Risk Factors for Hypertension in Koumbri Municipality, Burkina Faso, December 2016-April 2017

Pedwindé Hamadou Séogo^1,2,3, Salam Ouedraogo^2,4, Simon Antara¹, Bernard Sawadogo¹, Denis Yelbeogo², Brice Wilfried Bicaba², Yacouba Savadogo², Hyacinthe Euvrard Sow^1,2,3, Agballa Mébiny-Essoh Tchalla Abalo¹, Amado Traoré², Moussa Kagoné², Abdoulaye Nitiema², Harouna Sawadogo², André McKenzie⁵ , Mamadou Sawadogo^1,3, Oumarou Batoure¹, Patrice Zabsonré^2,3

 

¹West Africa Field Epidemiology Training Program, Ouagadougou, ²Ministry of Health, Ouagadougou, Burkina Faso, ³University of Ouaga I, Pr Joseph Ki Zerbo, Ouagadougou, Burkina Faso, ⁴University of Ouahigouya, Burkina Faso, ⁵Centers for Diseases Control and Prevention, Atlanta, USA

 

 

^&Corresponding author
Pedwindé Hamadou Seogo, Ministry of Health, Ouagadougou, P.O. Box 7000 Ouaga-dougou, Burkina Faso. seogoph@gmail.com

 

 

 

 

Chronic non-communicable diseases are on the rise worldwide. According to the World Health Organization (WHO), Non-communicable diseases (NCDs) kill more than 40 million people each year, accounting for 70% of all deaths worldwide [1-3]. The projections indicate that the annual number of deaths attributable to cardiovascular disease is expected to increase from 17 million in 2008 to 25 million in 2030 [4,5]. Hypertension (HT) or high blood pressure (HBP) is the most important risk factor for cardiovascular mortality. The magnitude is not well known by the population and by health workers [3,4,6]. Thus, the prevalence of hypertension varies from country to country and within a country. Between 2009 and 2011, a study of hypertension in rural and urban areas in four countries showed that prevalence of hypertension in rural areas was 19.3% in Nigeria and 21.4% in Kenya, and urban areas of 23.7% in Tanzania and 38.0% in Namibia [7].

 

Although the prevalence of hypertension in urban areas is higher than in rural areas, it is also increasing rapidly in rural areas. Indeed, in Ghana, the results of a survey in 1973 in 20 villages showed a prevalence of 4.5%, while recent studies, >20 years later in 2006, showed a prevalence of 25.4% in the rural district of Ga [8] and 35% in the Adankwame rural community of Ghana [9]. In north-central of Senegal, the prevalence was 23.4% in the rural communities of Labgar and Lougre Thiolly in 2011[10,11].

 

The classical risk factors of hypertension have been studied in Africa. These factors vary from one country to another and even within the same country.

 

Non-modifiable risks factors (e.g., age, sex, genetic predisposition), behavioural risks factors (e.g., alcohol, tobacco, salt, physical inactivity) and overweight are risks factors associated to hypertension in several studies [12].

 

These vary according to the place of residence (i.e., rural, semi-urban and urban) [13-15], the level of education ranging from non-schooling in Tunisia to the high level of study in Uganda [16,17]. The variation also concerns the female or male sex [18,19], ethnic groups [20,21], socioeconomic status of individuals and psychological aspects [22,23].

 

Thus knowledge or control of the different risk factors of hypertension specific to each country makes it possible to better direct public health policies to fight this pathology.

 

In Burkina Faso, hospital-based studies have identified hypertension as the leading cardiovascular risk factor. It is responsible for many complications with high mortality. Thus complications of hypertension (i.e., heart failure, renal failure, stroke) constitute 30-50% of hospitalisations in Cardiology Unit at the University Hospital Center Yalgado Ouédraogo (CHUYO) [24].

 

According to the STEPwise approach to Surveillance (STEPS) survey conducted in Burkina Faso in 2013, the national prevalence of hypertension was 17.6% in the 25-64 years old and 13.1% in the northern region for the same group of the population [25].

 

This survey also investigated other cardiovascular risk factors in Burkina Faso. Common risk factors for these diseases were tobacco, alcohol, unhealthy diet and physical inactivity [26]. Previous studies on hypertension in Burkina Faso have provided useful information on the association of other hypertension risk factors in the city of Ouagadougou in 2004 and the semi-urban and rural areas of Kaya in 2012 [13,27].

