Epidemiology and control of hypertension in Somaliland

Background: Hypertension is the leading risk factor for morbidity worldwide, responsible for approximately 11 million deaths annually, accounting for nearly 19.2% of total deaths. Hypertension is also a significant cause of disability. In 2019, an estimated 1.28 billion people worldwide had hypertension and the Global Burden of Disease 2020 study reported a 5% increase in the prevalence of high blood pressure from 2010 to 2019. This increase is attributed to several factors, including population growth, aging and behavioural risk factors, such as alcohol and tobacco use, physical inactivity, unhealthy diets and obesity. Obesity and overweight increased by 18% from 2010 to 2019 and these risk factors can also cause other conditions such as diabetes and dyslipidemia, which further increase the risk of complications of hypertension, including cardiac failure, stroke and renal failure.
Low- and middle-income countries (LMICs) have the highest number of people with hypertension and the highest prevalence of hypertension. According to data from the World Health Organization (WHO), the prevalence of hypertension is highest in the African region, at 27%. LMICs have weaker health systems and the proportion of undiagnosed, untreated and uncontrolled hypertension is higher in these countries than in high-income countries (HICs).
The increasing incidence of hypertension and its complications have a devastating impact not only on health and well-being, but also on socio-economic development. Patients with hypertension in LMICs often face prohibitively expensive care, leading to catastrophic expenditures that push patients and families into dependency and impoverishment. Indeed, families of patients spend a substantial amount of their income on hospitalization and patient care due to recurrent and chronic morbidities associated with hypertension, such as heart failure, stroke and kidney failure.
Somalia has long been suffering from a lack of organised public health service and the private sector and international organisations have been the main source of health service in the country for the last three decades. In particular, non-communicable diseases (NCDs) have been left behind as infectious diseases and nutritional deficiencies were prioritised in the packages to promote the provision of essential health services. In Somalia, hypertension is estimated to have caused 2,643 deaths (50.1 per 100,000 of the population) in 2020 and its incidence is increasing. Diabetes, cardiovascular diseases (CVDs) and cancers are also on the rise not only in Somalia but also in other sub-Saharan African countries.
Somaliland is an autonomous self-declared republic but officially unrecognised region of Somalia, with a population estimated at 5.7 million in 2021. Somaliland has six administrative regions and 30 districts and the Ministry of Health Development (MoHD) is the main actor and coordinator of healthcare in Somaliland. Hospitals are the main source of service and a network of health posts and mother and child health clinics make up another important tier for health service delivery. As public health service in Somaliland exhibits an exceptionally low level of performance, private institutions (i.e. privately owned hospitals, clinics and pharmacies) remain the main source of care for people. Often, financially poor people make up the largest proportion of patients seeking service from public institutions.
Information on the state of hypertension in Somaliland is extremely scarce and little data are available to measure the impact of hypertension and track its trend. Thus, understanding the epidemiology and control of hypertension in Somaliland will offer an opportunity to deepen the understanding of the current state of the problem and will serve as a valuable guide to set foundations for an integrated preventive programme to tackle NCDs in Somaliland. Hence, the overall objective of this thesis was to evaluate the status of hypertension and risk for CVD among patients seeking care from Hargeisa group hospital, Hargeisa, Somaliland.
Methodology: A health facility-based cross-sectional study was conducted at the main referral hospital of Hargeisa city, Somaliland, from June 13 to August 15, 2022. Built in 1951, Hargeisa group hospital (HGH) is the national and largest referral hospital in Somaliland. With more than 260 daily patient visits and 400 beds, it provides essential health services to more than 1 million inhabitants of Hargeisa, the capital city of Somaliland. It also offers referral care for other regions and districts of the country. The study was given approval by the Research Ethics Committee of the University of Hargeisa and was granted permission by the Somaliland Ministry of Health Development. The study enrolled participants aged 18 years and above, after obtaining written informed consents, using the WHO STEPwise surveillance approach to obtain patient information. Trained staff interviewed patients and collected data on their blood pressure, weight and height. The care of hypertension was analysed using a cascade of care approach. Logistic regression was applied to assess the association between risk factors and outcomes of interest, including hypertension, uncontrolled hypertension, awareness, treatment and control.
