Rural-urban variation in hypertension among women in Ghana: insights from a national survey

BMC Public Health, Volume 21, No. 1, Year 2021

Interprétation

Background: Hypertension is one of the leading causes of cardiovascular morbidities in Ghana and represents a major public health concern. There is dearth of information on the rural-urban disparity in hypertension among women in Ghana. Therefore, this study aimed at examining the rural-urban variation in hypertension among women in Ghana. Methods: We extracted data from the women’s file of the 2014 Ghana Demographic and Health Survey. The sample included 9333 women aged 15–49 with complete data on hypertension. The analysis was done using Pearson Chi-square and binary logistic regression at 95% confidence interval. The results of the binary logistic regression were presented as Odds Ratios (ORs) and Adjusted Odds Ratios (AORs). Statistical significance was set at p < 0.05. Results: Hypertension prevalence among urban and rural residents were 9.5% and 5.1% respectively. Rural women had lower odds of hypertension [OR = 0.59; 95% CI = 0.52, 0.67] compared to urban women, however, this was insignificant in the adjusted model [aOR = 0.84; 95% CI = 0.70, 1.00]. The propensity to be hypertensive was lower for women aged 15–19 [aOR = 0.07; 95% CI = 0.05, 0.11]. The poorest were less likely to be hypertensive [aOR = 0.63; 95% CI = 0.45, 0.89]. Single women were also less probable to have hypertension [aOR = 0.66; 95% CI = 0.46, 0.97]. Conclusions: Women from urban and rural areas shed similar chance to be hypertensive in Ghana. Therefore, the health sector needs to target women from both areas of residence (rural/urban) when designing their programmes that are intended to modify women’s lifestyle in order to reduce their risks of hypertension. Other categories of women that need to be prioritised to avert hypertension are those who are heading towards the end of their reproductive age, richest women and the divorced. In this study, we used data from the 2014 GDHS. Since the inception of the GDHS, it is only the 2014 edition that assessed hypertension status of Ghanaian women. The GDHS is a five-year interval nationally representative survey mostly carried out by the Demographic and Health Surveys (DHS) Program, Ghana Statistical Service and Ghana Health Service [25]. The survey seeks to collect, analyse, and circulate representative and reliable data on core health indicators in over 90 countries including Ghana. These core healthcare indicators comprise adult health and lifestyle including hypertensive status, nutrition as well as maternal and child health. In 2014, the survey recruited 9396 women within the 15–49 age group. The survey made use of an updated frame prepared for the 2010 Population and Housing Census (PHC) and had a response rate of 97%. We included 9333 women in the present study because this sample had complete information for the analysis. The sample was derived through a two-stage sampling approach aimed at permitting estimation of core indicators throughout the then 10 administrative regions. The first stage involved the selection of sample points or clusters made up of enumeration areas (EAs) whereas the second stage constituted a sampling of households following systematic sampling. Between January and March 2014, household listing was conducted for this purpose. Approximately 30 households were identified per cluster. This resulted in 427 clusters (with 216 from urban and 211 from rural settings) and 12,831 households throughout the country [25]. The sample excluded institutional and nomadic persons such as those in hotels and prisons. The data was deemed suitable for the study because it is nationally representative and the first of its kind to investigate the hypertensive status of women in their reproductive age at the national level. We had access to the dataset from the website of Measure DHS and is freely available through https://dhsprogram.com/data/available-datasets.cfm. Hypertensive status (measured by blood pressure) of Ghanaian women aged 15–49 was the dependent variable for the study. During the 2014 DHS, blood pressure was monitored and measured on three occasions following the UA-767F/FAC (A&D Medical) blood pressure with at least 10 min interval [25]. In determining hypertensive status, an average of the second and third measurements were computed, and this conforms to calibration by other studies on hypertension that are underpinned by the DHS datasets [16, 26, 27]. Following the Joint National Committee Seven (JNC7) guideline, hypertension was conceptualised as an average systolic blood pressure of ≥140 mmHg and/or an average diastolic blood pressure of ≥90 mmHg. Hypertensive women were coded as 1 whilst non-hypertensive women were coded otherwise ‘0’. The main explanatory variable was place of residence (rural or urban), in line with the categorisation of the DHS survey. The choice of this explanatory variable emerged from its statistically significant association with hypertension with dominance among the urban population [18, 28, 29] whilst some evidence also documents high inclination toward rural residents [9]. There was, therefore, the need to interrogate and identify the situation in Ghana. We included some socio-demographic characteristics of the women; age, wealth quintile, marital status, occupation, salted fish consumption, region and tobacco use (comprising cigarette, tobacco, and snuff). We included salted fish consumption because some evidence indicates an association between hypertension and salt intake [30, 31]. Behavioural factors such tobacco use and some related lifestyles have been documented as precursors to hypertension [32–34]. The following variables were recoded to suit the analysis; marital status was recoded as “single = 0”, “married = 1”, “cohabiting = 2”, “widowed = 3”, “divorced = 4” and “separated=5; occupation recoded into “not working=0” “agriculture = 1″ “manual = 2″ and “service = 1″; salted fish consumption into “No = 0″ and “Yes = 1.” In our analysis, we calculated the proportion of women with hypertension by place of residence (rural or urban) as shown in Fig. 1. We also computed the proportion of hypertension by the socio-demographic variables as shown in Table 1, and also explored which of them had a significant association with hypertension. Out of the ten variables tested (see Table Table1),1), six were significant and were used in our inferential analysis (residence, age, wealth, marital status, occupation, and region). To ensure that there is no multicollinearity between the explanatory variables, tests for multicollinearity was conducted and it was revealed that the socio-demographic variables are not highly correlated [mean VIF = 1.42, maximum = 2.31, minimum = 1.02]. Due to the dichotomous nature of our dependent variable, binary logistic regression analysis was conducted where odds ratios (ORs) and adjusted odds ratios (aORs) with their respective 95% confidence intervals (95% CI) were reported (Table 2). Model 1 focused on the bivariate analysis between residence and hypertension whilst Model 2 presents a multivariable model adjusting for the effect of the significant socio-demographic variables. The results were weighted in order to achieve proportionality at the national level and the entire analysis was conducted using Stata version 13. Rural/urban distribution of hypertension among women Socio-demographic characteristics and hypertension among Ghanaian women (n = 9333) Source: 2014 GDHS Binary logistic regression results on residential status and hypertension in Ghana Exponentiated coefficients; 95% confidence intervals in brackets, OR = Odd Ratio, aOR = Adjusted Odds Ratio, * p < 0.05, ** p < 0.01, *** p < 0.001, 1 = Reference categorys Source: 2014 GDHS DHS reports that informed consent was sought from all the women prior to their participation in the survey. The DHS sought ethical approval from the Ethics Committee of ORC Macro Inc. and that of Ghana Health Service. Authors of this manuscript were not directly involved in the data collection processes but rather obtained access by applying to the DHS (via https://dhsprogram.com/data/available-datasets.cfm) in order to obtain access.