 

However, few studies on hypertension have been done in rural municipalities. Also, the prevalence of hypertension and risk factors are not well known in population living in rural area. In addition, in 2015, an analysis of all hypertension data from the Ouahigouya health district between 2007 and 2014 revealed that the number of hypertension cases was tripled in the health facilities of the Koumbri´s municipality from 204 to 640, an increase of 214% and the Koumbri´s municipality was the most affected by hypertension.

 

But to our knowledge, few studies have looked at the association of these risk factors with hypertension in the rural municipalities du Burkina Faso as Koumbri.

 

This lack of knowledge about the effects of risk factors on the occurrence of hypertension in the population of Koumbri Municipality is a limiting factor in the choice of public health interventions at the local level. The main objective of our study was to identify the risk factors associated of hypertension among the population of Koumbri´s municipality to contribute to the fight against hypertension and its consequences in Burkina Faso.

 

 

Study setting

 

Koumbri´s municipality is located in the northern region of Burkina Faso, 225 kilometres from the capital Ouagadougou Figure 1. It is one of the 13 municipalities of Yatenga province. It has 10 health facilities, and 30 villages and sectors with 54781 inhabitants in 2016 and 38.5 % are 20 years old and over. Koumbri is a rural Municipality with 54 % female. In this part of the country, most people are farmers (90%).

 

Study design

 

We conducted an unmatched case-control study from December 16, 2016, to April 19, 2017, using the World Health Organization's (WHO) STEPwise approach to Surveillance (STEPS ). This approach consists of three Steps for measuring non-communicable disease (NCD) risk factors. Step 1 consists of collecting data on sociodemographic, behavioural, psychological and socio-cultural information; step 2 consists of measuring physical parameters such as height, weight, abdominal circumference waist and blood pressure and step 3 consists of blood analysis for biochemical measurements [28].

 

Study population

 

Participants included in our case-control study were adults of both sexes aged >18 years old who reside in the municipality of Koumbri since at least 6 months from the day of the survey. We defined a case as a person > 18 years old and residing in Koumbri´s municipality, diagnosed and/or followed for hypertension in a health facility for at least 3 weeks. We defined controls as neighbours to a case without hypertension and after a double check of hypertension on the day of selection.

 

The controls were people > 18 years old, not hypertensive and who did not take blood pressure medication. We took all the controls' blood pressure to make sure they weren't hypertensive. We used the WHO definition of hypertension. The WHO defines hypertension as systolic blood pressure (SBP) greater than or equal to 140 mmHg and/or diastolic blood pressure (DBP) greater than or equal to 90 mmHg in subjects who are not taking an antihypertensive. We excluded from the study, people with disabilities hampering their ability to answer the questions (e.g., serious mental disorder, hearing or intellectual disability) and pregnant women.

 

Sampling

 

We used Open Epi software to calculate sample size. For a bilateral confidence level of 95%, a power of 80% and an odds ratio of 2. We added 10% to take into account non-respondents or invalid responses. According to Fleiss, the theoretical sample size was 324 with 108 cases and 216 controls. We recruited cases from health facilities and controls in the community. The number of cases attributed to each health facility was based on its demographic weight (proportional sampling).

 

For the cases, we proceeded to a count of the registers of consultation and hospitalization of all health facilities of the municipality of Koumbri, ten in number, in search of all the cases of hypertension notified in the registers and residing in the department of Koumbri. We listed all hypertensive case from health facilities registers and then used a random digit numbering method with Excel software to select the cases to be included in our study. We contacted them by telephone mentioned in the registers or through community health workers for appointment making or through community health workers (community-based health workers (CBHW) were used to find cases in the villages of those without telephone contact). We subsequently visited them in the community. We selected controls in the community (i.e., household or same neighborhood) with case. We took all the controls' blood pressure to make sure they weren't hypertensive. The controls were selected after the administration of the case´s questionnaire. When we left the household of the case, we spun a pen and chose the tip of the pen as an indicator of the direction to take.

