Abstract
Purpose of Review
This study investigated and pooled the long-term trends in prevalence, awareness, treatment, and control of hypertension (HTN) in the Middle East and North Africa (MENA) region. In this systematic review and meta-analysis, we searched MEDLINE/PubMed, Web of Science, Google Scholar, EMBASE, and Scopus between database inception and November 2020. All cross-sectional studies that investigated the prevalence of pre-HTN, HTN, awareness, treatment, and control in the MENA counties were included. The selection study, data extraction, and quality assessment were conducted by two investigators independently. Heterogeneity between studies was assessed using Cochran’s Q test and I-squared, and due to sever heterogeneity between studies, the random effect model was used to pool the estimates. Sensitivity analysis was performed to estimate the long-term trends in prevalence, awareness, treatment, and control rates of HTN according to definition of HTN as systolic blood pressure of 140 mm Hg or more, or diastolic blood pressure of 90 mm Hg or more, or being on pharmacological treatment for HTN.
Recent Findings
Overall, 178 studies met the inclusion criteria. Studies comprised 2,262,797 participants with a mean age of 45.72 ± 8.84 years. According to random effect model, the pooled prevalence of pre-HTN and HTN was 33% (95% CI 28, 39) and 26% (25, 27), respectively. Over the past three decades, prevalence of hypertension increased significantly in the region. The pooled awareness, treatment, and control rates were 50% (48, 53), 41% (38, 44), and 19% (17, 21), receptively. The pooled awareness, treatment, and control rates of HTN were lower significantly in men than women. According to definition of HTN as blood pressures above 140/90 mm Hg, over the past three decades, although the awareness and treatment rates did not change significantly, the control rates improved significantly in the region.
Summary
The findings showed that HTN is a significant public health problem in the MENA region. Although there are low levels of pooled awareness, treatment, and control rates, the control rates improved over the past three decades in the region.
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Introduction
Hypertension (HTN) remains one of the significant risk factors for multiple complications such as stroke, coronary artery diseases, and renal failures [1]. Despite the efforts in managing HTN across the globe in recent years, a surge in the prevalence of the condition has been observed [2]. This remains a major public health concern, especially in low- and middle-income countries. Proper management of HTN leads to lower health complications for patients, as well as less burden on the health care system. Recent findings have shown an HTN prevalence rate of 17.5% in low- and middle-income countries. However, only 29.9% of these patients have received treatment for HTN and only 10.3% meet the target blood pressure [1]. In contrast, in high-income countries, the treatment rate seats at 40% with 25% of patients meeting the blood pressure target [1].
Emphasizing the importance of HTN management, every 10 mmHg reduction in systolic blood pressure level can decrease the risk of future cardiovascular events by up to 25% [2]. A screening program is of great value in identifying HTN at early stages, proposing treatment options and providing support for patients in managing their condition. Treatment options vary based on the degree of HTN progress. At the early stages, dietary and lifestyle changes have shown to be sufficient in controlling HTN. However, as the condition progress and is left untreated, pharmaceutical approach may be warranted to achieve optimal blood pressure control [2,3,4]. It is estimated that the prevalence of HTN will increase by more than twofold in the Middle East by 2025 [3]. This is a significant concern and calls on the Middle Eastern countries to develop a presentational strategy. Studies on the prevalence, awareness, treatment, and control rate of HTN are needed to set the path for the public health officials in developing these programs. The majority of studies have been conducted on high-income countries, with a handful focused on the Middle East and North Africa (MENA) region. Since there is not systematic review and meta-analysis based on individual and aggregated data to estimate the overall status of hypertension in the MENA region, thus this study aimed to pool data and estimate the long-term prevalence of pre-hypertension (pre-HTN), HTN, awareness, treatment, and control in this region.
Methods
This systematic review and meta-analysis were conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement [4].
Search Strategy
A systematic literature search was conducted in electronic databases, including MEDLINE/ PubMed, Google Scholar, EMBASE, Web of Science, and Scopus, for articles about the prevalence of pre-HTN, HTN, awareness, treatment, and management between databases inception and October 21, 2020. Searches were performed using the terms “pre-HTN,” “HTN,” “awareness,” “treatment,” and “control,” and other related keywords according to the search strategy of each database (Appendix Table 3). Searched was performed by one investigator, and the results were reviewed by another investigator.
Eligibility Criteria and Selection Study
All cross-sectional studies, in English that investigated the prevalence of pre-HTN, HTN, awareness, treatment, and control rate in adults and older adults (age ≥ 18 years), were included. All prevalence survey that selected sample participants represented the target population so that the age and sex structure of the sample was consistent with the target population structure for at national or subnational level were included in this study. For multiple publications that used the same source of data, the most recent publication was included. After removing duplicated studies, and removing all self-report studies on the subject, two investigators independently (NM and ES) examined the title, abstract, and full text of related studies, with respect to the eligibility criteria. Probable discrepancies were based on the third expert’s opinion (MQ).