Résumé de l’IA

Study Justification:

– Hypertension is a major public health concern in Ghana and one of the leading causes of cardiovascular morbidities.
– There is a lack of information on the rural-urban disparity in hypertension among women in Ghana.
– This study aims to examine the rural-urban variation in hypertension among women in Ghana to provide insights and inform public health interventions.

Highlights:

– The study used data from the 2014 Ghana Demographic and Health Survey, which is a nationally representative survey conducted by the Demographic and Health Surveys Program, Ghana Statistical Service, and Ghana Health Service.
– The study included 9,333 women aged 15-49 with complete data on hypertension.
– The prevalence of hypertension among urban and rural residents was 9.5% and 5.1% respectively.
– Rural women had lower odds of hypertension compared to urban women, although this difference was not significant in the adjusted model.
– Other factors associated with lower odds of hypertension included younger age, lower wealth status, and being single.

Recommendations:

– The health sector should target women from both rural and urban areas when designing programs to modify women’s lifestyle and reduce their risks of hypertension.
– Priority should be given to women who are heading towards the end of their reproductive age, the richest women, and those who are divorced.

Key Role Players:

– Ministry of Health
– Ghana Statistical Service
– Ghana Health Service
– Public health researchers and experts
– Healthcare providers and professionals
– Community health workers

Cost Items for Planning Recommendations:

– Development and implementation of lifestyle modification programs
– Training and capacity building for healthcare providers and community health workers
– Health education and awareness campaigns
– Monitoring and evaluation of program effectiveness
– Data collection and analysis
– Infrastructure and equipment for healthcare facilities
– Outreach and community engagement activities

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used data from a nationally representative survey, which enhances the generalizability of the findings. The analysis employed appropriate statistical methods, including binary logistic regression. However, there are some areas for improvement. First, the abstract does not provide information on the sample size or the response rate, which are important factors in assessing the reliability of the results. Second, the abstract does not mention any potential limitations of the study, such as the possibility of measurement error in blood pressure readings. To improve the evidence, the authors should include these missing details and acknowledge any limitations in the abstract.

Abstrait

In this study, we used data from the 2014 GDHS. Since the inception of the GDHS, it is only the 2014 edition that assessed hypertension status of Ghanaian women. The GDHS is a five-year interval nationally representative survey mostly carried out by the Demographic and Health Surveys (DHS) Program, Ghana Statistical Service and Ghana Health Service [25]. The survey seeks to collect, analyse, and circulate representative and reliable data on core health indicators in over 90 countries including Ghana. These core healthcare indicators comprise adult health and lifestyle including hypertensive status, nutrition as well as maternal and child health. In 2014, the survey recruited 9396 women within the 15–49 age group. The survey made use of an updated frame prepared for the 2010 Population and Housing Census (PHC) and had a response rate of 97%. We included 9333 women in the present study because this sample had complete information for the analysis. The sample was derived through a two-stage sampling approach aimed at permitting estimation of core indicators throughout the then 10 administrative regions. The first stage involved the selection of sample points or clusters made up of enumeration areas (EAs) whereas the second stage constituted a sampling of households following systematic sampling. Between January and March 2014, household listing was conducted for this purpose. Approximately 30 households were identified per cluster. This resulted in 427 clusters (with 216 from urban and 211 from rural settings) and 12,831 households throughout the country [25]. The sample excluded institutional and nomadic persons such as those in hotels and prisons. The data was deemed suitable for the study because it is nationally representative