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INTRODUCTION
The stable West-African country Ghana is a nation on the rise, recently being upgraded from a low- to a lower middle income country (1). However, economy and welfare are not exclusively rising in Ghana: hypertension and consequently cardiovascular diseases (CVDs) are on the rise as well (24).
Hypertension, defined by a blood pressure (BP) >140/90 mmHg, affects 1.13 billion people globally (5). It is the largest single contributor to burden of disease worldwide (6) and one of the most important causes of premature deaths (5), being a major risk factor for CVDs. CVDs are the biggest group of non-communicable diseases (NCDs) and the leading cause of death worldwide (31%) (7). Hypertension is referred to as a silent killer , since the majority of hypertensive people are asymptomatic, even though they are at risk of sudden fatal CVDs (8). Two-third of the total hypertensive population lives in low-and-middle income countries (LMIC) (5). The prevalence of hypertension in sub-Saharan Africa (SSA) is among the highest in the world and is predicted to increase over the coming decade (9,10).
The World Health Organization (WHO) set the prevalence of hypertension in Ghana at 20% in 2015 (11). However, recent population-based studies show a prevalence ranging from 13% to as high as 64% (24), depending on the included age groups and settings of the study. Risk groups in Ghana include older age groups (>45 years), urban residents, the physically inactive and obese, and wealthy and higher educated Ghanaians (4,9).
Awareness, treatment and control of hypertension are low in Ghana (table 2) (2,3,17). Political focus on hypertension only started to develop in recent years (2). A longer delay in having sufficient health care policies attacking hypertension will most likely lead to an even bigger challenge on Ghanas already overwhelmed health care system (18).
This literature review aims to identify and describe the social determinants of hypertension in Ghana. Being addressed to the minister of health, I hope this review will contribute to a better understanding, providing a basis for development of sustainable health policies.
METHODS
Search strategy
This is a literature review. Table 3 lists the search terms I used. In addition, I used the snowball technique to find additional articles. I screened the articles for applicability. Both quantitative and qualitative studies relating to non-pregnant adults with primary hypertension were included. I focused on essential hypertension (also primary or idiopathic hypertension; hypertension without an underlying disease, affecting 95% of hypertension patients (19)), as secondary hypertension (hypertension caused by another medical condition) doesnt share the same determinants. Articles written in any other language than English or Dutch were excluded. In case data from Ghana was lacking, I used data from (West-) Africa or global literature.
Conceptual model
The model of Dahlgren and Whitehead (20) was used to describe social determinants of hypertension in Ghana. This widely used model is comprehensive and well organized, and covers all relevant determinants of hypertension.
FINDINGS
A variety of studies covering the determinants of hypertension in Ghana were found.
Age, sex and constitutional factors
Age, sex and constitutional factors are the most important non-modifiable determinants of hypertension (21).
Age
Ageing is characterized by an increase in endothelial dysfunction and diminished vascular elasticity which can lead to hypertension (22). The adverse effects of certain lifestyle factors (section 3.2) on hypertension are piling up as age progresses as well. Socio-economic development and improved health systems are causal factors of Ghanas ageing population (table 1) (23).
Sex
Due to the protective effect of the female sex hormone estrogen on endothelial function and vasodilation, women have a lower BP compared to men until they reach menopause (25). The risk of hypertension increases rapidly after the age of 60 for women (24). Some Ghanaian studies indicate a higher prevalence among women in the general population (64% versus 54% in men) (3). Most likely, this can be explained by gender differences: e.g. women are more likely to be obese (section 3.2.2 and 3.5.2) and have a sedentary occupation, like table-top selling (section 3.2.1).
Constitutional factors
A family history of hypertension is a risk factor for developing hypertension (26). Ones genetic make-up can also cause predisposition to obesity or addictions (27), which in their turn increase the risk of hypertension. No significant difference in odds of becoming hypertensive was found between different ethnic groups in Ghana (table 6) (4).
Most important medical conditions related to primary hypertension are previous cardiovascular disease (including pregnancy induced hypertension and (pre-)eclampsia), diabetes, high cholesterol, and renal disease (22). This can partially be explained by overlapping biological factors, but similar lifestyle choices elevating the risk of these diseases play a role as well.
Individual lifestyle factors
Individual lifestyle factors are modifiable risk factors for hypertension. Often, these individual lifestyle choices go hand in hand (28).
Physical inactivity
Physical inactivity is a large-scale issue in Ghana, especially in urban areas: 94.7% of young females and 70.5% of young males in Accra are physically inactive (29). Although the mechanism is not yet fully understood, physical activity is thought to lower the BP by a decrease in peripheral vascular resistance (30). Inactivity is closely related to obesity (section 3.2.2). Being physically active decreases the odds of becoming hypertensive in Ghanaians (table 6) (4).