Data Extraction Strategy
Two independent investigators performed data extraction with an electronic data extraction form (NM and ES). The following data was extracted: first author, population, study year, sample size, male/female ratio, age (mean or range), HTN definition (cutoff point), level of study, and prevalence/proportion with 95% confidence interval (CI) for each outcome. Any probable discrepancy was resolved based on the third expert’s opinion.
Definition
Awareness, treatment, and control rate of HTN were calculated in the included studies as the proportion of participants with HTN who were aware of their disease, who were treated, and whose HTN was controlled.
Quality Assessment
Quality assessment of included studies was done based on the Newcastle–Ottawa Scale adapted for cross-sectional studies. The scale has seven items and is consisted of selection, comparability, and outcome components. The total score ranged from 0 to 10, with a higher score indicating a lower risk of bias. Quality assessment of studies was categorized as follows: 0 to 4 for “unsatisfactory studies,” 5–6 points for “satisfactory studies,” 7–8 points for “good studies,” and 9–10 points for “very good studies.” The quality assessment was conducted independently by two investigators (NM and ES). Probable discrepancies were resolved based on the third expert’s opinion (MQ).
Statistical Analysis
Heterogeneity between studies was assessed using Cochran’s Q test and I-squared. Due to sever heterogeneity between studies, a random effect model was used to pool prevalence of HTN [5]. A meta-analysis of proportions was used to calculate the pooled prevalence of HTN, awareness, treatment, and control rates [6]. The subgroup meta-analysis was performed based on gender, study period, level of income, HTN definition, study level (regional, sub-national, national), country, and year. Subgroup analysis, according to the country income level, was done according to the World Bank income classifications [7]. Pooled prevalence, awareness, treatment, and control rates of HTN at country level were estimated for countries with more than 4 studies. Subgroup analysis was categorized into studies conducted from 1990 to 1999, 2000 to 2009, and 2010 to 2020. Sensitivity analysis was performed to estimate the long-term trends in prevalence, awareness, treatment, and control rates of HTN according to standard definition of HTN (definition of HTN as systolic blood pressure of 140 mm Hg or more, or diastolic blood pressure of 90 mm Hg or more, or being on pharmacological treatment). In sensitivity analysis, studies which used other definitions were excluded from analysis. Meta-regression model was fitted to explain the heterogeneity in terms of study-level covariates. STATA 14 (StataCorp, College Station, TX, USA) was used for the analysis.
Results
Search Results
Overall, 2892 studies extracted from the initial search. Upon exclusion of 549 duplicate reviews, the titles, abstracts, and full text of reviews were examined. Totally 178 studies [8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185] met the inclusion criteria. The screening and selection processes of studies are summarized in Fig. 1.
Studies search and review flowchart
Qualitative Synthesis
The studies were conducted in the 17 MENA countries from 1992 to 2020. Studies comprised of 2,262,797 participants with a mean age of 45.72 ± 8.84 years. Appendix Table 4 shows the general characteristics and the estimated prevalence of pre-HTN and HTN and also awareness, treatment, and control rates of HTN in the included studies. The most included studies were conducted in Iran (107 studies), and the least were conducted in Qatar and Syria (one study). Totally 140 reported prevalence used 140/90 mmHg, 21 used 130/90 mmHg, and 17 used 160/90 mm Hg as the cutoff for the diagnosis of HTN. The rate of awareness, treatment, and control of HTN varied among countries. Jordan had the highest awareness rate with 62% (59, 66), and Lebanon had the highest treatment and control rate of HTN with 45% (31, 58) and 27% (16, 38), respectively. Overall rate of HTN awareness ranged from 12 (10–14; Syria) to 69% (63–75; Jordan). Overall rate of HTN treatment ranged from 8 (7–11; Syria) to 78% (75–81; Iran).
Quantitative Synthesis
Sever heterogeneity was noted among the included studies in all subgroups of pre-HTN and HTN prevalence and awareness, treatment, and control rate of HTN (I-squared = 99.95, 99.90, 99.34, 99.46, 99.58%, respectively, P < 0.001). Therefore, meta-analysis was performed using random effect model.
Prevalence of Pre-HTN and HTN
The pooled prevalence of pre-HTN and HTN according to gender, population, level of income, HTN definition, and level of studies are illustrated in Table 1. The pooled prevalence of pre-HTN was 33% (95% CI 28, 39). Pre-HTN was more prevalent in males (40%) than females (30%). Pre-HTN was more prevalent in the high-income countries and at national level.