and the first of its kind to investigate the hypertensive status of women in their reproductive age at the national level. We had access to the dataset from the website of Measure DHS and is freely available through https://dhsprogram.com/data/available-datasets.cfm. Hypertensive status (measured by blood pressure) of Ghanaian women aged 15–49 was the dependent variable for the study. During the 2014 DHS, blood pressure was monitored and measured on three occasions following the UA-767F/FAC (A&D Medical) blood pressure with at least 10 min interval [25]. In determining hypertensive status, an average of the second and third measurements were computed, and this conforms to calibration by other studies on hypertension that are underpinned by the DHS datasets [16, 26, 27]. Following the Joint National Committee Seven (JNC7) guideline, hypertension was conceptualised as an average systolic blood pressure of ≥140 mmHg and/or an average diastolic blood pressure of ≥90 mmHg. Hypertensive women were coded as 1 whilst non-hypertensive women were coded otherwise ‘0’. The main explanatory variable was place of residence (rural or urban), in line with the categorisation of the DHS survey. The choice of this explanatory variable emerged from its statistically significant association with hypertension with dominance among the urban population [18, 28, 29] whilst some evidence also documents high inclination toward rural residents [9]. There was, therefore, the need to interrogate and identify the situation in Ghana. We included some socio-demographic characteristics of the women; age, wealth quintile, marital status, occupation, salted fish consumption, region and tobacco use (comprising cigarette, tobacco, and snuff). We included salted fish consumption because some evidence indicates an association between hypertension and salt intake [30, 31]. Behavioural factors such tobacco use and some related lifestyles have been documented as precursors to hypertension [32–34]. The following variables were recoded to suit the analysis; marital status was recoded as “single = 0”, “married = 1”, “cohabiting = 2”, “widowed = 3”, “divorced = 4” and “separated=5; occupation recoded into “not working=0” “agriculture = 1″ “manual = 2″ and “service = 1″; salted fish consumption into “No = 0″ and “Yes = 1.” In our analysis, we calculated the proportion of women with hypertension by place of residence (rural or urban) as shown in Fig. 1. We also computed the proportion of hypertension by the socio-demographic variables as shown in Table 1, and also explored which of them had a significant association with hypertension. Out of the ten variables tested (see Table Table1),1), six were significant and were used in our inferential analysis (residence, age, wealth, marital status, occupation, and region). To ensure that there is no multicollinearity between the explanatory variables, tests for multicollinearity was conducted and it was revealed that the socio-demographic variables are not highly correlated [mean VIF = 1.42, maximum = 2.31, minimum = 1.02]. Due to the dichotomous nature of our dependent variable, binary logistic regression analysis was conducted where odds ratios (ORs) and adjusted odds ratios (aORs) with their respective 95% confidence intervals (95% CI) were reported (Table 2). Model 1 focused on the bivariate analysis between residence and hypertension whilst Model 2 presents a multivariable model adjusting for the effect of the significant socio-demographic variables. The results were weighted in order to achieve proportionality at the national level and the entire analysis was conducted using Stata version 13. Rural/urban distribution of hypertension among women Socio-demographic characteristics and hypertension among Ghanaian women (n = 9333) Source: 2014 GDHS Binary logistic regression results on residential status and hypertension in Ghana Exponentiated coefficients; 95% confidence intervals in brackets, OR = Odd Ratio, aOR = Adjusted Odds Ratio, * p < 0.05, ** p < 0.01, *** p < 0.001, 1 = Reference categorys Source: 2014 GDHS DHS reports that informed consent was sought from all the women prior to their participation in the survey. The DHS sought ethical approval from the Ethics Committee of ORC Macro Inc. and that of Ghana Health Service. Authors of this manuscript were not directly involved in the data collection processes but rather obtained access by applying to the DHS (via https://dhsprogram.com/data/available-datasets.cfm) in order to obtain access.