 

Once in this direction, we recruited the controls step by step from the household of the case. In the household of a control, if there were more than two possible controls, we proceeded to a simple random choice without replacement. Thus we assigned numbers to all the members of the household then randomly we drew two numbers corresponding to the two controls.

 

In a household where we don't have the two desired controls, at the exit of the household we turned to our left. Once in this direction, we recruited the other control step by step from the household of the first control and in the same way. We administered a semi-structured questionnaire to collect data on socio-demographic, behavioural, psychological and socio-cultural characteristics. We measured anthropometric parameters, blood pressure and fasting capillary blood glucose levels.

 

We used WHO-approved electronic blood pressure monitors (OMRON M6 Comfort IT electronic arm blood pressure monitor) for blood pressure measurements. We systematically measured for each control his blood pressure two times. The systolic and diastolic blood pressures were measured at the two arms after a 15-minute rest without crossing legs. The measurements were separated by 5 minutes intervals. The mean of these two readings was considered for the definition of HBP.

 

For fasting capillary blood glucose, we informed cases and controls the day before to fast (at least eight hours). We measured capillary blood glucose in cases and controls using a glucometer. Any participant with a fasting capillary glucose level greater than or equal to 1.26g/l (7.0 mmol/l) or a postprandial capillary glucose level greater than or equal to 2g/l (11.1 mmol/l) for those who fasted less than 8 hours was classified as diabetic. We recruited and trained 10 data collectors. We also supervised them when collecting data in the field.

 

Study variables

 

The dependent variable in our study was hypertension (i.e., SBP >140 mmHg and/or DBP >90 mmHg ).The independent variables included: demographics (i.e., age, sex, marital status, place of residence, occupation, education level), personal and family history of hypertension, behavioral measures (i.e., consumption of alcohol, fruit, vegetables, current use of smoked and non-smoked tobacco products, intensity of physical activity), psychological and sociocultural (i.e., intra-familial conflicts, death of a loved one, loss of crops, loss of work, loss of livestock, crop loss, fire, death, illness, work accident), physical measures (i.e., weight, height, abdominal circumference waist) and biochemical measures (i.e., fasting glucose).

 

Data management

 

We used Epi Info 7.2 software to analyse the data. We proceeded to bivariate, stratified and logistic regression analysis and calculated odds ratio (ORs), adjusted odds ratios (AOR) and 95% confidence interval to identify risk factors.All the factors whose p ? 0.20 in the bivariate analysis were included in the logistic regression model (stepwise descending procedure), and proceeded to a gradual elimination until the final model. The variables retained as factors associated with hypertension in the final model were those with p <0.05.

 

Availability of data and materials The dataset for this study can be availed upon request. The dataset is an epi info and Excel dataset.

 

 

Ethical Considerations

 

We obtained the approval of the Ethics Committee for Health Research (CERS) of Burkina Faso. We also obtained approval from the Burkina Faso Ministry of Health authorities for data collection through the notes from the Northern Regional Health Director and the General Secretary of the Ministry of Health. Participation in this study was voluntary, and only participants who gave informed and voluntary consent were included in the study. People in the community with high blood pressure, high blood sugar, overweight and obesity were counselled and referred to health facilities for proper management and regular follow-up. The interviews were made with respect for confidentiality. The various interviews with the cases and the controls took place only with the data collectors without the presence of other family members.

 

 

Characteristics of cases and controls

 

We interviewed 336 participants including 112 cases and 224 controls. The median age of cases was 57.10 years old range (30-87 years old). The median age of controls was 52.56 years range (23-86 years old). The illiteracy rate was 63.39% for the cases and 57.14% for the controls. The majority of cases (60.71%) and controls (58.04%) were farmers. Almost all cases (98.21%) and controls (99.55%) were married Table 1.

 

Risk factors associated with hypertension in the population of Koumbri municipality in bivariate analysis

 

The advanced age (40 years old and over) (OR=4.65, 95%CI (1.78-12.13), family history of hypertension (OR=1.66, 95%CI (1.04-2.66), lack of physical activity (OR= 2.71, 95%CI (1.70-4.32), presence of family conflict (OR=2.04, 95%CI (1.08-3.79), abdominal overweight/obesity (OR=2.56, 95%CI (1.60-4.08) were risk factors associated of hypertension in the bivariate analysis in the population of Koumbri Table 2.

