Final Full P Paper Theme 9: Health, Mortality and Longevity - - PDF document

Final Full P Paper Theme 9: Health, Mortality and Longevity

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

Prevalence ce a and d dete terminants ts o

• f h

hyperte tension in in Namibia - a n nati tional l level cr cross-secti tional s stu tudy Craig, LS1,2, Gage, AJ1,3

1 Tulane University School of Public Health and Tropical Medicine; 2 lcraig1@tulane.edu; 3 agage@tulane.edu

Abstr tract ct Ba Backgr ground: : Globally, an estimated 28 million people die from non-communicable diseases (NCDs) such as cardiovascular disease, cancer, chronic respiratory disease and diabetes every year. By 2030, it is projected that NCDs will become the leading cause of death in sub-Saharan Africa. In Namibia, the emergent NCD epidemic is largely driven by hypertension, with evidence indicating remarkably high prevalence among urban residents. This study estimates the prevalence and determinants of hypertension among Namibian adults. Meth thods: : The analysis is based on 2,537 women and 2,163 men aged 35-64 years from the nationally- representative 2013 Namibia Demographic and Health Survey. Odds radios and 95% confidence intervals were estimated using logistic regression. Results ts: : The prevalence of hypertension was 32.8% (men: 30.2%; women: 34.9%; p=0.0059). Older age, urban residence, and being obese were positively associated with the odds of hypertension (p<0.05). For women, the odds of hypertension were significantly increased for those who were diabetic and reduced for those with higher levels of education. Co Concl clusion: : The prevalence of hypertension is high and associated with metabolic and socio-demographic factors among Namibian adults. Future research examining disease comorbidity and behavioral risk factors could better inform on the disease burden and help target resources to optimize prevention and control.

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 1-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

Ba Backgr ground In recent years, non-communicable diseases (NCDs) such as cardiovascular diseases, diabetes, cancer and chronic respiratory diseases have emerged as a major threat to global economies and health systems, as well as individual health and well-being.1–4 The current death and disability burden from NCDs disproportionately affects low- and middle-income countries (LMICs) and is projected to increase substantially over the next two decades with a near tripling of disease mortality in Latin America and the Caribbean, the Middle East, and sub-Saharan Africa (SSA).2–7 This threat is especially concerning for resource-constrained regions, including those countries in SSA, which must now contend with a double burden in disease and mortality from communicable diseases and NCDs.4 In SSA, the NCD epidemic is largely driven by hypertension,2,8,9 with evidence from a 2017 pooled analysis

• f worldwide trends in blood pressure showing that the highest levels of blood pressure worldwide have

shifted from high-income countries to low income countries in South Asia and SSA.10 Data from these pooled analyses suggest that both mean systolic and diastolic blood pressures have increased among men and women in SSA – although estimated trends in this region are noted to carry larger uncertainty due to use of small sample sizes or non-national samples.10 In addition, a gender differential in the burden of disease has been identified, with a female excess in age-standardized mean systolic blood pressure and hypertension prevalence in SSA.10 One 2012 cross-sectional study of hypertension across four rural and urban communities in SSA reported age-standardized prevalence estimates of 19.3% (95%CI:17.3–21.3), 21.4% (19.8–23.0), 23.7% (21.3– 26.2) and 38.0% (35.9–40.1) in rural Nigeria, rural Kenya, urban Tanzania and urban Namibia, respectively.6 These estimates support theories of the magnitude of the hypertension burden in SSA and provide shocking evidence of a remarkably high burden among urban Namibian residents (crude: 32%; age-standardized: 38%) which is similar to that of non-Hispanic black adults in the USA (38.6%).9,11 Despite evidence of high disease prevalence in urban Namibia, few studies have addressed the national burden of NCDs while, to the best of my knowledge, no research has yet been directed towards the social aspects of these diseases. Consistent global information has been described as imperative to inform on the national burden of NCDs, improve understanding of blood pressure levels and trends, identify vulnerable populations, and guide the design and implementation of needed interventions.10 Accordingly, among the nine global NCD targets, endorsed by the World Health Assembly in 2013, is to lower the prevalence of raised blood pressure, by 25% by 2025.3,10 Nationally representative data from the 2013 Namibia Demographic and Health Survey (NDHS) are now available, and include physical and biochemical measurements of common NCD biomarkers (e.g. blood pressure, fasting blood glucose, body mass index) among a subsample of women and men, 35-64 years of age. This study aims to estimate the prevalence of hypertension among Namibian adults 35-64 years of age, and the associations with select socio-demographic, metabolic and behavioural determinants, in order to

