Abstract
Background: Excess body weight was associated with a higher chance for hypertension detection.
Aim: To compare the anthropometric characteristics and blood pressure levels between Burkinabè adults who had ever been screened for hypertension and those who had never been screened, and to assess the associated factors with the uptake of hypertension screening.
Setting: Urban and rural Burkina Faso.
Methods: This was a secondary analysis using the Burkina Faso 2013 WHO Stepwise approach to Surveillance cross-sectional survey. Data from 3831 adult men and women were analysed. Descriptive and analytical analyses were performed using Student’s t, ANOVA, χ2, Fisher’s exact tests and logistic regression.
Results: Among participants, 41.6% (95% CI: 40.0–43.1) had never been screened for hypertension, and compared to those who had ever been screened, they had significantly lower mean weight, waist circumference and body mass index, and lower prevalence of overweight or obesity and abdominal obesity. The prevalence of prehypertension was similar between the two groups (around 40%) and the prevalence of hypertension was lower in those who had never been screened (17.3% vs 20.8%; p = 0.007). Overweight or obesity (adjusted odds ratio [aOR] = 1.3; p = 0.03) and abdominal obesity (aOR = 1.3; p = 0.002) were associated with screening uptake.
Conclusion: The Burkinabè adults who had never been screened for hypertension were apparently thin, but pre-hypertension or hypertension was also common among them. Increasing body size (excess weight or abdominal obesity) may be the reason for screening uptake.
Contribution: Specific awareness-raising messages to motivate slim people to undergo screening need to be developed.
Keywords: screening for hypertension; blood pressure; body sizes; thin-looking build; Burkina Faso.
Introduction
Hypertension leads to the risk for cardiovascular events, disability and premature mortality1, and more than four-fifths of people with hypertension live in low- and middle-income countries (LMICs).2 The challenge of reducing the burden of cardiovascular disease, particularly in LMICs in sub-Saharan Africa (SSA), includes efforts to improve the detection and management of hypertension.3 Excess body weight was a consistent determinant of hypertension in SSA4 and overweight or obese status has been associated with a lower risk of remaining undiagnosed for hypertension.5 Barriers to screening should be tracked, and it can be hypothesised that specific barriers may also be related to self-perception of body size or image in relation to susceptibility to diseases such as hypertension. The first STEPwise approach to surveillance (STEPS) survey in Burkina Faso used a nationally representative sample to assess uptake of hypertension screening and included the real-time measurements of anthropometric and blood pressure (BP) characteristics. Compared with people living with undiagnosed hypertension in Burkina Faso, people with known hypertension were more likely to be overweight (by more than 10 points difference) or obese (by more than 20 points difference).6
Although excess body weight is a significant risk factor for hypertension, it is also worth considering the possibility of selection bias in participation and/or screening provision. This seems to be relevant in view of the significant rate of metabolic disorders reported in Burkinabè of normal weight.7
Our study aimed to compare the anthropometric characteristics and blood pressure levels between adults who had ever been screened for hypertension and those who had never been screened at the time of the first STEPS survey in Burkina Faso, and to assess the factors associated with screening uptake.
Research methods and design
Study design
A secondary cross-sectional analysis was performed using data from the World Health Organization (WHO) STEPS8 survey conducted in Burkina Faso in 2013. This study is a recommended tool for surveillance of chronic diseases and their risk factors in the WHO member countries. The survey is a standardised method to collect, analyse and disseminate data. It is a sequential process that starts with gathering key information about the risk factors with a questionnaire; subsequently, simple physical measurements are collected. The WHO STEPS includes a representative sample of the study population, which allows the results to be generalisable to the entire population.
Study population, sample size, participants’ selection and data collection
The study population was adults of both the sexes, aged between 25 and 64 years, who had been living in Burkina Faso for at least 6 months on the day of the survey.
The total sample size calculation and the data collection process throughout the country have been described in a previous publication.9 The calculation was based on the prevalence of hypertension as primary outcome, and was estimated at 29.6% (95% confidence interval [CI]: 27.3–31.9). The nationally-representative sample size, based on 20.0% non-response, was estimated as 4785 (rounded up to 4800) adults aged 25–64 years. Since the national adult rate of those who have ever been screened for hypertension was previously unknown, if the approximate LMICs’ rate was assumed (at about one-third),10 the sample size would roughly be identical.
To select participants, a stratified three-stage cluster proportional to the size sampling was used. The sample was stratified to provide adequate representation of both the rural and urban residences. An Excel spreadsheet was used to draw households from each selected cluster. One individual aged 25–64 years was randomly selected from each household using the Kish method.11
Data collection was conducted from 03 September 2013 to 24 October 2013 and household sociodemographic information was recorded via face-to-face interviews in the language spoken by the participant after BP and anthropometric measurements were collected.