 

Risk factors associated with hypertension in the population of Koumbri municipality in stratified analysis

 

Factors associated with hypertension were stratified by age group and sex to assess for possible confounding factors and effect modification Table 3. Those who were >40 years old were more likely to have hypertension than those aged <40 years old. Also age modified the effect of male participant having hypertension; the effect of age was more evident in the age group >40 years old males were 13.57 times more likely to have hypertension, and this was statistically significant with a 95% CI of (1.79 to 103.05). Male participants in the age group <40 years old were 2.39 times more likely to be have hypertension than females.

 

Multivariate analysis of risk factors associated of hypertension in the population of Koumbri

 

The factors that were put in the logistic model were: advanced age (≥ 40 years), existence of family history of hypertension, level of physical activity, presence of intra-family conflicts, level of abdominal waist circumference, crop loss, consumption of tobacco (smoked or not smoked), death of a loved one, consumption of tea and/or coffee, consumption of vegetable portion, the level of body mass index and the level of fasting capillary blood glucose.

 

The independent risk factors found, significantly associated of hypertension in the population of Koumbri´s Municipality were intra-family conflicts (adjusted odds ratio (AOR)=2.26, 95%CI (1.03-4.9),p=0.040), family history of hypertension (AOR=2.13 (1.2-3.8),p=0.009, age ≥ 40 years (AOR=4.10, 95%CI)1.5-11.3),p=0.006), abdominal overweight/obesity (AOR=2.56, 95%CI (1.5- 4.4),p= p<0.0001) and physical inactivity (AOR=3.82, 95%CI (2.0-7.2), p<0.0001) Table 4

 

 

In our study, the intra-familial conflicts were identified as risk factors for hypertension. Our results corroborate those of Seedat in South Africa (Zulu) [29]. Indeed, conflicts cause stress which is a big factor contributing to the development of hypertension [30]. Our results can be explained by the fact that in rural areas, stress can be caused by conflicts of inheritance in families, land conflicts and disagreements between family members. Also, levirate, the accusation of witchcraft, forced marriages are harmful practices at the rural level and which also generate intra-family confits. Abdominal obesity was associated with a higher risk of hypertension in our study. This risk was proportional to the increase in abdominal waist circumference. The association between overweight, obesity and hypertension is well known, and reducing BMI is one of the most important things to do in the management of hypertension. Abdominal obesity is increasingly recognized as a major risk factor for cardiovascular disease (CVD) including hypertension [31]. Compared with body mass index (BMI), abdominal obesity appears to be more strongly associated with metabolic risk factors, cardiovascular events and death [32,33]. It is an independent risk factor. The cardio-metabolic risk associated with abdominal obesity is attributed to the presence of visceral adipose tissue (VAT) that promotes insulin resistance, dyslipidemia and arterial hypertension. This is consistent with previous research that demonstrates that abdominal obesity is an independent risk factor for CVD beyond other correlations of abdominal obesity [32,33,35]. Also participants with elevated BMIs as well as normal BMIs associated with central obesity have the same risk of developing hypertension. The increase in obesity has a relationship with the improvement of socio-economic status, particularly with the increase of wealth indices and the nutritional transition in Africa. In rural areas, the lack of physical activity and sedentary life contribute to the development of abdominal obesity [34,35].

 

In our study, those with a family history of hypertension were more likely to suffer from hypertension than those who did not. Our results corroborate those of several studies in Africa that have shown that there is an association between hypertension and family history of hypertension or with a personal history of heart disease or stroke. These are Seedat in South Africa in 1982, Fazeu in Cameroon in 2010, Bala in 2012 in Sudan, Kotwani in Uganda in 2013 and Soubeiga in Burkina Faso in 2016 [12,18,26,36-38] . Previous studies (Burnier M. 2009) have also shown that essential hypertension is a common disease, complex and polygenic whose phenotype is the result of multiple interactions between genes and the environment [39] . In our context, the environmental aspects of family feeding practices or cultural aspects could also explain the association between family history and hypertension.