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 2-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

provide baseline data on the hypertension burden in country and inform the targeting of interventions to improve overall management and prevention of these diseases. Meth thods This study used data from the 2013 NDHS, the fourth comprehensive, national-level population and health survey conducted in Namibia as part of the global DHS programme.12 Namibia, one of the least densely populated countries in the world, is a middle-income country in SSA with a population just over 2 million.12 The country is divided into 3 main regions – north, central and south – and, despite rapid urbanization, remains largely rural.12 The 2013 NDHS used a nationally-representative two-stage stratified cluster design and represents the first national survey in Namibia to include biomarker measurements of blood pressure and fasting blood glucose.12 Biomarker measurements were performed in half of the survey households, using guidelines that were largely consistent with the World Health Organization (WHO) “STEPwise approach to the surveillance of non-communicable diseases” (STEPS) methodology.12,13 Details of the survey design, sampling procedures and data collection methods are provided in the country report.12 Following the exclusion of pregnant women, the study sample included 2,537 eligible women and 2,163 eligible men, 35-64 years of age. Variables The primary outcome in this study was hypertension prevalence, which was defined, according to WHO criteria as systolic blood pressure (SBP) of 140 mmHg or greater, diastolic blood pressure (DBP) of 90 mmHg or greater, and/or currently taking antihypertensive medications.2 Additional analyses also explored variation in secondary outcomes of hypertension awareness, treatment and control by socio- demographic characteristics. Awareness of hypertension was defined according to self-report of previous diagnosis of high blood pressure (hypertension) by a doctor or other health worker. Treatment of hypertension was defined as self-reported use of prescribed medication to control blood pressure. Control of hypertension was defined as pharmacologic treatment of hypertension associated with an average SBP <140 mm Hg and an average DBP <90 mm Hg. Independent variables were coded categorically and included the sex of the respondent (male or female), age-group (35–39, 40–44, 45–49, 50–54, 55–59 or 60–64 years), highest level of education (no education

• r preschool only, primary schooling, or secondary school or higher), place of residence (urban or rural),

marital status (never married, currently married, or formerly/ever married), employment status (not currently working, or currently working), and quintiles of wealth. The NDHS 2013 did not explicitly allow for self-report of ethnicity so language of the respondent was used as a proxy (Oshiwambo, Damara/Nama, Afrikaans, Herero or other). Smoking was classified into three categories (do not currently smoke, smoke cigarettes, or smoke pipes, cigars, etc.). Body mass index (BMI) was classified based on WHO categories of underweight (less than 18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 3-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

(25.0–29.9 kg/m2) and obese (≥30 kg/m2).2 Diabetes was defined as having a fasting plasma glucose value ≥ 7.0 mmol/L (126 mg/dl) or being on medication for raised blood glucose.2 Statistical Analysis Descriptive statistics and frequency distributions were used to describe participant characteristics. Age- standardized prevalence estimates of hypertension were calculated using the WHO World standard population14 by taking weighted means of age-sex-specific estimates, with use of age weights from the standard population. In separate analyses by sex, odds radios (ORs) and 95% confidence intervals (CIs) for determinants of hypertension were estimated using logistic regression analyses. All data were analyzed using Stata version 12 (StataCorp., College Station, TX, USA) and statistical significance accepted when p<0.05. Results ts Subject characteristics by sex are summarized in Table 1. Women were slightly older than men, with mean ages of 46.81 vs. 45.99 years, respectively (p=0.0017). Compared to men, women in the sample were less likely to live in urban areas (p=0.0000), be currently working (p=0.0000), be in the middle to highest quintiles of wealth (p = 0.000) or smoke (p=0.0000). Women were, however, more likely to be

• verweight (p=0.0000) and obese (p=0.0000).