The pooled prevalence of HTN was 26% (25, 27). The highest and lowest pooled prevalence of HTN was in low-middle-income (29%) and high-income countries (24%). The highest prevalence of HTN was reported in studies used the cutoff of 130/90 mm Hg as the definition of HTN. Over the past three decades, the prevalence of hypertension increased significantly in the region (7% increment).
The highest pooled prevalence of HTN in the region was observed in United Arab Emirates with 36% (28–43). Over the three past decades, prevalence of HTN in Iran increased from 22 (1990–2000) to 26% (2010–2020).
HTN Awareness, Treatment, and Control Rates
The pooled awareness, treatment, and control rates of HTN according to gender, population, level of income, HTN definition, and level of studies are illustrated in Table 2. By random effect model, the pooled awareness, treatment, and control rates were 50% (48, 53), 41% (38, 44), and 19% (17, 21), receptively. The pooled awareness, treatment, and control rates were lower significantly in men than women. While the highest awareness of HTN was in upper-middle-income countries with 52% (49, 55), high-income countries had highest rate of treatment and control of HTN with 43% (33, 53) and 25% (17, 33), respectively. The pooled awareness, treatment, and control rates of HTN in studies that used cutoff 160/90 mm Hg for definition were higher in comparison to other definitions. Based on study level, the highest awareness, treatment, and control rates of HTN were at subnational level.
The highest pooled awareness rate of HTN was observed in Jordan (61%), and in all other countries, the awareness rate was approximately 50%. The pooled treatment rates of HTN ranged 40–47% at country level in the region. The highest and lowest pooled control rates of HTN were observed in Lebanon and Turkey, respectively (Appendix Table 5).
Sensitivity Analysis
Sensitivity analysis according to definition of HTN for pooled prevalence of HTN, awareness, treatment, and control rates is presented in Fig. 2. As it shows in the forest plot (Fig. 3), the pooled prevalence of HTN, awareness, treatment, and control rates did not change significantly according to HTN cutoff point > 140/90 mmHg compare to all definitions. According to standard definition of HTN (> 140/90 mm Hg), over the past three decades, the prevalence of hypertension increased linearly in the region. Although over the past three decades, the pooled awareness and treatment rates of HTN did not change significantly, the pooled control rate improved significantly in the region (approximately 10% improvement in the two recent decades) (Fig. 2).
Forest plot of pooled prevalence, awareness, treatment, and control rate of hypertension according to definition of hypertension in the MENA region
Forest plot of pooled prevalence, awareness, treatment and control rates of hypertension according to definition of hypertension more than 140/90 mmHg by study period in the MENA region
Meta-regression
The results of meta-regression showed that heterogeneity among the included studies explained by level of income and level of study for pre-HTN, by mean age of study population, country, level of study for the prevalence of HTN, by mean age of study population and definition for awareness and treatment rate, and by mean age of study population, definition, and level of study for control rate (Appendix Table 6).
Discussion
In the present comprehensive systematic review and meta-analysis study on the prevalence of HTN and its management in 17 MENA countries between 1992 and 2020, the pooled prevalence of pre-HTN and HTN was estimated to be 33% and 26%, respectively. In this regard, the results of a large population-based cohort of Chinese, Malay, and Indian populations showed the HTN prevalence of 31.1% [186]. In a multinational cross-sectional study from six Latin American countries, HTN prevalence was reported as 44%, which is significantly higher than the prevalence rate in the MENA countries [187]. The global prevalence of pre-HTN and HTN in adults has been estimated at 36% and 31%, respectively, in the systematic analyses of population-based studies [188, 189], which is above the MENA countries. Healthcare infrastructure for HTN screening, access to health services, as well as social and economic status could account for this discrepancy.
Pre-HTN was more common in males and high-income countries, while HTN was more prevalent in low-middle-income countries. It seems that there is a relationship between the prevalence of pre-HTN and HTN and the socio-economic status (SES). Results of a meta-analysis confirmed an association between low SES and high blood pressure [190]. However, another opinion is that in developed countries, lower SES is associated with a higher prevalence of HTN. In contrast, in developing countries, higher SES is accompanied by higher HTN prevalence due to higher sodium and alcohol intakes and a higher prevalence of obesity [191].
Moreover, the prevalence of HTN in male and female was not statistically different. This finding is inconsistent with previous studies [153, 192]. To the extent of that in a multi-ethnic cross-sectional survey in the Asian population, age and education have been consistently associated with HTN across all ethnic groups [186].
