Low utilization of health care services following screening for hypertension in Dar es Salaam (Tanzania): a prospective population-based study.

BACKGROUND: Drug therapy in high-risk individuals has been advocated as an important strategy to reduce cardiovascular disease in low income countries. We determined, in a low-income urban population, the proportion of persons who utilized health services after having been diagnosed as hypertensive and advised to seek health care for further hypertension management. METHODS: A population-based survey of 9254 persons aged 25-64 years was conducted in Dar es Salaam. Among the 540 persons with high blood pressure (defined here as BP >or= 160/95 mmHg) at the initial contact, 253 (47%) had high BP on a 4th visit 45 days later. Among them, 208 were untreated and advised to attend health care in a health center of their choice for further management of their hypertension. One year later, 161 were seen again and asked about their use of health services during the interval. RESULTS: Among the 161 hypertensive persons advised to seek health care, 34% reported to have attended a formal health care provider during the 12-month interval (63% public facility; 30% private; 7% both). Antihypertensive treatment was taken by 34% at some point of time (suggesting poor uptake of health services) and 3% at the end of the 12-month follow-up (suggesting poor long-term compliance). Health services utilization tended to be associated with older age, previous history of high BP, being overweight and non-smoking, but not with education or wealth. Lack of symptoms and cost of treatment were the reasons reported most often for not attending health care. CONCLUSION: Low utilization of health services after hypertension screening suggests a small impact of a patient-centered screen-and-treat strategy in this low-income population. These findings emphasize the need to identify and address barriers to health care utilization for non-communicable diseases in this setting and, indirectly, the importance of public health measures for primary prevention of these diseases.

A longitudinal study on different models of postabortion care in Tanzania.

OBJECTIVE: To identify women having unsafe abortions and elucidate whether an acceptable follow-up rate among these women can be retrieved. STUDY POPULATION: One thousand three hundred and fifty-seven women attended Temeke Municipal Hospital, Dar es Salaam with an abortion-related diagnosis. METHODS: Women having unsafe abortions were identified by an empathetic dialogue, offered a contraceptive service and asked to return for follow-up. Three different ways of achieving follow-up information were tested. In phase 1, a combination of hospital-based and home-based interviews was utilized, in phase 2, an additional 1-month control visit was added to the protocol, and in phase 3, the contraceptive counseling and service was provided by technically well-skilled counselors. RESULTS: Seven hundred and eighty-eight women were identified as having had unsafe abortions and 491 women as spontaneous abortions. Women having unsafe abortions were younger, more often single and of higher parity than women having spontaneous abortions. The follow-up rate achieved varied from 47%-72%, being lowest in phase 1 and highest in phase 3. The two most common reasons for loss to follow-up were the interviewer's inability to locate the respondent's house either because of an unspecific or a remote address (58%) and migration (29%). CONCLUSION: If hospital-based and confidential home-based interviews are used combined and if the women having unsafe abortions are counseled by technically well-skilled counselors, it is possible to achieve a reasonable follow-up rate among women having unsafe abortions.

Discordant prevalence of hypertension using two different automated blood pressure measurement devices: a population-based study in Dar es Salaam (Tanzania).

OBJECTIVE: The estimation of blood pressure is dependent on the accuracy of the measurement devices. We compared blood pressure readings obtained with an automated oscillometric arm-cuff device and with an automated oscillometric wrist-cuff device and then assessed the prevalence of defined blood pressure categories. METHODS: Within a population-based survey in Dar es Salaam (Tanzania), we selected all participants with a blood pressure >/= 160/95 mmHg (n=653) and a random sample of participants with blood pressure <160/95 mmHg (n=662), based on the first blood pressure reading. Blood pressure was reassessed 2 years later for 464 and 410 of the participants, respectively. In these 874 subjects, we compared the prevalence of blood pressure categories as estimated with each device. RESULTS: Overall, the wrist device gave higher blood pressure readings than the arm device (difference in systolic/diastolic blood pressure: 6.3 +/- 17.3/3.7 +/- 11.8 mmHg, P<0.001). However, the arm device tended to give lower readings than the wrist device for high blood pressure values. The prevalence of blood pressure categories differed substantially depending on which device was used, 29% and 14% for blood pressure <120/80 mmHg (arm device versus wrist device, respectively), 30% and 33% for blood pressure 120-139/80-89 mmHg, 17% and 26% for blood pressure 140-159/90-99 mmHg, 12% and 13% for blood pressure 160-179/100-109 mmHg and 13% and 14% for blood pressure >/= 180/110 mmHg. CONCLUSIONS: A large discrepancy in the estimated prevalence of blood pressure categories was observed using two different automatic measurement devices. This emphasizes that prevalence estimates based on automatic devices should be considered with caution.

