than brachial pulsatile haemodynamics onvariations in end-organ measures across the full adult blood pressurerange. J Hypertens 2017;35:2443–2453.11. Gómez-Olivé FX, Ali SA, Made F, Kyobutungi C, Nonterah E,Micklesfield L, Alberts M, Boua R, Hazelhurst S, Debpuur C, MashinyaF, Dikotope S, Sorgho H, Cook I, Muthuri S, Soo C, Mukomana F,Agongo G, Wandabwa C, Afolabi S, Oduro A, Tinto H, Wagner RG,Haregu T, Wade A, Kahn K, Norris SA, Crowther NJ, Tollman S,Sankoh O, Ramsay M; AWI-Gen and the H3Africa Consortium.Regional and sex differences in the prevalence and awareness of hy-pertension. An H3Africa AWI-Gen study across 6 sites in Sub-SaharanAfrica. Global Heart 2017;12:81–90.12. Monakali S, Ter Goon D, Seekoe E, Owolabi EO. Prevalence, aware-ness, control and determinants of hypertension among primaryhealth care professional nurses in Eastern Cape, South Africa. Afr JPrm Health Care Fam Med 2018;10:e1–e5.13. Beaney T, Burrell LM, Castillo RR, Charchar FJ, Cro S, Damasceno A,Kruger R, Nilsson PM, Prabhakaran D, Ramirez AJ, Schlaich MP,Schutte AE, Tomaszewski M, Touyz R, Wang J-G, Weber MA, PoulterNR; MMM Investigators. May Measurement Month 2018: a pragmaticglobal screening campaign to raise awareness of blood pressure bythe International Society of Hypertension. Eur Heart J 2019;40:2006–2017.H118 A.J. Woodiwiss et al.Downloaded from https://academic.oup.com/eurheartjsupp/article/22/Supplement_H/H115/5898729 by Walter Sisulu University user on 01 July 2021

May Measurement Month 2018: an analysis of blood pressure screening results in South Africa

Walter Sisulu University

http://vital.seals.ac.za:8080/vital/access/services/Download/vital:44105/SOURCE1

May Measurement Month 2018: an analysis of blood pressure screening results in South Africa

Abstract

Similar works

Full text

Available Versions

South East Academic Libraries System (SEALS)

Walter Sisulu University