The 2019 revised WHO/International Society of Hypertension (ISH) risk score charts for the Eastern sub-Saharan Africa were used to assess the 10-year risk of developing CVDs. The scores were determined based on five CVD risk factors, including sex, age, smoking habits, body mass index (BMI) and systolic blood pressure.
Principal findings: Of the 469 individuals invited to participate, 319 (54.2% males; mean age 40.4 years) had complete data records (interviews and physical measurements). The prevalence of hypertension was 22.6% (95% confidence interval (CI); 18.2–27.6%), with a higher prevalence in males (24.9%, 95% CI: 18.8–32.1%) than females (19.9%, 95% CI: 13.9–27.4%). Age, cholesterolaemia and obesity were significantly associated with hypertension. Obesity was significantly associated with hypertension in females, but not in males, while cholesterolaemia was significantly associated with hypertension in males but not in females.
We found a high awareness of hypertension among outpatients, with 91.7% (95% CI; 82.1–96.5) knowing their condition. Among patients who were aware of hypertension, 92.4% (95% CI; 82.5–97.2%) were on treatment for blood pressure control, but only 9.8% (95% CI; 4.1–20.9%) had their blood pressure level under control. The logistic regression model revealed that individuals aged ≥65 years, females, those who consumed Khat, those who were obese and those with hypercholesterolaemia had higher odds of uncontrolled blood pressure.
Out of the 319 participants with complete data records, 134 were 40 years or older. Based on the 2019 revised WHO/ISH chart for Eastern sub-Saharan Africa, 58 (43.3%) had a risk level below 5% and were at very low risk of fatal or non-fatal cardiovascular (CV) events (CHD or stroke) over the next 10 years. A risk level between 5% and 10% was predicated for 33 (24.6%) who were at low risk of CV events. Another 33 (24.6%) had a risk level between 10% and 20% and were at moderate risk of CV events. Additionally, 10 (7.5%) of the participants had a risk level higher than 20%, and hence, were at high risk of CV events.
Conclusion/significance: The results of our study indicate that nearly a quarter of the outpatient population in Hargeisa suffer from hypertension. Moreover, 86% of the outpatient population who has been prescribed antihypertensive medications did not achieve their treatment goals and one-third of outpatients are at a high or very high risk of developing non-fatal or fatal CV events over the next decade. This increased risk for CV events underscores the need for early detection and monitoring of risk factors and outcomes associated with hypertension and other NCDs. Our findings also suggest that hypertension is linked to low levels of education, smoking, Khat consumption and obesity. Therefore, reducing obesity, implementing public health education programmes and strengthening policies and programmes against smoking and Khat consumption can have a significant impact on lowering hypertension and reducing the risk of CVD. These observations highlight the importance of strategies to prevent and properly manage hypertension and other chronic NCDs in Somaliland. Consequently, there is a need for a multipronged intervention and surveillance programme on risk factors and outcomes of hypertension and other NCDs, as well as strategies to screen, prevent and control such diseases in Somaliland. Research on the challenges associated with the prevention and management of NCDs in Somaliland is also critical.
Our study has significant policy implications. First, the substantial proportion of individuals with high risk for CV events indicates the need for strategies targeting high-risk individuals. Second, the high prevalence of individuals with low- to moderate-risk necessitates public policies that focus on the whole population. Finally, the overall low level of predicted risk and the increase of risk with age demand comprehensive CV care. Our findings should encourage the development of a national programme to improve public awareness of hypertension and to train healthcare providers for better screening and treatment of hypertension. Appropriate screening strategies are crucial for the early identification of people with raised blood pressure, but to date, there are no standard clinical guidelines for either screening or treatment of hypertension in Somaliland. The implementation of a pilot project adapting the WHO Package of Essential Non-communicable Disease (PEN) intervention using total CVD risk-based assessment approach in primary care settings might be valuable for the prevention and control of hypertension. Such a project may set a foundation for a national programme on the integrated management of NCDs and their underlying risk factors in Somaliland. Measurable improvement in awareness, treatment and control of hypertension has been achieved in countries where PEN interventions were implemented. In addition, such interventions might enable concerned stakeholders to better understand the operational prospects and value for investment for early detection and management of NCDs and their risk factors. Given the scarcity of available evidence and the absence of established clinical guidelines in Somaliland, we do not provide a decision-making algorithm for hypertension. However, we suggest the implementation of contextually appropriate collaborative interventions to prevent and combat NCDs.