Obesity
Obesity (Body Mass Index (BMI) > 30 kg/m2) is on the rise in Ghana (table 1) (11). Women are more likely to be obese than men (15% versus 4%) (11). Physical inactivity, unhealthy diets and psychological factors (e.g. depression) contribute to this fact (31). The relationship between obesity and hypertension is partly explained by these common risk factors, but obesity in itself is a risk factor for hypertension as well (31). Obesity leads to increased peripheral vascular resistance and circulating blood volume (31).
Dietary factors
Excessive intake of salt can lead to hypertension due to retention of circulating sodium, leading to an increase in blood volume (32). WHO advises a maximum of 2 gram sodium per day for adults (33). Ghana has one of the highest sodium intakes of SSA (average 6 gram/day for both men and women (11)) (34). The rise of highly salted processed fast foods in Ghana seem to present a bigger problem than the use of salt in food seasoning (34). These processed foods are not only highly salted, but also rich in saturated fats, another risk factor for hypertension. Diets rich in saturated fats increase cholesterol level, which contributes to the development of hypertension (35).
Smoking
Smoking has an acute hypertensive effect (by stimulation of the sympathetic nervous system) and a chronic hypertensive effect (by causing endothelial dysfunction and arterial stiffness) (36). Prevalence of smoking is low in Ghana (4%), with a clear gender difference (7% of men versus 0.3% of women) (11,37). Cultural and religious influences, community-level interactions and effective public health policies are influencing the prevalence of smoking in Ghana (38).
Alcohol consumption
The relationship between alcohol use and hypertension is complex. Next to the biological effects that intake of larger amounts of alcohol have on hypertension, different pathways lead to inflammation and circulation changes, multiple behavioral and lifestyle connections influence the relationship as well (39). Harmful alcohol use (>4 units/day) in Ghana is higher among men (5%) versus women (1%) (11), and in urban versus rural populations (3).
Social and community networks
Community networks can influence the prevalence and awareness of hypertension indirectly through lifestyle choices and common health care seeking behavior.
Perception and knowledge of hypertension
Perception and knowledge of hypertension differs greatly among communities in Ghana. Lack of knowledge is associated with low educational background and rural residency (40). In Northern Ghana, hypertension is experienced as spiritual attack or even witchcraft in some communities (41), influencing health seeking behavior.
Religion
Compared to Muslims and Traditionalists, Christians have the highest odds of becoming hypertensive (table 1 and 6) (4). Christians are found to often defer their hypertensive disorder to an active and divine Deity (God) , taking a passive role in dealing with the condition (e.g. not adhering to lifestyle advises) (42).
Community initiatives
Community involvement and -initiatives could be an important factor influencing lifestyle choices and contributing to prevention and control of hypertension. Only one community program was found specifically directed towards hypertension in ghana, showing promising results (table 4) (43,44).
Marital status
Divorced/widowed Ghanaian women have a higher chance of developing hypertension compared to married or single women (table 6) (4). Increased psychological stress might be an explanation for this. Long lasting psychological stress has a biological effect on hypertension, but is also associated with an inactive lifestyle, obesity, smoking, and alcohol abuse (30).
Living and working conditions
Living and working conditions are influencing all other layers of the conceptual model, but in their turn, are being influenced by all other layers as well, creating a complex integrated web (20).
Agriculture and food production
Food availability and affordability is affecting dietary factors contributing to hypertension. Interestingly, prevalence of hypertension in the rural Volta region was found to be relatively high compared to other rural areas (33%). In rural Ghana, agriculture is the most common occupation. In the Volta region however, being home to lake Volta, fishing and salt production are more common. Dietary levels of sodium are thought to be higher in this region (45).
Education
Educated Ghanaians are more likely to become hypertensive, compared to their uneducated countrymen (table 6) (4). There is a positive association between education and pro-active health care seeking behavior, probably influencing the prevalence of hypertension in this group (46). Education influences other determinants of hypertension, like work environment, SES, urbanization and thus lifestyle choices (4).
Work environment
Economic growth and urbanization have led to an increase in sedentary occupations in Ghana, and thus a more inactive lifestyle compared to e.g. agricultural occupations. Women and higher educated individuals are more likely to have a sedentary occupation (47).
Unemployment
Unemployed Ghanaians have higher odds of developing hypertension compared to the employed (table 6) (4). The underlying relationship between unemployment and hypertension is not entirely clear, since determinants related to employment (e.g. high education and SES) are known to increase the odds of developing hypertension in Ghana. Possible factors to take into account could be psychological stress related to joblessness (e.g. financial worries, ones place in society) and a possible inactive lifestyle (4).
