Reasons for poor blood pressure control in Eastern Sub-Saharan Africa: looking into 4P’s (primary care, professional, patient, and public health policy) for improving blood pressure control: a scoping review

Hypertension is a major risk factor for cardiovascular diseases that significantly increases the risks of developing heart, brain, kidney, and other vascular diseases [1‐3]. Globally less than 20% of people with hypertension have controlled their blood pressure [4]. Hypertension is responsible for at least 45% and 51% of deaths due to heart disease, and stroke, respectively [5]. The health system in SSA has the worst performance, with only 18–29.9% of participants received treatment, and 5–10.3% achieved control of their hypertension [6, 7]. In reality, it could be possible to achieve adequate blood pressure (BP) targets in about 70–80% of patients by improving adherence and/or intensifying drug therapy [8, 9].

Hypertension is the most extensively studied risk factors for cardiovascular disease [10‐13]. However, its management and control are unsatisfactory. Studies indicated that the current prevalence is expected to double by 2030, unless health system, professionals, and SSA patients take steps to prevent and control hypertension. Additionally, moving from the current 7% BP control to WHO sustainable development goal target of 50% BP control and reducing NCDs' mortality by one-third in 2030 might be an ambition to the region [14‐16].

Knowing the reasons for the worst blood pressure control in Eastern Sub-Sharan Africa will have several public health advantages. It will give direction for selecting and prioritizing interventions that can provide better patient outcomes for policymakers. For health care providers, it will provide information on the unmet needs of hypertension care. For patients, it will improve BP control and reduce hypertension associated morbidity and mortality. Finally, it will highlight areas that need further research to improve blood pressure control in sub-Saharan Africa for researchers. Several studies were conducted concerning hypertension care in SSA countries. Yet, none of them are comprehensive enough to provide a clear picture for policymakers, providers, primary healthcare systems, and patients concerning the reasons for the worst BP control in the region. Therefore, this scoping review was conducted based on PRISMA extension for scoping review protocol to identify and describe the possible reasons for poor blood pressure (BP) control based on 4Ps (patient, professional, primary healthcare system, and public health policy factors) among ten Eastern SSA countries [17, 18].

In this scoping review, we addressed hypertension care and reasons for the worst BP control among 10 Eastern SSA courtiers from a 4P (patient, provider, primary healthcare, and public health policy and politics) perspective [21‐39]. The mean national prevalence of hypertension and the level of BP control among adults + 18 years in 10 Eastern SSA countries was 20.95% and 11.55%, respectively [21‐39]. In reality, it is possible to achieve effective BP targets in about 70–80% of patients by improving adherence and/or intensifying drug therapy [8, 9]. Lack of early detection, inadequate treatment, and poor treatment adherence were the main contributors to poor BP control. These main contributors can be described from 4Ps (patients, professionals, Primary healthcare system, and Public health policy) perspective [14, 15, 123, 124].

Only three countries (Kenya, Malawi, and Zambia) started annual screening in 2017 [75‐77]. The recent systematic review conducted in SSA showed that only a small proportion of the people with hypertension were aware of their hypertensive status [15]. Therefore, ‘a May is Measurement Month’ experience of Kenya, Malawi, and Zambia can be expanded to other countries like Ethiopia. Looking for new healthcare task force opportunities will have paramount importance to minimize the possible costs and enhance feasibility. For example, in Ethiopia, graduating class health science students have an annual community deployment program before graduation. The integration of yearly screening of high-risk patients for hypertension can be done with a slight orientation on patients’ comprehensive screening for cardiovascular disease based on a total risk approach.

High political commitment and downward accountability culture from these countries’ governments are needed to improve access to necessary technologies and essential drugs for managing hypertension to cope with associated demand increase due to the annual screening program [61, 74]. In addition to this, the capacitation of primary healthcare workers in the front line for hypertension care through training or continuous professional development is important to improve hypertension management and BP control. In this regard, a practical approach to care kit (PACK) clinical decision support tool designed to simplify, standardize, and strengthen primary healthcare delivery in LMICs can be helpful [127].

The great majority of hypertensive patients in Eastern SSA were non-adherent to medications prescribed by healthcare professionals. For example, 94.9%, 78%, and 82.0% were not taking anti-hypertensive medications in Malawi, Rwanda, and Zambia [21‐39]. Determinants of nonadherence include patient-related factors (e.g., low health literacy and weak involvement in treatment decision-making), physician-related factors (e.g., polypharmacy complex regimens, ineffective communication, and uncoordinated care by multiple physicians), and healthcare systems related (e.g., short consultation time, limited access to care and lack of health information technology) [128‐131].

