Background

Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs—and its variation between countries and population groups—by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage.

Methods

In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval.

Findings

Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9–74·3) had ever had their blood pressure measured, 39·2% of participants (38·2–40·3) had been diagnosed with hypertension, 29·9% of participants (28·6–31·3) received treatment, and 10·3% of participants (9·6–11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade.

Interpretation

Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage.

Funding

Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

中文翻译：

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44个低收入和中等收入国家的高血压护理状况：一项针对具有全国代表性的1·100万成年人的个人水平数据的横断面研究

背景

来自低收入和中等收入国家（LMIC）的全国代表性研究的证据很少，其中连续性患者失去了高血压护理。但是，此信息对于有效确定医疗服务部门的干预措施并监测改善高血压护理的进展至关重要。我们旨在通过将护理过程的进展（从需要护理到成功治疗）分为不同阶段，并测量每个阶段的损失，来确定44个中低收入国家的高血压治疗的级联及其在国家和人群之间的差异。

方法

在这项横断面研究中，我们汇总了来自44个LMIC的基于个人的基于人口的数据。我们首先从2005年或以后的WHO逐步监测方法（STEPS）中搜索具有全国代表性的数据集。如果LMIC无法获得STEPS数据集（或者我们无法访问它），我们将对调查数据集进行系统搜索；否则，我们将对调查数据集进行系统搜索。这些搜索的纳入标准是，该调查是在2005年或更晚时进行的，在全国范围内代表至少三个年龄在15岁以上的10岁年龄组，包括了测得的血压数据，并包含了至少两个高血压护理级联的数据脚步。高血压定义为收缩压至少为140 mm Hg，舒张压至少为90 mm Hg，或已报道使用药物治疗高血压。在患有高血压的人中 我们计算了曾经测过血压的个人比例；被诊断出患有高血压；已经接受过高血压治疗；并且已经控制了他们的高血压。在确定全球和地区级别的高血压护理级联时，我们根据国家/地区的人口规模对国家进行了加权评估。我们按年龄，性别，受教育程度，家庭财富五分位数，身体质量指数，吸烟状况，国家和地区来分类高血压护理级别。我们使用线性回归分别根据每个人均国内生产总值（GDP）来预测一个国家的绩效，从而使我们能够确定其绩效不在95％预测区间之内的国家。被诊断出患有高血压；已经接受过高血压治疗；并且已经控制了他们的高血压。在确定全球和地区级别的高血压护理级联时，我们根据国家/地区的人口规模对国家进行了加权评估。我们按年龄，性别，受教育程度，家庭财富五分位数，身体质量指数，吸烟状况，国家和地区来分类高血压护理级别。我们使用线性回归分别根据每个人均国内生产总值（GDP）来预测一个国家的绩效，从而使我们能够确定其绩效不在95％预测区间之内的国家。被诊断出患有高血压；已经接受过高血压治疗；并且已经控制了他们的高血压。在确定全球和地区级别的高血压护理级联时，我们根据国家/地区的人口规模对国家进行了加权评估。我们按年龄，性别，教育程度，家庭财富五分位数，身体质量指数，吸烟状况，国家和地区来细分高血压护理的级联。我们使用线性回归分别根据每个人均国内生产总值（GDP）来预测一个国家的绩效，从而使我们能够确定其绩效不在95％预测区间之内的国家。在确定全球和地区级别的高血压护理级联时，我们根据国家/地区的人口规模对国家进行了加权评估。我们按年龄，性别，受教育程度，家庭财富五分位数，身体质量指数，吸烟状况，国家和地区来分类高血压护理级别。我们使用线性回归分别根据每个人均国内生产总值（GDP）来预测一个国家的绩效，从而使我们能够确定其绩效不在95％预测区间之内的国家。在确定全球和地区级别的高血压护理级联时，我们根据国家/地区的人口规模对国家进行了加权评估。我们按年龄，性别，受教育程度，家庭财富五分位数，身体质量指数，吸烟状况，国家和地区来分类高血压护理级别。我们使用线性回归分别根据每个人均国内生产总值（GDP）来预测一个国家的绩效，从而使我们能够确定其绩效不在95％预测区间之内的国家。

发现

我们的汇总数据集包括1100507名参与者，其中192441名（17·5％）患有高血压。在患有高血压的人中，有73·6％的参与者（95％CI 72·9–74·3）曾经测量过血压，有39·2％的参与者（38·2–40·3）被诊断出患有高血压。高血压，有29·9％的参与者（28·6–31·3）得到了治疗，而10·3％的参与者（9·6–11·0）实现了高血压的控制。相对于基于人均GDP的预期表现，拉丁美洲和加勒比海地区的国家总体表现最佳，而撒哈拉以南非洲地区的国家表现最差。孟加拉国，巴西，哥斯达黎加，厄瓜多尔，吉尔吉斯斯坦和秘鲁在所有照料级联步骤上的表现均明显好于根据人均国内生产总值预测的结果。作为一个女人，年纪大一些，受过高等教育，比较富有，

解释

我们的研究为中低收入国家高血压的健康政策和服务干预措施的设计和确定目标提供了重要的证据。我们展示了在我们研究的44个国家中，高血压护理过程的步骤和针对谁的差距。我们还确定了世界各个地区的经济发展情况要好于预期的国家，这些国家可以将政策制定者引向重要的政策课程。鉴于中低收入国家由高血压引起的高疾病负担，本研究构建的全国代表性的高血压护理级联是实现全民健康覆盖的重要指标。

资金

哈佛·麦克伦南家族基金，亚历山大·冯·洪堡基金会。