 

The lack of physical activity was significantly related to the onset of hypertension in our study. This same observation was made by Mayega in 2012 in Uganda and Mayami in 2008 in Nigeria [40,41]. In fact, physical activity improves cardiac and vascular perfusion, thus reducing heart and vascular pressure. Sport also helps lower blood pressure. Physical ctivity and sport also help burn fat [42,43].

 

Our results can be explained on the one hand,y the advanced age of the cases (median age of the cases was 57.10 years) and on the other hand ,by the fact that the old people tend to be sedentary in rural environment and to delegate work requiring physical force to a third party. Added to this, is the lack of promotion of physical activity and sports for this age group in rural areas. In our study advanced age (40 years old and over) was associated with hypertension in the rural population of Koumbri. Our results could be explained by aging, which leads to a loss of elasticity of the blood vessels and consequently an increase in blood pressure [44]. Also, the accumulation of risk factors for hypertension increases with the age of individuals. The STEPS survey found that hypertension increased with age [25]. This same finding was found with a more detailed analysis with the data of the STEPS respondent from Burkina Faso by Soubeiga[26]. Our results corroborate those found in Burkina Faso by Niakara, Doulougou and Soubeiga [13,27] and also Seedat in South Africa in 1982, Fazeu in Cameroon in 2010, Bala in Sudan in 2012, Kotwani in Uganda in 2013 who found that advanced age was associated with the occurrence of hypertension. In our study, tobacco consumption (smoked and not smoked) was not associated of hypertension. Our results are at odds with most studies.

 

A study conducted in Burkina Faso by Soubeiga found an association between hypertension and tobacco. Also, epidemiological studies in Sweden have shown that the use of prized tobacco is a risk factor associated of hypertension [45]. In fact, each cigarette leads to a rise in blood pressure in the smoker during a period of 20 to 40 minutes, as well as an increase in heart rate of around 40%, which prematurely wears the heart and weakens the walls of the arteries. The low proportion of people with this pattern of tobacco use (2.82%) in our sample may explain our results. Also, in our context, smoking tobacco in rural areas is still a luxury and allowed to those with high economic power. The consumption of non-smoked tobacco is a reality in Burkina Faso, especially in the female subject whereas smoked tobacco in the male subject. According to the STEPS survey, the prevalence of non-smoked tobacco consumption was 8.9% [1].

 

In our study, alcohol consumption was not associated with hypertension. Our results corroborate those of Doulogou in 2014 and Soubeiga in 2016 in Burkina Faso. However, they contradict Olarinde's results in 2013 in Nigeria [46], Kotwani in 2012 in Uganda and Addo in 2012 [36]and Agyemang in 2006 [47] in Ghana, which found association between consumption of alcohol and hypertension. Our results can be explained by the low proportion of people who consume alcohol due to informationbias. Also, the study area is made up largely (94.5%) of Muslims where to consume alcohol publicly a taboo [48].

 

In our study the consumption of vegetables or fruits was not found as a protective effect in the occurrence of hypertension. This same observation was made by Soubeiga in Burkina Faso [26]. However, the beneficial effect of vegetables and fruits on reducing the incidence of hypertension is demonstrated by several studies [49-51]. Indeed, fruits and vegetables are essential to the development and functioning of the body by their role as catalysts. The low proportion of people consuming fruits and vegetables, the period of data collection and the study area may explain our results. According to STEPS survey results, in Burkina Faso, only 5% of the population aged 25 to 64 consumed at least five servings of fruit or vegetables per day [25]. Also, to have a protective effect, regular and prolonged consumption of fruits and vegetables is necessary. Populations in our context, occasionally consume fruits and vegetables. This consumption is not as sustained in duration or quantity. We also did not evaluate the duration of consumption of these fruits and vegetables. A cohort study in rural Burkina Faso will provide answers on the benefits of vegetables, fruits in relation to the incidence of hypertension.

 

In our study, hyperglycemia was not found as a risk factor significantly associated of the occurrence of hypertension. Our results corroborate those of Soubeiga in Burkina Faso. However, several African studies have shown the association between hyperglycemia and hypertension [18,37,52]. Indeed, hyperglycemia is an important factor associated with coronary artery disease and potentiates the risk of vascular and renal complications if it coexists with hypertension. Diabetes and hypertension are closely related. Diabetes mellitus may precede the onset of hypertension while studies at the beginning of the last decade show that people with hypertension were more likely to develop diabetes mellitus than normotensive individuals [52]. The low proportion of people with high blood glucose could explain our results. Our results may not be generalised to the entire population of Yatenga, or the northern region as we worked in only one of the 13 municipalities in Yatenga province. There may also be selection biases because controls were recruited in the community level and memorization bias.