Treatment adherence is not directly translated to BP control in most countries included in this review [9, 132]. The revealed inconsistency between adherence and BP control suggests three things. The first is how treatment adherence is measured. This is because treatment adherence should be evaluated comprehensively (i.e., medication and healthy lifestyles) [40]. The second is what methods are used to measure adherence. Most of the adherence studies stated self-reported adherence. It is important to consider more robust adherence measurement tools, like therapeutic drug monitoring for uncontrolled BP patients taking an intensified dose of three drugs [132]. The third point is the quality of medicines being used for the management of hypertension. For example, in Rwanda, focusing on cardiovascular medicines showed two of 10 products purchased from private outlets were substandard [133]. Similarly, counterfeit and sub-standard drugs were reported in the Ethiopian pharmaceutical supply chain [134]. Poor access to medicines, weak technical capacity, poor pharmaceutical sector governance, and low community awareness are backbones for drug trafficking [135].

Hypertension related awareness and knowledge is low in Eastern SSA. Enhancing individuals' and communities' health literacy is an important measure to improve the acceptability of NCD interventions and BP control [16, 40, 136‐138]. Patients who have better knowledge about the disease and its treatment outcomes were more likely to adhere to treatments prescribed by professionals [15, 35, 82‐87]. The medication adherence club experience form Kenya can be contextualized and applied in other countries. The approach has reduced loss to follow-up and supported burden reduction and flexibility of regular clinical review for patients [139].

Lack of access to medicines for hypertension is one of the major barriers to hypertension care in Eastern SSA. It can be addressed by improving medicine financing, selection process, manipulating the procurement process for efficiency [133, 140], removing taxes and duties on essential medicines and control markups, improving the health insurance system, and providing incentives for pharmaceutical manufacturers to invest in quality medicine production. Accessibility of health services can be addressed by increasing operational hours of clinics providing free or subsidized care, decreasing waiting times by streamlining organizational processes and changes in regulations, and increasing the perceived quality of care [133, 140].

Quality of medicines can be ensured by strengthening the capacity of the National medicines regulatory authorities, creating a business environment that is favorable for the private sector to invest in secure supply chains, regular quality testing at procurement and sales sites, and consumer short message service (SMS) and mobile application verification of product authenticity [133, 140]. The availability of evidence-based guidelines is essential for care standardization and improving patient outcomes. Therefore, it is essential to ensure their availability in both public and private health facilities. However, in Eastern SSA, guideline availability is only concerned in public health facilities. Patients may use private facilities for their NCD management or medication refill due to accessibility, affordability, or medicines availability in private facilities.

Adherence to lifestyle factors was poor in Eastern SSA. Adherence to health behaviors is highly dependent on public health policy related variables [141]. Therefore, it is critical to enact strong specific laws and follow the implementation of the laws to reduce cardiovascular disease-related complications. All countries included in this review have no specific laws against unhealthy diet consumption. Almost all have partially implemented laws against tobacco smoking, physical activity, and harmful alcohol [21‐39].

Poor diet killed more people globally than tobacco and high blood pressure [102, 142]. The majority of peoples in eastern SSA were farmers. However, more than 80% of patients took < 5 servings fruits and vegetables per day [21‐39]. Therefore, the modernization of farming, empowering farmers to produce more fruits and vegetables, and increasing awareness about a healthy diet for the general public will have a paramount contribution to change the very low consumption of fruits and vegetables in the region.

The globalization of unhealthy lifestyles (smoking, high-fat diets, salt consumption, and alcohol use) is a political and trade issue. Therefore, enacting strong policies with priority to citizens' health, re-evaluating trade policies, and agreements and collaborating and controlling industries working in this area is critical. It is also equally important to ensure transparency of strategies and actions to control business owners' big hands in the area, as it is a source of billion dollars investment [117].

The rate of BP treatment and control and medication adherence was very low in Eastern SSA. The low treatment rate is mainly due to under-diagnosis and lack of screening service for a high-risk population. Poor adherence to prescribed medicines was related to patients, professionals, the primary healthcare system, and public health policy. In addition to this, medication adherence is not directly translated to BP control. Adherence to healthy lifestyles was also extremely low. Eight out of 10 adults aged ≥ 18 years above had at least one cardiovascular disease risk factor, indicating awaiting future burden of NCDs in the region. The worst BP control reasons were poor treatment adherence, lack of early screening, weak political commitment, and socioeconomic factors, including maternal and child malnutrition.

Based on this scoping review findings, we provide the following recommendations for Eastern SSA countries to improve BP control. (1) Improving government commitment to achieving sustainable development goal 3.4, as evidenced by weak political commitment. (2) Improving patient awareness through facility-based health education or mass media. (3) Improving access to essential medicines and necessary CVD care technologies. (4) Ensuring availability of evidence-based guidelines in both public and private health facilities. (5) Improving fruit and vegetable consumption through improving awareness about nutrition for heart health. (6) Designing country-specific annual screening systems for high-risk patients. (7) Evaluating trade policies in light of citizens' health is a priority to reduce the import of obesogenic foods. (8) Conducting medication adherence research by using more strong tools for patients with uncontrolled BP after appropriate dose intensification.