The prevalence of hypertension was higher in women than men (crude: 32.82%; men: 30.21%; women: 34.94%; p=0.0059), with mean systolic and diastolic blood pressures of 128.65mmHg (SD 21.04) and 82.97 (SD 13.23), respectively. Mean systolic blood pressure was 2.85 mmHG lower for females than males (p=0.0001) while mean diastolic blood pressure was 1.23mmHg higher for females than males (p=0.0056). Table 1 1 Characteristics of sample of 35-64 year old adults in Namibia, by gender

Men (n=2,163) Women (n=2,537) Total (N=4,700) Age-groups (%) 35-39 years 581 (27.61%) 645 (26.54%) 1226 (27.02%) 40-44 years 515 (24.08%) 493 (19.80%) 1008 (21.72%) 45-49 years 377 (17.44%) 443 (16.80%) 820 (17.09%) 50-54 years 290 (13.12%) 432 (17.20%) 722 (15.37%) 55-59 years 205 (9.46%) 281 (10.26%) 486 (9.90%) 60-64 years 195 (8.28%) 243 (9.40%) 438 (8.90%) Education level (%)

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 4-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries No education/Preschool 366 (15.02%) 366 (13.38%) 732 (14.11%) Primary 608 (27.96%) 816 (31.56%) 1424 (29.95%) Secondary or higher 1155 (57.02%) 1334 (55.06%) 2489 (55.94%) Ethnicity (%) Oshiwambo 846 (48.47%) 1024 (50.30%) 1870 (49.48%) Damara/Nama 329 (10.42%) 392 (10.48%) 721 (10.45%) Afrikaans 325 (11.50%) 352 (10.79%) 677 (11.11%) Herero 239 (9.28%) 260 (7.84%) 499 (8.49%) Other 422 (20.33%) 506 (20.59%) 928 (20.47%) Place of residence (%) Urban 1172 (58.78%) 1225 (50.14%) 2397 (54.01%) Rural 991 (41.22%) 1312 (49.86%) 2303 (45.99%) Marital status (%) Never married 637 (30.02%) 756 (31.00%) 1393 (30.56%) Currently married 1410 (65.53%) 1348 (51.82%) 2758 (57.96%) Formerly/ever married 97 (4.45%) 412 (17.18%) 509 (11.48%) Employment status (%) Not currently working 594 (37.60%) 1285 (60.69%) 1879 (50.94%) Currently working 1014 (62.40%) 794 (39.31%) 1808 (49.06%) Wealth quintile, (%) Lowest 275 (13.30%) 433 (17.92%) 708 (15.85%) Second 355 (15.40%) 463 (18.09%) 818 (16.88%) Middle 434 (19.17%) 459 (17.55%) 893 (18.28%) Fourth 538 (24.24%) 588 (21.54%) 1126 (22.75%) Highest 561 (27.89%) 594 (24.90%) 1155 (26.24%) Smokers (%) Do not currently smoke 1207 (74.06%) 1997 (89.73%) 3204 (83.26%) Smoke cigarettes 402 (20.02%) 175 (5.42%) 577 (11.45%) Smoke pipes, cigars, etc. 111 (5.92%) 117 (4.85%) 228 (5.29%) Body mass index, kg/m2 (%) Underweight 253 (16.57%) 210 (9.83%) 463 (12.56%) Normal weight range 911 (55.62%) 864 (41.50%) 1775 (47.23%) Overweight 290 (17.72%) 542 (23.97%) 832 (21.44%) Obese 175 (10.09%) 598 (24.70%) 773 (18.77%)

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 5-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries Fasting blood sugar levels, mmol-1 (%) Normal 1200 (88.24%) 1650 (87.93%) 2850(88.05%) Prediabetes 86 (6.28%) 138 (7.22%) 224 (6.84%) Diabetes 78 (5.48%) 99 (4.86%) 177 (5.11%) Hypertensiona (%) 667 (30.21%) 917 (34.94%) 1584 (32.82%)

a Hypertension defined as systolic blood pressure of 140 mmHg or greater, or diastolic blood pressure of 90 mmHg or greater, or currently taking

antihypertensive medications.