Health care services
Awareness, treatment, and control of hypertension are low in Ghana (table 2) (3), partly due to multiple barriers in accessibility of health services. Regarding to availability: Ghanaian health services are more likely to be adequately supplied with malaria medications (85%), than with essential hypertension drugs (35%) (49). Regarding to affordability: poor Ghanaians suffer from out-of-pocket (OOP) payments for hypertensive medications (50). Overall enrollment in the National Health Insurance Scheme (NHIS) remains low (40%) (51), as poorer Ghanaians cant afford the premiums (52). Wealthy, educated Ghanaians living in urban areas are most likely to be covered by the NHIS (53). Individuals covered by the NHIS are more likely to have their BP measured and adhere to treatment (table 2) (2,50). Awareness is higher among younger Ghanaians (table 5) compared to the general population (table 2) and among women compared to men (table 2).
Housing & water and sanitation
No data could be found on water and sanitation and housing as individual determinants for hypertension in adults, although one study suggests a link between household air pollution and BP levels in pregnant women in Ghana (54).
General socioeconomic, cultural and environmental conditions
This overlapping layer of the conceptual model is affecting all other determinants. On the contrary, this layer is also influenced by the underlying layers, as well as by globalization (54).
Socioeconomic conditions
Ghanaians with a higher income/SES have increased odds of becoming hypertensive (table 6) (4). Higher SES is often achieved by higher educated, urban residents (18). As previously described, these factors often relate to lifestyle changes. Physical inactivity (including less labor intense occupations), obesity, unhealthy diets, alcohol consumption and smoking are associated with urban areas (47).
Cultural conditions
Gender roles play an important role in the determinants of hypertension for men and women, as has already been highlighted in the previous sections. The ideal female body image in Accra appears to be slightly overweight (56). A higher BMI is being associated with wealth and success (56). Desirable activities from a socioeconomic point of view also play an important role: driving to work is seen as a status symbol (56). Religion and perception of hypertension have been addressed in section 3.3.
Environmental conditions
Environmental conditions are different in rural versus urban settings, whereby cities usually present less healthy environments, predisposing its inhabitants to hypertension (table 6) (18). Accra has very few sidewalks, parks and fitness facilities, attributing to an inactive lifestyle of its residents (57). In 2013, 68% of restaurants in the urban Greater Accra Region served fast food (58). The effect of globalization is especially noticeable in urban areas, influencing the determinants of hypertension on a population level, health care sector level and economical and political level (55). Figure 2 lists some of the most important effects of globalization on the determinants of hypertension in Ghana. This figure tries to be illustrative instead of comprehensive, as this goes beyond the scope of this article.
National attention for hypertension and NCDs only started to develop recently (59). An estimated 80% of Ghanas health care budget annually is spent on communicable diseases (49). Lack of reliable data and research, limited political interest and donor investments which are not directed at NCDs are barriers to implementation of policies targeting hypertension (59). The current health sectors response to hypertension is mainly focusing on treatment rather than prevention (60).
DISCUSSION
It is clear that hypertension is a major health concern. Taking into account the most important social determinants of hypertension in Ghana age, physical inactivity, obesity, high educational level, high SES, and urban residency one can expect hypertension prevalence to rise over the coming decades in Ghana, as the population is expected to continue to age and economic growth and urbanization are striving.
Limitations of this study are that the majority of data being used originates from the population-based Study on global AGEing and adult health (SAGE) , commissioned by the WHO in 2008 (23). The two most important epidemiological reviews after this period use this studys database (3,4). Next to the fact that the data is over decade old, part of the results were self-reported, making them susceptible to selection bias. Another review cited in this article (2) used the database of a large population-based study performed in 2014, the Ghana Demographic and Health Survey (61). However, the included age group in this study was restricted to 15-49 years. Virtually all other population-based studies on hypertension in Ghana have been carried out in subpopulations (e.g. women of reproductive age or rural communities). This highlights the need for more hypertension research in Ghana.
The biggest strenght of this article is that it is the first to list all important social determinants of hypertension in Ghana in a clear order, using a comprehensive conceptual model. It shows what political policies and public health care programs should focus on to turn the tide.
The low awareness, treatment and control of hypertension among Ghanaians (table 2 and 5) means that a large amount of people with hypertension are unaware of their increased risk of CVDs, like sudden fatal heart attack or stroke. In order to improve awareness, measures to reduce health inequities have to be developed. Furthermore, the ongoing trend of making lifestyle choices which are not beneficial to ones health, often being influenced by longstanding cultural conditions in combination with recent economic growth, urbanization and globalization, should be put to a halt.
CONCLUSION/RECOMMENDATIONS
This article created a basis for policy making by unraveling the determinants of hypertension. Practical recommendations to the minister of health include:
- Create an enabling environment, encouraging healthy lifestyle choices, with a focus on women, and highly educated, urban residents with high SES.
- Promote healthy diets and physical activity
- Ban global fast food companies
- Create parks and walkways in urban areas
- Encourage community involvement and initiatives
- Include health education and sports in the educational curriculum
- Improve the access of hypertension related health services, with a focus on the poor, men and elderly (>49 years).
- Expand the NHIS coverage
- Provide adequate stockings of hypertensive treatment
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