What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Hypertension. Intervention: Hypertension care cascade assessment vs. Low-Income Countries (LICs) vs Lower-Middle Income Countries (LMICs). Primary outcome: Hypertension prevalence (LICs vs LMICs) (p=<0.001).

October 12, 2023Open Access

Care Cascades for Hypertension in Low-Income Settings: A Systematic Review and Meta-Analysis

Q: What are the key findings of this study?

In low- and lower-middle-income countries, the average hypertension prevalence was 33%, with only 48% awareness, 35% treatment, and 16% control, highlighting significant gaps in the care cascade.

Key Result

In low- and lower-middle-income countries, the average hypertension prevalence was 33%, with only 48% awareness, 35% treatment, and 16% control, highlighting significant gaps in the care cascade.

Study Design

Type

Meta-Analysis

Structured PICO

Population

Adults (≥18 years) in Low-Income Countries (LICs) and Lower-Middle Income Countries (LMICs). Pooled from 95 articles (100 cascades of care) representing approximately 1.5 billion individuals.

Outcome

Hypertension care cascade steps: prevalence, awareness, treatment, and control of hypertension

This meta-analysis reveals severe attrition across the hypertension care cascade in low- and lower-middle-income countries, with only 16% of hypertensive individuals achieving blood pressure control.

Main Result

Absolute Event Rate: 25% vs 34%

p-value: p=<0.001

Limitations

Diverse methods employed for blood pressure measurement in certain studies
Digital (OMRON) sphygmomanometers were not systematically applied
Paper-based questionnaires may have introduced bias in data recording
Limited reporting on gender, diabetes, smoking, and BMI across studies
Uneven representation of countries and methodological differences leading to heterogeneous results
JBI quality scores for some included studies were low
Inclusion of May Measurement Month (MMM) studies which rely on voluntary participants and may result in non-representative sampling
Lack of specific measures pertaining to the quality of health services in the care cascade framework

Abstract

Objective: High blood pressure is the leading risk factor for cardiovascular disease. The hypertension care cascade (HCC) is increasingly being used to evaluate the effectiveness of interventions. This systematic review aims to examine HCC in low-income settings. Methods: The search strategy included articles published between January 2010 and April 2023. We excluded studies with incomplete HCC, on fragile patients or aged 18 years, reviews. We used the MOOSE guideline. Five researchers retrieved data on the survey year, country, population, HCC and diagnostic methods for hypertension. We used JBI Critical Appraisal Tools for quality assessment. Results: Ninety-five articles were analyzed. Average hypertension prevalence was 33% (95% CI: 31%–34%), lower in LICs than in LMICs (25% vs. 34%). The overall mean awareness of hypertension was 48% (95% CI: 45%–51%), its treatment was 35% (95% IC: 32%–38%) and its control 16% (95% CI: 14%–18%). In almost all steps, percentages were lower in LICs and in Sub-Saharan Africa. Conclusion: Trends in HCC vary between countries, with poorer performance in LICs. This review highlights the need for interventions tailored to low-income settings in order to improve hypertension care.

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