Why is there a gap in self-rated health among people with hypertension? A decomposition of determinants and rural‒urban differences

Background: Hypertension affects over one billion people globally and is one of the leading causes of premature death. The low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from the more affluent and urban population towards the poorer and rural communities. Our study examined inequalities in self-rated health among people with hypertension and whether there is a rural-urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. Methods: We utilized the Zambia Household Health Expenditure and Utilization Survey for the data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from a previous study. The linear probability model provided a preliminary assessment of the association between self-rated health and independent variables. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. Results: Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (62%), district HIV prevalence (26%) and household expenditure (12%) being the most important determinants that explain the health gap. Conclusions: Urban hypertension patients have better SRH than rural patients in Zambia. Educational interventions, financial protection schemes and strengthening hypertension health services in rural areas can significantly reduce the health gap between the two regions.