Management of Hypertension and Diabetes in Health Centers in Sub Saharan Africa Countries

Presentation

J Community Med Health Care. 2023; 8(1): 1063.

Management of Hypertension and Diabetes in Health Centers in Sub Saharan Africa Countries

Sessa A1,4*; Cecchini G2,4; Chiappa L3,4; Putoto G4; Carraro D4

1Internal Medicine Unit, Isber Clinic, Varese, Italy

2Pediatrician, Varese, Italy

3Department of Cardiology, Desio Hospital, Monza-Brianza, Italy

4Doctors with Africa NGO – CUAMM ONLUS, Padua, Italy

*Corresponding author: Sessa Aurelio Internal Medicine Unit, Isber Clinic, Via Sonzini 8, I-21100 Varese, Italy. Tel: +39 (0)332242971; +39 3482619602 Email: [email protected]

Received: June 20, 2023 Accepted: July 25, 2023 Published: August 01, 2023

Abstract

Non-communicable diseases are increasing the incidence and prevalence in last ten years and only now national health systems are looking this phenomenon and they are searching to improve strategies to limit damages. Non-governmental organizations that work in these countries can contribute to improve strategies and tools against these chronic diseases.

Keywords: Non-communicable diseases; Hypertension; Diabetes mellitus; Health centers; Out-patients departments

Background

While communicable diseases such malaria, tuberculosis, human immunodeficiency virus syndrome, low respiratory tract infections, diarrheal diseases have been rated among the top ten global causes of death in Sub-Saharan Africa (SSA) [1], it is now apparent that non-communicable diseases such as hypertension and diabetes mellitus are undoubtedly adding to the multiple burdens the peoples in this region suffer [2] .

Usually health systems in these countries are designed around the need of acute and non-chronic care [3] as such there is a lack of coherent policies on chronic disease prevention, management and guidelines whereas non-communicable diseases are the second most common cause of deaths in SSA accounting for 2.6 million deaths equivalent to about 35% of all deaths [4].

The burden of non-communicable diseases is increasing rapidly in particular diabetes and hypertension [2]. The International Diabetes Federation reported that the prevalence of diabetes in SSA is anticipated to double between 2010 and 2030 and the number of adults with diabetes in Africa is predicted to rise to 55 million by 2045 (an increase of 134%) [5]. It is estimated that of approximately 650 million people in SSA, 10-20 million may have hypertension [6].

These estimates are based on scarce heterogenous studies and many countries in SSA still lack detailed up-to-date basic data on the prevalence of hypertension [7].

While on the one hand there have been rapid improvements in HIV care programs in SSA, on the other hand health services for non-communicable diseases in SSA remains poor. No investments in health services, laboratory capacity, health information systems, healthcare workers capacity have led to non-communicable diseases as a forgotten issue in public health.

Health service prevision for non-communicable diseases in SSA remains poor and the care is limited with only 5-20% of people with diabetes or hypertension thought to be in regular care [8].

One of the biggest inadequacies in the development agenda is the omission of non-communicable diseases from the United Nations Millenium Developed Goals. The ability of SSA countries to effectively respond to the hypertension and diabetes epidemic has been hindered by limited funding.

Hypertension

Hypertension is now recognized as one of the most important diseases contributing for about 40% of cardiocerebrovascular diseases in the continent [9,10].

An increasing burden of hypertension will thus result in severe consequences as only very few people get treatment and control is likely to be low [11].

Prevalence of hypertension in Africa is estimated 27% of the adult population [12] and the awareness, diagnosis, treatment and control remain low [13,14]. Major challenges for people living with hypertension relate to the asymptomatic nature of the condition leading to delayed diagnosis and treatment initiation. After diagnosis, hypertension requires lifelong lifestyle modifications, frequent medical check-ups, ongoing counselling and regular adaptation of treatment dosage or drug regimen [15]. Sub-Saharan health systems remain poorly adapted to provide comprehensive cardiovascular disease care, with insufficiency trained, equipped and supported workforce, limited availability of treatment options, and infrequent or non-existing monitoring of treatment outcomes, such as blood pressure control and end-organ function [16].

To overcome barriers a care model promoted is the task-shifting/sharing where there is a planned transfer of care duties from physicians to non-physicians such nurses or community health workers [17,18].

In a community based cross-sectional study conducted in Ethiopia 19.6% (95% CI: 13.7-25.5) people were hypertensive, higher in the urban population (23.7%) than in mixed rural and urban (14.7%) (19); in another study conducted in Gondar region (Ethiopia) 37% of people didn’t know their hypertension [20].

Self-awareness as well as the treatment and control of hypertension are very low and these factors have contributed to the increasing burden of stroke [21] and myocardial infarction [22] where patients were diagnosed with hypertension only after these complications occurred.

Diabetes Mellitus

In 2019, the International Diabetes Federation (IDF) Atlas estimated that about 24 million individuals in SSA have diabetes with a potential rise to about 55 million by 2045 [5].