Assessing the prevalence of hypertension in populations: are we doing it right?

BACKGROUND: Although it is well recognized that the diagnosis of hypertension should be based on blood pressure (BP) measurements taken on several occasions, notably to account for a transient elevation of BP on the first readings, the prevalence of hypertension in populations has often relied on measurements at a single visit. OBJECTIVE: To identify an efficient strategy for assessing reliably the prevalence of hypertension in the population with regards to the number of BP readings required. DESIGN: Population-based survey of BP and follow-up information. SETTING AND PARTICIPANTS: All residents aged 25-64 years in an area of Dar es Salaam (Tanzania). MAIN OUTCOME MEASURES: Three BP readings at four successive visits in all participants with high BP (n = 653) and in 662 participants without high BP, measured with an automated BP device.RESULTS BP decreased substantially from the first to third readings at each of the four visits. BP decreased substantially between the first two visits but only a little between the next visits. Consequently, the prevalence of high BP based on the third reading--or the average of the second and third readings--at the second visit was not largely different compared to estimates based on readings at the fourth visit. BP decreased similarly when the first three visits were separated by 3-day or 14-day intervals. CONCLUSIONS: Taking triplicate readings on two visits, possibly separated by just a few days, could be a minimal strategy for assessing adequately the mean BP and the prevalence of hypertension at the population level. A sound strategy is important for assessing reliably the burden of hypertension in populations.

Distribution of blood pressure, body mass index and smoking habits in the urban population of Dar es Salaam, Tanzania, and associations with socioeconomic status.

OBJECTIVE: To estimate the distribution of blood pressure (BP), body mass index (BMI), smoking habits and their associations with socioeconomic status (SES) in an urban population in early epidemiological transition. METHODS: Cross-sectional survey of the entire population aged 25-64 years in five branches of Dar es Salaam (Tanzania) through visits to all homes in the study area. Blood pressure was based on the mean of the second and third readings with an automated device. Socioeconomic status was estimated with indicators of education, occupation and wealth. RESULTS: In all 9254 people were examined. Age-adjusted prevalence (%) among men/ women aged 35-64 years was 27.1/30.2 for BP > or = 140/90 mmHg or antihypertensive medication, 13.1/17.7 for BP > or = 160/95 mmHg or antihypertensive medication, 28.0/27.4 for BMI of 25.0-29.9 kg/m(2), 6.9/17.4 for BMI > or = 30 kg/m(2), and 22.0/2.6 for smoking (> or = 1 cigarette per day). Prevalence of categories of drinking frequency and history of diabetes are also reported. After adjustment for covariates, SES was associated inversely with BP and smoking and directly with BMI. Body mass index was associated positively with BP (1.01 and 0.91 mmHg systolic BP per 1 kg/m(2) BMI in men and women, respectively) and inversely with smoking (-1.14 kg/m(2) in male smokers versus non-smokers). Hypertension treatment rates were low, particularly in people of low SES. CONCLUSIONS: High prevalence of several cardiovascular risk factors in the urban population of a low-income country stresses the need for early public health interventions and adaptation of the health care infrastructure to meet the emerging challenge of cardiovascular disease. The direct SES-BMI association may drive increasing BMI and BP while the population becomes more affluent.