The prevalence of hypertension increased consistently with age for both genders until 55-59 years (Table 2). Adjusted to the WHO world population, the prevalence of hypertension for all ages was 32.70% (95%CI 30.05-35.35) for men and 36.38% (95%CI 34.10-38.66) for women. The age- and sex-specific prevalence of hypertension is illustrated in Figure 1. Table 2 Prevalence of hypertension among 35-64 year old Namibian adults, by age-groupⱡ

All Men en Wom

• men

Age-grou

• up

% 95% 95% CI CI % 95% 95% CI CI % 95% 95% CI CI 35-39 yrs 19.69 16.88 - 22.51 19.56 15.48 - 23.65 19.81 15.94 -23.67 40-44 yrs 28.91 25.55 - 32.26 25.35 21.08 - 29.62 32.42 27.89 - 36.96 45-49 yrs 34.70 31.00 - 38.40 28.64 23.24 - 34.03 39.81 34.75 - 44.88 50-54 yrs 39.37 35.10 - 43.65 34.93 28.33 - 41.53 42.13 36.92 - 47.34 55-59 yrs 50.23 44.87 - 55.59 50.32 42.50 - 58.13 50.16 43.28 - 57.04 60-64 yrs 47.93 42.58 - 53.27 52.70 45.01 - 60.40 44.51 37.23 - 51.78 Total 32.82 31.02 - 34.62 30.21 27.62 - 32.80 34.94 32.62 - 37.27 Total adj ⱡ 34.69 32.89 - 36.49 32.70 30.05 - 35.35 36.38 34.10 - 38.66

ⱡAge-standardized using the WHO standard population via direct standardization methods.

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 6-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

Overall, 47.18% of the population was aware that they had hypertension. Women tended to be more aware of their hypertension than men (Figure 2a). Older age-groups were more aware of their hypertension and more likely to be on treatment (Figure 2b). No significant differences were observed for control rates across sex or age-groups. In fully adjusted analyses (Table 2), age was significantly, positively associated with hypertension in both men and women (p <0.001). Similarly, several socio-demographic and metabolic factors were significantly

20 29 35 39 50 48 20 25 29 35 50 53 20 32 40 42 50 45 10 20 30 40 50 60 70 80 90 100 35-39 40-44 45-49 50-54 55-59 60-64 Prev eval alenc nce e of Hype pertens nsion

• n (%)

Age ge-grou

• ups

s (year ears)

Age- an and se sex-specific ic pr prevale lence of

• f Hy

Hypertensio ion

All Men Women 20 40 60 80 100 Awareness Treatment Control (%)

Fig 2a. Awareness ss, Treatm tment & & Con

• ntrol
• f
• f Hyp

ypertension by by sex

Total Men Women p = 0.0000 p = 0.6456 p = 0.1354 20 40 60 80 100 Awareness Treatment Control (%) %)

Fig 2b.

• b. Awareness, Treatment &

& Con

• ntrol of
• f

Hyp ypertension by by age-group

35-39 40-44 45-49 50-54 55-59 60-64 p = 0.0000 p = 0.0206 p = 0.3972

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 7-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

associated with hypertension. Both men and women had significantly increased odds of hypertension if they lived in an urban region or were classified as obese. For women, the odds of hypertension were almost doubled for those of Herero ethnicity and those who were diabetic (i.e. had a fasting blood glucose level greater than 7.0 mmol/L) while higher education levels nearly halved the likelihood of