Variables of interest extracted from the STEPwise approach to surveillance (STEPS) survey database
The participants’ demographic variables included: gender, residence (rural or urban), age (in the range of: 25–64 years), marital status (grouped into: (1) married or cohabitating; (2) single), education level (grouped into: (1) no formal schooling; (2) primary school; and (3) secondary or higher) and occupation (grouped into: (1) public or private formal employment; (2) employment without or with uncertain income such as students, housekeepers or unemployed).
The STEPS questionnaire included the yes or no question on being ever screened for hypertension, and was: ‘Did a doctor or other health professional ever measure your BP?’.
Physical measurements: Anthropometric characteristics were weight (kg), height (m), body mass index (BMI; weight/height2, kg/m2) and waist circumference (WC, in cm). Height was measured to the nearest 0.1 cm using a stadiometer (SECA 214) on a subject without shoes, while weight was measured to the nearest 0.1 kg with a personal scale (SECA 813) on a lightly clothed subject without shoes. Waist circumference was measured to the nearest 0.1 cm (as per the WHO recommendations) with a measuring tape (SECA 203) at the midpoint between the last rib and the iliac crest, with the subjects standing upright and breathing normally. The BMI was used to characterise underweight (BMI < 18.5 kg/m2), normal (BMI = 18.5 kg/m2 – 24.9 kg/m2) overweight (BMI = 25 kg/m2 – 29.9 kg/m2) and global obesity (BMI ≥ 30 kg/m2) states and thus BMI ≥ 25 kg/m2 defined overweight/obesity.12 The WC was used to characterise abdominal obesity. Recently, the African Partnership for Chronic Disease Research (APCDR) specifically recommends the cut-offs of 81.2/81.0 cm for detecting abdominal obesity in men/women in SSA,13 while the cut-offs of 94/80 cm for men/women were previously recommended by the International Diabetes Federation (IDF).14
Systolic blood pressure (SBP, in mmHg) and diastolic blood pressure (DBP, in mmHg) values were measured three times using a mobile device (CardioChek™ 1708 PA, Indiana, United States [US]), with their mean value being used in the analysis. Individuals with mean values of SBP/DBP < 120/80 mmHg were considered normotensive, those with SBP between 120 mmHg and 139 mmHg and/or DBP between 80 mmHg and 89 mmHg were considered prehypertensive, while those with SBP/DBP ≥ 140/90 mmHg and/or medication as hypertensive.15
All devices for measurement were provided by the WHO and the measurements were carried out on the same day.
Participants included in the analyses
After data collection, 105 individuals were not eligible or had invalid data regarding sex, and 10 had missing data on marital status or education level, 649 did not provide response to the yes/no question on ‘ever being or not screened for hypertension’, while 61 participants did not have valid data on BP and 144 on anthropometric parameters. In total, 3831 participants were included for the present secondary analyses. Without an increase of 20% assumed as the rate for possible nonresponse in the initial study design,9 the sample size was approximately 3828 participants.
Statistical analyses
StataCorp™ Stata Statistical Software for Windows (Version 14.0, College Station, Texas, US) was used to analyse the data. The quantitative (continuous) variables are expressed as the means ± standard deviations (s.d.s), and the qualitative (categorical) variables are expressed as percentages (%) with 95% confidence interval (CI)s. Student’s t-test was used to compare quantitative variables, and the Chi-square test was used to compare categorical variables. We used both the APCDR and the IDF cut-offs to describe and compare abdominal obesity. Logistic regression analysis was performed using ‘ever been screened for hypertension’ (from the binary item, yes/no response) as the outcome, while the overweight/obesity state and abdominal obesity (according to the APCDR cut-offs) were explanatory variables, and all the six sociodemographic factors were the variables for adjustment. We proceeded by a progressive elimination of factors by decreasing the order of significance, i.e. with high level of the p-value. For all analyses, a p-value less than 5% was considered significant.
Ethical considerations
The Ethics Committee for Health Research of the Ministry of Health of Burkina Faso approved the protocol of the WHO STEPS (deliberation No: 2012-12092; 05 December 2012). Each participant provided a written informed consent and the language used for the informed consent was the language spoken by the participant.
