Epidemiology, awareness, health seeking behaviour and capacity of health systems to deal with Hypertension in a Ugandan rural context

Thesis summary


The burden of non-communicable diseases in sub-Saharan Africa is substantial and increasing. Reliable, large-scale, population based data on hypertension in Uganda are scarce; although available evidence suggest that hypertension is on the rise. Moreover, data on health seeking behaviours for hypertension and the capacity of healthcare systems to manage hypertension are lacking.


The purpose of this thesis is to fill the information gap in order to contribute to the urgently needed data to inform programming for hypertension in a low income setting in sub-Saharan Africa. The specific objectives of the thesis are: 1) To estimate and characterize the prevalence of high blood pressure (Paper I, II & III); 2) To explore and
understand the health seeking behaviour of people with hypertension (Paper IV & V); 3) To assess the capacity of the health system to provide care for people with hypertension (Paper VI); and 4) To propose intervention strategies to improve prevention, detection, treatment and control of hypertension (Paper VII).  


To estimate and characterize the prevalence of high blood pressure (Paper I, II & III), a community based cross sectional survey was conducted in 2012 among 4563 people aged 15 years and above in two districts (Mukono and Buikwe) in Uganda. Respondents were evaluated using the World Health Organization STEPwise approach to
chronic disease risk factors surveillance (STEPS). The approach included a questionnaire on social demographic and behaviour factors such as smoking, alcohol consumption, health history and physical measurements including blood pressure, weight, height, and waist circumference using standardized methods. To explore and understand the health seeking behaviour for people with hypertension (Paper IV & V), 258 people aware of their hypertension were questioned about their use of alternative medicines for hypertension, advice about uptake of lifestyle interventions, and their attitudes towards using alternative medicines (Paper IV). In addition, a sub-sample (48) of the  aware hypertensive was followed up in 2014 for a deeper qualitative inquiry using semi structured in-depth 16 interviews (Paper V). In order to understand the capacity of healthcare systems to provide care for hypertension, 145 registered health facilities were surveyed in the two districts (Paper VI). To propose strategies to improve management of hypertension, a dissemination workshop was held in January 2015. The proceedings were analysed and a proposition paper generated (Paper VII).


The prevalence of hypertension among people aged > 15 years was 21.8% (95% CI 20.6-23.0), and was similar among females (21.7%;95%CI:20.2-23.2) and males (22.3%;95%CI:20.3-24.3). The prevalence of the haemodynamic sub-types of uncontrolled hypertension, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic-diastolic combined (SDH) were 7.2%, 4.2% and 8.8% respectively suggesting that the distribution of uncontrolled hypertension increases in the order IDH, ISH and SDH. The prevalence of prehypertension (SBP=120mmHg-<140mmHg or DBP=80mmHg <90mmHg) was 35.2% (95%CI:33.8-36.7) higher among males (43.7%;95%CI:41.2-46.3) compared to females (30.5%;95%CI:28.9-32.3). Among the hypertensive participants, a small percentage was aware of their hypertension 28.2% (95%CI:25.4-31.0). Awareness was higher among females (37.4%;95%CI:33.7-41.2) compared to males (12.4%;95%CI:9.0 15.8). Control among the hypertensive was very low, with more females controlled (13.2%;95%CI:10.6-15.8) compared to males (2.5%;95%CI:0.9-4.1). The prevalence of hypertension increased linearly with age (p<0.001) and the increase was more marked among females compared to males. The aware hypertensive sought multiple channels of care for their hypertension. The channels included self-medication and access to anti hypertensive drugs with or without prescription from drug outlets, consultations with modern as well as traditional practitioners and use of herbal remedies. Routine monitoring of BP was not a common practice (Paper V). More than one in four were using alternative medicine alone or a combination of modern and alternative medicine (Paper IV). Use of alternative medicine was underpinned by the belief that it was effective (adjusted OR 2.6; 95%CI:1.40-4.82), (Paper IV). Qualitative inquiries revealed multifactorial dimensions for health seeking behaviours and compliance and were related to the patient, health system
and structural environment (Paper V). The health system challenges included deficiencies 17 in diagnostic equipment, anti-hypertensive drugs and personnel (Paper VI). Recommendations to improve the deficiencies and address the burden of hypertension included creating a favorable policy environment, strengthening health systems,
integration of chronic care and a change in strategy from an infectious disease management model that is provider centered to a patient centered model for chronic disease management (Paper VII).   


The prevalence of hypertension, prehypertension and uncontrolled hypertension are substantial in this population. Awareness is very low but even among the aware hypertension control is a challenge. Strategies are urgently needed to enhance prevention, awareness and control of hypertension.