Matériaux

N/A

Innovations

Based on the information provided, it seems that the study focused on examining the rural-urban variation in hypertension among women in Ghana using data from the 2014 Ghana Demographic and Health Survey (GDHS). The study aimed to identify factors associated with hypertension and provide insights for improving access to maternal health.

To improve access to maternal health and address the issue of hypertension among women in Ghana, the following innovations could be considered:

1. Telemedicine: Implementing telemedicine services can help overcome geographical barriers and provide remote access to healthcare professionals. This can be particularly beneficial for women in rural areas who may have limited access to healthcare facilities.

2. Mobile health (mHealth) interventions: Utilizing mobile phones and applications to deliver health information, reminders, and support can help educate and empower women to manage their hypertension and overall maternal health. This can include sending text messages with reminders for medication adherence, lifestyle modifications, and prenatal care appointments.

3. Community health workers: Training and deploying community health workers in rural areas can improve access to maternal health services. These workers can provide education, support, and monitoring for women with hypertension, ensuring they receive appropriate care and follow-up.

4. Health education programs: Implementing targeted health education programs can raise awareness about hypertension, its risk factors, and preventive measures. These programs can be conducted in schools, community centers, and through mass media to reach a wider audience.

5. Collaborative care models: Establishing collaborative care models that involve healthcare professionals from different disciplines, such as doctors, nurses, midwives, and pharmacists, can provide comprehensive and coordinated care for women with hypertension. This can ensure that women receive timely and appropriate interventions throughout their pregnancy and postpartum period.

6. Integration of maternal health services: Integrating maternal health services with existing primary healthcare facilities can improve access to hypertension screening, diagnosis, and management. This can be achieved by training healthcare providers in these facilities to effectively manage hypertension and provide appropriate referrals when needed.