In contrast to developed countries, where the majority of the people with diabetes are over 60 years, the SSA diabetic population is in the economically productive age group of 30 to 45 years old. The late diagnosis of diabetes in this region, coupled with inequalities in accessing care, leads to early presentations of diabetic complications [23].

Rising prevalence of diabetes in SSA countries is associated with a nutritional transition from a high-fiber traditional diet to an energy-dense western diet leading to an unhealthy weight gain, raised fasting blood glucose levels, raised blood pressure and hyperlipidemia, all of which increase the risk of cardiovascular disease [24]. Moreover increasing prevalence of diabetes has been associated with ageing and lifestyle changes which accompany urbanization such a decrease in physical activity and changes in dietary patterns [25].

Gestational diabetes is a real problem with a prevalence of 12.04% [95% CI (8.17-15.90)] in rural and mixed setting (urban and rural) in Ethiopia [26].

Metabolic and infective complications are so far the major reasons for the excess mortality associated with diabetes in SSA.

Type 2 Diabetes Mellitus (T2DM) is the most common form of diabetes (90–95%) in Africa [3], exhibiting an alarming prevalence among peoples.

Access to diabetic control is very poor. Beran and colleagues surveyed the availability of diagnostic testing tools in a sample of healthcare settings in three countries and found that in Mozambique urine glucose strips were available in just 18% of health centers surveyed, ketone testing strips in 8% and blood glucose meter and strips in 21%, whilst availability in Mali was 54%, 53% and 13% and in Zambia 61%, 54% and 49% [27].

If we consider type 1 diabetes the situation is much worse. Of 99 type 1 diabetics in the Tanzanian survey, only one person achieved good glucose control. None of them had the ability to monitor their glucose level at home, and hospital were unable to do it routinely [28]. The cost of diabetes monitoring equipment is high and usually there is an inability to afford monitoring equipment to test blood sugar levels [29].

Because of strained economic resources and a poor health care system, most of the patients are diagnosed only after they have overt symptoms and complications.

Microvascular complications are the most prevalent, but metabolic disorders and acute infections cause significant mortality. The high cost of treatment of type 2 diabetes and its comorbidities, the increasing prevalence of its risk factors, and the gaps in health care system necessitate that solutions be planned and implemented urgently.

Aggressive actions and positive responses from well-informed governments appear to be needed for the conducive interplay of all forces required to curb the threat of type 2 diabetes in SSA.

The availability of drugs is very limited and the majority, including insulin, are dispended by hospital pharmacies in the towns. Sometimes patients buy their medications directly from local pharmacies without attending clinics to obtain an appropriate prescription to avoid healthcare and transportation costs [30]. Moreover traditional “doctors” will, of course, provide patients with a range of alternative remedies.

A systematic review evaluating the efficacy of herbal medicine for glucose control showed that although they were safe to use, there was inconclusive evidence to prove their efficacy [31].

Another challenge associated with the management of diabetes in SSA countries is the relationship between diabetes and HIV-infected persons. A multicenter cohort study concluded that the incidence rate for diabetes among HIV-infected men in highly active antiretroviral therapy was 4.7 cases per 100 person-years compared with 1.4 cases per 100 person-years among HIV-seronegative men [32].

While most studies have focused on diabetes as a risk factor for Tuberculosis (TB), emerging evidence suggests that the relationship is bidirectional, with a higher prevalence of diabetes found among TB-infected people [33]. Therefore not only TB increases the risk of diabetes but like many other infections, it also complicates diabetes management. For example TB treatment including isoniazid have hyperglycemic effects and interfere with insulin release, hence impairing glycemic control among diabetics who are in this medications [34].

Time to Action

The chief problem in SSA countries is how to make the management of hypertension and diabetes (and other lifelong diseases) more readily available [35]. One approach can be to take the necessary facilities to the rural areas, nearer to patient’s home establishing a system of delivery of chronic diseases treatment at the rural Health Centers (HC) and in Out-Patient Departments (OPD) in country hospitals. This must involve nurses taking records, equipment and medicines on a regular basis to the health centers and arranging for patients to attend these peripheral clinics. The scheme should substantially reduce the travelling distance and time for many people with hypertension and diabetes and encourage them to attend more regularly. For this system to succeed in the long term, nurses will have to be trained in hypertension and diabetes management independently from physicians.

We must also remember that in SSA countries two health systems coexist, the western biomedical healthcare system and the traditional health care model [36]. Approximately 50% of diabetic patients visiting hospitals in urban cities like Lagos and Benin have used some forms of traditional medicine during the course of their disease management [37] and traditional healers use biomedical knowledge and terminologies to maximize the effectiveness of their traditional treatment.

The key challenges to chronic diseases as hypertension and diabetes care should be faced by some strategies as summarized in the Table 1 [38,39].