David Peiris1, Arpita Ghosh2,3, Jennifer Manne-Goehler4, Lindsay M Jaacks5, Michaela Theilmann4, Maja E Marcus6, Zhaxybay Zhumadilov7, Lindiwe Tsabedze8, Adil Supiyev9, Bahendeka K Silver10, Abla M Sibai11, Bolormaa Norov12, Mary T Mayige13, Joao S Martins14, Nuno Lunet15, Demetre Labadarios16, Jutta M A Jorgensen17, Corine Houehanou18, David Guwatudde19, Mongal S Gurung20, Albertino Damasceno21, Krishna K Aryal22, Glennis Andall-Brereton23, Kokou Agoudavi24, Briar McKenzie1, Jacqui Webster1, Rifat Atun5, Till Bärnighausen4, Sebastian Vollmer6, Justine I Davies25,26,27, Pascal Geldsetzer4,28. 1. The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia. 2. The George Institute for Global Health, UNSW Sydney, New Delhi, India. 3. Manipal Academy of Higher Education, Manipal, India. 4. Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany. 5. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America. 6. Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Goettingen, Germany. 7. Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan. 8. Eswatini Ministry of Health, Mbabane, Eswatini. 9. Laboratory of Epidemiology and Public Health, Center for Life Sciences, National Laboratory Astana, Nazarbayev University, Astana, Kazakhstan. 10. St. Francis Hospital Nsambya, Kampala, Uganda. 11. Department of Epidemiology & Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon. 12. National Center for Public Health, Ulaanbaatar, Mongolia. 13. National Institute for Medical Research, Dar es Salaam, Tanzania. 14. Faculty of Medicine and Health Sciences, Universidade Nacional Timor Lorosa'e, Dili, Timor-Leste. 15. Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal. 16. Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa. 17. Department of Public Health, University of Copenhagen, Copenhagen, Denmark. 18. Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin. 19. Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda. 20. Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan. 21. Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique. 22. Monitoring Evaluation and Operational Research Project, Abt Associates, Kathmandu, Nepal. 23. Non-Communicable Diseases, Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago. 24. Togo Ministry of Health, Lomé, Togo. 25. Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom. 26. Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa. 27. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa. 28. Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America.
Abstract
BACKGROUND: Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. METHODS AND FINDINGS: We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. CONCLUSIONS: This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.
BACKGROUND: Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. METHODS AND FINDINGS: We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. CONCLUSIONS: This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.
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