7. Mobile clinics: Setting up mobile clinics that visit rural areas on a regular basis can bring healthcare services closer to women in remote areas. These clinics can provide hypertension screening, antenatal care, and counseling services, ensuring that women receive the necessary care without having to travel long distances.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and resources available in Ghana.

AI Innovations Description

Based on the information provided, the study highlights the rural-urban variation in hypertension among women in Ghana. The prevalence of hypertension was found to be higher among urban women compared to rural women. The study suggests that targeting women from both rural and urban areas is important when designing programs to reduce the risk of hypertension. Additionally, certain groups of women, such as those approaching the end of their reproductive age, the wealthiest women, and those who are divorced, should be prioritized in efforts to prevent hypertension.

To develop this recommendation into an innovation to improve access to maternal health, the following steps can be taken:

1. Increase awareness: Develop educational campaigns and materials to raise awareness about the importance of maternal health and the risks of hypertension. These campaigns should target both rural and urban areas and should be tailored to the specific needs and cultural context of each community.

2. Improve healthcare infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas where access to healthcare facilities may be limited. This can include building or upgrading healthcare facilities, ensuring the availability of essential medical equipment and supplies, and training healthcare providers to deliver quality maternal health services.

3. Strengthen community-based healthcare: Implement community-based healthcare programs that focus on maternal health. This can involve training community health workers to provide basic maternal health services, conducting regular health screenings in communities, and promoting healthy lifestyle practices among women.

4. Enhance collaboration: Foster collaboration between different stakeholders, including government agencies, non-governmental organizations, and community leaders, to work together towards improving access to maternal health services. This can involve coordinating efforts, sharing resources and expertise, and leveraging existing networks and partnerships.

5. Utilize technology: Explore the use of technology to improve access to maternal health services. This can include telemedicine initiatives to provide remote consultations and support, mobile health applications to deliver health information and reminders, and electronic health records to ensure continuity of care.

By implementing these recommendations and innovations, access to maternal health can be improved, leading to better health outcomes for women in Ghana.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Increase awareness and education: Implement targeted awareness campaigns to educate women, especially those in rural areas, about the importance of maternal health and the risks associated with hypertension. This can be done through community health workers, local clinics, and mobile health units.

2. Improve healthcare infrastructure: Invest in improving healthcare infrastructure in rural areas, including the establishment of more clinics and health centers. This will ensure that women have access to quality maternal healthcare services closer to their homes.

3. Strengthen referral systems: Develop and strengthen referral systems between rural health facilities and higher-level healthcare facilities in urban areas. This will ensure that women with complications during pregnancy or childbirth can be quickly and efficiently transferred to appropriate facilities for specialized care.

4. Provide training for healthcare providers: Offer training programs for healthcare providers, particularly those working in rural areas, to enhance their skills and knowledge in managing maternal health issues, including hypertension. This will improve the quality of care provided to pregnant women and reduce the risk of complications.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify specific indicators that will be used to measure the impact of the recommendations, such as the number of women receiving prenatal care, the number of women screened for hypertension, or the number of women referred for specialized care.

2. Collect baseline data: Gather baseline data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, or data from existing health information systems.

3. Implement the recommendations: Put the recommendations into action, ensuring that all relevant stakeholders are involved and committed to the process.

4. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommendations. Collect data on the selected indicators at regular intervals to assess progress and identify any challenges or areas for improvement.

5. Analyze the data: Analyze the collected data to determine the impact of the recommendations on improving access to maternal health. This can be done through statistical analysis, comparing the baseline data with the data collected after the implementation of the recommendations.

6. Draw conclusions and make adjustments: Based on the analysis, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Identify any gaps or areas that need further attention and make adjustments to the recommendations as necessary.

7. Communicate the findings: Share the findings with relevant stakeholders, including policymakers, healthcare providers, and community members. Use the findings to advocate for further investment and support in improving access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions for future interventions.

Auteur

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.1186/s12889-021-12204-7

Research Areas:

Food Security, Health System and Policy, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Substance Abuse

Study Countries:

Ghana

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

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