This systematic review showed that the prevalence of pre-HTN and HTN varied widely in different countries. Early detection of pre-HTN is essential to prevent the development of HTN through cost-effective dietary programs, lifestyle modifications, and regular blood pressure measurements. Reducing tobacco, alcohol and sodium intake, as well as increasing physical activity and consumption of fruits and vegetables are worth considering as a primary prevention method for HTN [193].
Our findings showed that the prevalence HTN increased significantly in the region (7% increment). In contrast, an analysis of nationally representative surveys of high-income countries reported no noticeable change in HTN prevalence from 1976 to 2017, with some age and sex groups showing a decline or increment in prevalence rate [194]. It seems that strategies such as developing evidence-based guidelines for healthcare providers and implementing regular blood pressure measurements have been useful in controlling HTN [194].
The overall awareness, treatment, and control rates of HTN in the MENA countries were estimated at 50%, 41%, and 19%, respectively. About half of the patients with HTN in the MENA were aware of their disease; however, only one-fifth of the patients have managed to control their blood pressure. While in Africa, the treatment and control rate was reported at 59.9% and 24.6%, respectively [195], and the treatment rate reached 82% in Canada [196]. In a multinational population-based study, 46.5% of participants with HTN were aware of their disease, with a controlled rate of 32.5%, which is higher than the MENA [168]. The observed differences in HTN awareness and treatment among countries may be attributable to variations in lifestyle and cultural factors [197, 198].
During the past two decades, the pooled control rate of HTN improved significantly in the region (approximately 10% improvement in the two recent decades). Analysis of 12 high-income countries’ national surveys revealed improvement in HTN awareness, treatment, and control since the 1980s and 1990s. However, the control rates have been plateaued during the past decade in these countries [194].
The low control rate of HTN and the gap between detection and treatment of HTN could be attributed to the high cost of anti-hypertensive agents, poor access to physicians and healthcare facilities, and plow perceptions of the benefit of adherence to medications. Therefore, based on the results of previous experiences, the use of polypill as a combination therapy and initial treatment with non-physician healthcare workers could be reasonable strategies for the prevention and control of HTN in low- and middle-income countries [199].
Regarding the awareness, treatment, and control of HTN, the women and high-income countries had a higher rate. In agreement with similar studies conducted on the Asian population [186], men were more likely to be left undetected and untreated than women. Moreover, in high SES countries, the awareness and control of HTN are generally better because of high access to healthcare services and higher literacy levels [168, 186, 200, 201].
The rate of awareness, treatment, and control of HTN could be translated to the overall healthcare system performance at the national level. In the present study, although the prevalence of HTN in Iran has increased over the past two decades, the level of awareness, treatment, and control of HTN has slightly improved. In a meta-analysis that was conducted on 417,392 Iranian adults, the prevalence of HTN was estimated at 20%, which is comparable to the findings of this review [192].
There has been no other comparative study of long-term trends in HTN prevalence, awareness, treatment, and control in the MENA. The meta-analysis approach with comprehensively investigating databases in the longest possible time to determine the prevalence of HTN was the advantage of this study. One of the limitations of the present study is that some studies did not include prevalence information by gender and other categories. Another limitation was the unequal number of studies in different countries. Moreover, methodological differences between included studies and over time caused high heterogeneity among studies should not be overlooked completely, although we performed subgroup and metaregression analysis. Also, the quality score of some of the included individual studies was low, which could have affected our results.
Conclusion
The result of this study showed that HTN is a significant public health problem in the MENA countries. About half the patients with HTN are unaware of their medical condition. Although the diagnosed patients receive relatively good treatment, the condition is controlled only in a small number of patients. The present study provides a great tool for public health authorities in the MENA to understand the status of screening, prevention, and treatment in their countries. Implementing clinical guidelines with simplified recommendations, alongside regular screening, and physician consultation could provide a major benefit in managing HTN.
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Acknowledgements
We acknowledge Imam Ali and Rajaei Clinical Development Research Center, Alborz University of Medical Sciences for their administrative assistances.
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This study was funded by Alborz University of Medical Sciences.
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MQ, NMK, and SD designed the study. NMK, SD, JH, and AMG searched data. NMK, ES, and BHZ screened and extracted data. ES, AS, NMK, and MQ analyzed data and prepared results. NMK, HSE, and MQ wrote the first draft of the paper. All other authors provided input into interpretation.
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Mohammadian Khonsari, N., Shahrestanaki, E., Ejtahed, HS. et al. Long-term Trends in Hypertension Prevalence, Awareness, Treatment, and Control Rate in the Middle East and North Africa: a Systematic Review and Meta-analysis of 178 Population-Based Studies. Curr Hypertens Rep 23, 41 (2021). https://doi.org/10.1007/s11906-021-01159-0
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DOI: https://doi.org/10.1007/s11906-021-01159-0