 

The risk factors for pregnancy-induced hypertension were not identified as pregnant women were excluded from our study. The physical activity, consumption of fruits, vegetables and alcohol varying with the climatic seasons were limits related to the period of data collection. In addition, consuming certain fruits or vegetables or alcohol is sometimes taboo in some cultures. We did not collect data on some variables known as potential risk factors for hypertension in the literature. These variables are (i) information on cholesterol (total cholesterol and HDL cholesterol) and triglycerides; (ii) the daily amount of salt consumed (urine dosage possible); (iii) consumption of products containing licorice (pastis, candy, cotton candy); (iv) Socio-economic status (poverty, living conditions of households). Our study nevertheless provided information on risk factors associated of hypertension that will be useful for the control of hypertension in the Koumbri municipality. It also provided information for the formulation of hypotheses for furthermore detailed studies on hypertension in the northern region.

 

 

Our study identified risk factors associated of hypertension in the population of Koumbri rural municipality. Thus, the modifiable risk factors associated of hypertension were abdominal obesity, lack of physical activity, and the presence of intra-family conflicts. The non-modifiable ones associated of hypertension were advanced age and family history of hypertension. This study then allowed us to explore the relationship between hyperglycemia and hypertension in the population of Koumbri municipality. No evidence of association was found between hyperglycemia and hypertension on the one hand and on the other hand between alcohol, tobacco, fruit and vegetable consumption and the risk of hypertension occurring in the population of the Koumbri´s municipality.

 

We recommend to the population of the municipality of Koumbri to practice regular physical activity, to adopt a healthy and balanced diet, to use family or marriage counselors in the management of intra-family conflicts and to prevent stress by early resolution of intra-family conflicts.

 

We recommend also to the officials of the Ministry of Health to strengthen the capacity of health workers on hypertension, to promote physical activities in all sectors and residences in collaboration with the Ministry of Sport and leisure and to initiate an in-depth study on hypertensions´ risk factors in Burkina Faso rural area. A study considering the urinary salts, triglycerides, HDL cholesterol and total cholesterol, the consumption of products containing licorice may be considered to better assess the risk factors of hypertension in rural Burkina Faso. We hope that our results will enable health authorities to make effective public health intervention choices to reduce the risk factors associated of hypertension in the population of Koumbri´s municipality and hence in Burkina Faso.

 

 

The authors declare no competing interests.

 

 

SPH, OS, SB, AS, YD, OB, AMTA and ZP developed the protocol, collected and analyzed the data, interpreted the data and wrote the manuscripts. BWB, SY, TA, KM, NA, SEE contributed to the analysis of the data, interpretation and reviewing several drafts and made a substantial contribution to the writing of the manuscripts. SH, OB, AMTA, MA and SM contributed to the interpretation of the data and the revision of the manuscripts. All authors read and approved the final manuscript.

 

 

We would like to express our sincere thanks to; West African Field Epidemiology Training Program, African Field Epidemiology Network, West African Health Organization (WAHO), CDC-Atlanta, and Ministry of Health, Burkina Faso. Many thanks also go to all participants for their consent to allow us to interview them.

 

 

Table 1: Sociodemographic characteristics of hypertension Cases and controls Koumbri Municipality, Burkina Faso, December 2016-April 2017

Table 2: Sociodemographic and familial factors associated of hypertension in bivariate analysis, Koumbri municipality, Burkina Faso, December 2016-Apr. 2017

Table 3: Factors associated of hypertension in the population of Koumbri stratified by Age group and sex, Koumbri municipality, Burkina Faso, December 2016-April. 2017.

Table 4: Independent factors associated of hypertension in multivariate analysis, Koumbri Municipality, Burkina Faso, December 2016-April 2017

Figure 1: Map of Burkina Faso showing the northern region (Gray color), the Thiou district (purple color) and the Municipality of Koumbri (red color), study site

 

 

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