• hypertension. Being underweight was associated with a 50% less likelihood of hypertension in both men

and women. Additionally, men who were overweight had 2.3 times the odds of hypertension as men of normal weight (p <0.001). Table 2 2 Hypertension prevalence, among 35-64 year old Namibian adults, by sex and socio-demographic determinants

Mal ales es Fem Femal ales OR OR 95% 95% CI CI p-val alue OR OR 95% 95% CI CI p-val alue Age-group (years) 35-39 yrs 1.00 (ref.) 40-44 yrs 1.59 1.05 - 2.40 0. 0.029 29 1.78 1.26 - 2.52 0. 0.001 01 45-49 yrs 1.63 1.07 - 2.50 0. 0.023 23 2.45 1.66 - 3.60 0. 0.000 00 50-54 yrs 2.91 1.81 - 4.68 0. 0.000 00 2.58 1.78 - 3.76 0. 0.000 00 55-59 yrs 4.54 2.73 - 7.55 0. 0.000 00 4.30 2.67 - 6.92 0. 0.000 00 60-64 yrs 4.34 2.44 - 7.70 0. 0.000 00 3.53 2.16 - 5.78 0. 0.000 00 Education level (%) No education/ Preschool 1.00 (ref.) 1.00 (ref.) Primary 0.92 .60 - 1.41 0.691 0.66 .46 - .96 0. 0.032 32 Secondary or higher 0.85 .53 - 1.36 0.498 0.64 .43 - .96 0. 0.033 33 Ethnicity (%) Oshiwambo 1.00 (ref.) 1.00 (ref.) Damara/Nama 0.79 .50 - 1.24 0.303 0.89 .62 - 1.27 0.511 Afrikaans 0.65 .39 - 1.07 0.088 0.89 .58 - 1.39 0.618 Herero 1.05 .65 - 1.69 0.853 1.73 1.09 - 2.74 0. 0.021 21 Other 0.71 .46 - 1.11 0.134 0.96 .70 - 1.31 0.785 Place of residence (%) Rural 1.00 (ref.) 1.00 (ref.) Urban 1.71 1.19 – 2.45 0. 0.004 04 1.74 1.25 - 2.43 0. 0.001 01 Marital status (%) Never married 1.00 (ref.) 1.00 (ref.) Currently married 0.99 .72 - 1.37 0.952 1.09 .81 - 1.46 0.561

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 8-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries Formerly/ever married 0.71 .35 - 1.43 0.340 1.25 .86 - 1.81 0.250 Employment status (%) Not currently working 1.00 (ref.) 1.00 (ref.) Currently working 0.80 .58 - 1.11 0.181 1.25 .93 - 1.66 0.135 Wealth quintile, (%) Lowest 1.00 (ref.) 1.00 (ref.) Second 1.38 .84 - 2.27 0.210 1.25 .86 - 1.81 0.237 Middle 1.09 .66 - 1.83 0.729 1.24 .83 - 1.86 0.289 Fourth 1.07 .59 - 1.93 0.836 1.19 .76 - 1.86 0.449 Highest 0.87 .44 - 1.73 0.697 0.83 .45 - 1.53 0.556 Smokers (%) Do not currently smoke 1.00 (ref.) 1.00 (ref.) Smoke cigarettes 0.85 .59 - 1.23 0.396 1.48 .92 - 2.39 0.108 Smoke pipes, cigars, etc. 0.73 .40 - 1.35 0.314 1.15 .68 - 1.93 0.603 Body mass index, kg/m2 (%) Normal weight 1.00 (ref.) 1.00 (ref.) Underweight 0.49 .32 - .74 0. 0.001 01 0.52 .34 - .80 0. 0.003 03 Overweight 2.31 1.55 - 3.44 0. 0.000 00 1.32 .99 - 1.76 0.060 Obese 3.94 2.19 - 7.12 0. 0.000 00 2.49 1.81 - 3.42 0. 0.000 00 Fasting blood sugar levels, mmol-1 (%) Normal 1.00 (ref.) 1.00 (ref.) Prediabetes 1.25 .71 - 2.19 0.431 1.16 .74 - 1.83 0.517 Diabetes 0.77 .46 - 1.29 0.317 1.86 1.12 - 3.09 0. 0.016 16