Results
The sample was made up of 2009 (52.4%) female participants and the mean age was 38.5 ± 11.1 years. The participants were predominantly rural residents (78.8%), illiterates (75.9%) and married or cohabiting (85.8%) (Table 1).
| TABLE 1: Sociodemographic characteristics of overall sample and for those who have ever been screened or never been screened for hypertension. |
Globally, 41.6% (95% CI: 40.0–43.1) of the participants had never been screened for hypertension before the 2013 STEPS survey when compared with those who had ever been screened, they had lower mean weight, WC and BMI, but were taller (Table 2). The proportion of participants with normal weight was high among those who had never been screened, while the proportion of those with overweight and obese status was lower. Using the IDF or APCDR cut-offs, there was a significantly lower prevalence of abdominal obesity among participants who had never been screened. The mean SBP was identical between the never and ever hypertension screening groups as well as the frequency of normal blood pressure or prehypertension. The prevalence of hypertension was significantly lower in the never-screened groups compared to their counterparts (17.3% vs 20.8%, p = 0.007).
| TABLE 2: Comparison of the anthropometric and blood pressure features between adults who have ever been screened and who have never been screened for hypertension. |
Table 3 summarises the results of the logistic regression and shows that both the presence of overweight or obesity (adjusted odds ratio [aOR] = 1.3; 95% CI: 1.1–1.5; p = 0.03) and abdominal obesity (aOR = 1.3; 95% CI: 1.1–1.6; p = 0.002) were significantly associated with the uptake of hypertension screening (Table 3). In addition, favourable sociodemographic correlates were urban residence, female gender, older in age (in the range of 55–64 years), being educated, employed with formalised income and married or cohabiting.
| TABLE 3: Associated factors with the uptake of the screening for hypertension. |
Discussion
The adults who had never been screened for hypertension in Burkina Faso tended to have a slim appearance, supporting our hypothesis based on empirical observation, while the rates of prehypertension and hypertension were also important in these individuals.
Unscreened adults in Burkina Faso
Proportion of Burkinabè adults who had never been screened for hypertension (41.6%) before this first national survey was substantial. The burden of undiagnosed hypertension in SSA is high and the screening is the STEPS survey leading to the diagnosis and treatment.3 Therefore, more appropriate strategies for screening are needed in Burkina Faso.
Low anthropometric characteristics in participants who had never been screened
Body sizes were significantly correlated with body image perceptions and BP16 and therefore increased BMI was independently associated with a lower risk of being screened for pre-diabetes or diabetes17 (a metabolic disorder such as hypertension). For example, the term ‘diabesity’ has been coined to reflect the strong relationship between obesity and diabetes,18 yet in public health interventions or education, careless or unbalanced communication may have sometimes occurred. In some participants, the subjective misperception of being taller with lower weight, BMI and WC may have led to the belief that they were free from cardiovascular diseases. It is therefore necessary to be careful, especially in general communication, as metabolically obese with normal weight have been reported to reach up to 16% of apparently healthy individuals (especially women in the fourth quartile of normal weight) in Burkina Faso.7 Approximately 64% of Tanzanians and 43% of Nigerian women perceived an association between excess body weight and hypertension or cardiovascular disease19,20 and overweight/obesity was often associated with the occurrence of a cardiovascular event (stroke) in Beninese people.21
The frequent absence of both overweight or obesity and abdominal obesity in the participants who had never been screened may potentially lead to the high degree of body image satisfaction in health domains22 and limit their engagement in screening. The finding that the presence of both overweight or obesity and abdominal obesity was associated with screening uptake in a multivariable analysis reinforces our view that weight gained, by altering body image perceptions, is a potential driver of screening uptake. Perhaps the popularised and disseminated public health message or the invitation to be screened for hypertension was unclear or more selective, targeting only overweight/obese individuals or those who subjectively considered themselves to be overweight or obesity. Thus, there is a need for incitement messages for all adults, regardless of their perceptions of body size. However, more research, including qualitative studies, is needed to accurately assess the effect of self-perceived body size or image on misconceptions and adherence23 to screening. The results should help to specify public health messages targeting misconceptions of ‘apparently healthy body size’ as a potential barrier to hypertension screening, especially as metabolically obese with normal weight is substantial in some of the groups.7
Blood pressure characteristics among participants who had ever or never been screened
The mean SBP was identical between the two groups and there was a similar prevalence of normotensive or prehypertensive individuals. The 11-year risk factor of hypertension in prehypertensive Mauritians24 and the high prevalence of prehypertension (even in the never screened groups) should be considered a major public health concern in Burkina Faso, where the population is predominantly young (mean 38.5 ± 11.1 years in our study). In those who had never been screened, the rate of progression to hypertension may not be detected and was slow. Although the prevalence of hypertension (17%) was statistically lower among participants who had never been screened, it is a significant public concern as they may benefit from early antihypertensive therapy to reduce the burden of potential complications. In particular, people who had never been screened could not comply with healthy lifestyle behaviours such as the practice of physical activity, consumption of fruit and vegetables, abstinence from alcohol and/or tobacco use, salt consumption, among others. It can be hypothesised that this level of unknown hypertension may contribute to the high number of surprising cardiocerebrovascular events recorded in the Burkina Faso hospital settings (hypertension was reported in 82% of stroke patients).25