Discussion Data from this study indicate that the prevalence of hypertension among Namibian adults, adjusted to the WHO world population, is approximately 35%, with significant differences between men and women. In fully adjusted analyses, men and women had significantly increased odds of hypertension if they were

• f older age-groups, lived in an urban region or were classified as obese. For women, the odds of

hypertension were also increased for those of Herero ethnicity and those classified as diabetic (i.e. had a fasting blood glucose level greater than 7.0 mmol/L), while higher education levels were associated with lower odds of hypertension. For men, being overweight was associated with greater likelihood of hypertension.

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 9-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

The results of this study are consistent with those in the literature reporting high prevalence of hypertension in certain regions of Namibia and relatively lower prevalence of diabetes.6,15–18 Furthermore, this study similarly reports low levels of awareness of hypertension among Namibian adults with significant difference across sex and age-groups. This finding may be indicative of education as an important area for intervention in national efforts to address the prevention and control of NCDs, given lower rates of hypertension among more educated women as well as evidence (from a previous study among formal sector employees across 13 industries in Namibia17) which demonstrated overall low knowledge and self-perceived risk of NCDs. There are, however, several study limitations to be considered. First of all, in comparison to other published studies which were conducted in subnational samples or specific population subgroups, a major strength of this study is in the use of the 2013 NDHS, which represents the first national survey in Namibia to include biomarker measurements of blood pressure and fasting blood glucose.12 However, the sample of respondents from whom objective assessments were measured was limited to those 35-64 years of age, narrowing the representativeness of estimates and precluding exploration of the burden and distribution of disease across younger and older age-groups. Besides young and/or ageing populations, other areas of interest in the investigation of the burden of hypertension include social class inequalities and lifestyle factors such as alcohol consumption, physical inactivity and fruit and vegetable

• consumption. This is because the risk of developing hypertension, like so many other NCDs, is strongly

determined by social factors – including overweight/obesity, smoking, diabetes, dietary patterns, physical inactivity, and alcohol use – which fall increasingly on poorer people within all countries, often at younger ages, and are widely distributed in the population, with all individuals at risk but differing in the extent of their risk.2,4,5,7,19,20 Unfortunately, such social factors, including knowledge of and screening for breast and cervical cancer, were only elicited in a sub-sample of respondents 15-49 years of age and thus not applicable to full population studied here (data not shown but available from author upon request). Overall, this study supports evidence and predictions of a high national prevalence of hypertension as well as the need for effective management and prevention strategies to prevent disease progression and

• complications. In response to a generally increasing morbidity and mortality burden from NCDs, the

Ministry of Health and Social Services in Namibia has been strengthening its national systems response, developing policies, passing legislation and launching several initiatives to raise awareness, promote healthy behaviors and support increased prevention throughout neighborhoods, schools and communities.15,21 In targeting prevention and management strategies to populations at greater risk, comorbid hypertension and diabetes may prove an important area for investigation and intervention given similar underlying pathophysiological disease mechanisms in addition to evidence of significant differences in prevalence of comorbid hypertension and diabetes by sex (males: 6.0%, females: 6.9%; p=0.0000). Finally, since in many African contexts, NCDs have not simply displaced communicable diseases as the primary cause of morbidity and mortality, future research should also explore the double burden on disease – or the coexistence of infectious communicable diseases and chronic NCDs – as this occurrence has significant implications for health systems and health outcomes and can signify the need for new

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 10-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

policies, investments in health infrastructure and integrative services.4 Future work should also consider the significant and concurrent use of both traditional remedies and prescription medication among men and women as this may have significant implications for intervention design, patient education strategies and adverse drug interactions and outcomes. Co Conclusion The prevalence of hypertension among Namibian adults is high and associated with metabolic- and socio- demographic factors. Future research examining trends and comorbidity with other infectious and/or chronic diseases are needed, to better understand the disease burden in this population and target resources to optimize disease prevention, management and control.