Favourable sociodemographic factors for hypertension screening
Most of the sociodemographic parameters were associated with hypertension screening uptake and were consistent with the common sociodemographic or socioeconomic correlates of inequalities in undiagnosed hypertension in LMICs.26 Urban participants may benefit from geographical proximity to healthcare facilities, improved education about hypertension and regular invitations to screening.27 Employees may be frequent screeners because of their high-income levels. Education leads to a better understanding of hypertension issues. Even attending the first level of the national education system was helpful, so health literacy should be implemented with a focus on cardiovascular health education and adapted for the general population.28 Female gender was more affected by overweight or obesity, especially in urban areas,29 leading to the screening. This attitude should place women in the key role of the family-based approaches to cardiovascular health promotion or risk reduction.30 This is appropriate, as being in the married or cohabiting groups was also associated with the practice of hypertension screening. Older adults (55–64 years) may benefit from their general life experience. In fact, the average age of patients with cardiocerebrovascular events admitted to country hospitals was reported to be around 60 years,31 and hypertension was found in most of the cases.25 People in their 60s may know others (parents, siblings, colleagues, etc.) who have had such events (stroke, ischemic heart disease, etc.). Knowing about such events makes them want to take precautions and get screened.
Insights from our findings
Metabolically obese normal weight (cardiometabolic disorders in those with normal BMI) could occur in up to 16% of some apparently healthy individuals7 and in the Burkina Faso referral hospitals, hypertension was reported in 82% of stroke patients.25 The mean BMI of those who had never been screened was not significantly different from the mean BMI of stroke patients admitted to these hospitals (22.1 ± 4.8 kg/m2).31 Motivating thin-looking people to be screened for hypertension is an important issue, and they should be made aware of their potential vulnerability through specific, tailored recommendations, without triggering a reaction of panic, stress or social stigmatisation. Community-based interventions to improve mother–child32 care and prevent specific infectious diseases33 have been successfully tested in Burkina Faso. This framework of interventions can be tailored for hypertension screening and management. Therefore, interventions at the primary care level supported by specific community-based interventions will be useful.
As a follow-up to our findings, the hypothesis that thin people are less likely to be screened for hypertension is currently being tested in urban population in Burkina Faso using a mixed method. Data have been collected and quantitative analyses are ongoing, while a further qualitative study will use individual and group interviews with a still limited sub-sample.
Limitations
The STEPS method was interesting in the hypothetical case where the subject would be informed of their hypertensive status by a health worker or doctor; however, it could happen that individuals themselves could detect their hypertensive status by using automatic electronic devices. The analysis did not compare levels of unhealthy lifestyle behaviours between the two groups. Furthermore, this study was not doubled with a qualitative study which could explore how the anthropometric sizes influence the self-perceived body image dissatisfaction or satisfaction in relation to the attitudes and practices towards hypertension screening.
Conclusion
Although sociodemographic characteristics were important in analysing factors associated with uptake of hypertension screening among Burkinabè adults, our study suggests that the effects of self-perceived body size should also be considered. Thinness may be a potential barrier to the adherence to hypertension screening, and this was consistent with empirical observations in Burkina Faso. Further research, including qualitative studies, should provide sufficient evidence to support this hypothesis, which in turn will help to refine public health messages and interventions to increase screening uptake among all adults in the country. As has been undertaken successfully to improve mother–child care and prevent specific infectious diseases, an adapted framework of interventions at the primary care and community levels should be tailored for hypertension screening and management.
Acknowledgements
The authors thank the Ministry of Health for providing them with the STEPS survey database. A preprint version of this work was previously published on Research Square (https://doi.org/10.21203/rs.3.rs-1205819/v1), and we acknowledge its role in shaping the final manuscript.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
J.D, T.R. and J.K. contributed to drafting the article and performing the statistical analysis; J.D., A.N.Z., H.T., A.M., S.O. and S.K. interpreted the results. All authors read and approved the final article.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The database of the STEPS survey used for this secondary analysis is available at the Ministry of Health and Public Hygiene of Burkina Faso – https://www.sante.gov.bf/; email: contact@sante.gov.bf.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or publisher. The authors are responsible for this article’s results, findings and content.
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