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 11-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

Reference ces 1. BeLue R, Okoror T, Iwelunmor J, et al. An overview of cardiovascular risk factor burden in sub- Saharan African countries: a socio-cultural perspective. Global Health. 2009;5(1):10. doi:10.1186/1744-8603-5-10. 2. World Health Organization (WHO). Global Status Report on Noncommunicable Diseases 2010.;

• 2011. http://www.who.int/nmh/publications/ncd_report_full_en.pdf?ua=1. Accessed March 9,

2015. 3. World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020.; 2013. http://www.who.int/nmh/events/ncd_action_plan/en/. Accessed March 9, 2015. 4. Dagadu HE, Patterson EJ. Placing a Health Equity Lens on Non-communicable Diseases in sub- Saharan Africa. J Heal Care Poor Underserved. 2015;26(3):967-989. doi:10.1353/hpu.2015.0097. 5. Yach D et al. Global burden of chronic diseases. Overcoming impediments to prevention and

• control. J Am Med Assoc. 2004;291(21):2616-2622.

6. Hendriks ME, Wit FWNM, Roos MTL, et al. Hypertension in Sub-Saharan Africa: Cross-Sectional Surveys in Four Rural and Urban Communities. PLoS One. 2012;7(3). doi:10.1371/journal.pone.0032638. 7. Samb B, Desai N, Nishtar S, et al. Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries. Lancet. 2010;376:1785-1797. doi:10.1016/S0140-6736(10)61353-0. 8. Murray, Christopher JL; Lopez AD. Mortality by cause for eight regions of the world : Global Burden of Disease Study. L. 1997;349(9061):1269-1276. doi:10.1016/S0140-6736(96)07493-4Cite. 9. Kayima J, Wanyenze RK, Katamba A, Leontsini E, Nuwaha F. Hypertension awareness, treatment and control in Africa: a systematic review. BMC Cardiovasc Disord. 2013;13(1):54. doi:10.1186/1471-2261-13-54. 10. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet (London, England). 2016;(in press)(16):37-55. doi:10.1016/S0140-6736(16)31919-5. 11. Shobana J, Semere M, Sied M, Eyob T, Russom M. Prescribing Pattern of Anti - Hypertensive Drugs among Hypertension Patients with Cardiac Complications in Eritrea. Lat Am J Pharm. 2013;32(5):745-748. 12. The Nambia Ministry of Health and Social Services (MoHSS) and ICF International. The Namibia Demographic and Health Survey 2013. Windhoek, Namibia, and Rockville, Maryland, USA; 2014. 13. Hirai M, Grover N, Huang C. The Measurement of Non-Communicable Diseases in 25 Countries with Demographic and Health Surveys.; 2015. 14. Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJ, Lozano R, Inoue M. Age Standardization of Rates: A New WHO Standard.; 2001. http://www.who.int/healthinfo/paper31.pdf. Accessed September 23, 2017. 15. Harris TR. Multiscale spatial modelling of diabetes and hypertension in Namibia. 2017. http://41.205.129.132/bitstream/handle/11070/1952/harris_2017.pdf?sequence=1&isAllowed=y.

Final Full P Paper Theme 9: Health, Mortality and Longevity

• 12-

Leslie Craig & Anastasia Gage, Tulane University School of Public Health & Tropical Medicine Topic 910: Non-communicable diseases & their related risk factors in developing countries

Accessed September 23, 2017. 16. Kaputjaza DM. An epidemiological investigation of risk factors for hypertension in Windhoek, Khomas region Namibia. 2017. http://repository.unam.edu.na/bitstream/handle/11070/2069/kaputjaza2017.pdf?sequence=1&is Allowed=y. Accessed September 23, 2017. 17. Guariguata L, de Beer I, Hough R, Mulongeni P, Feeley FG, Rinke de Wit TF. Prevalence and Knowledge Assessment of HIV and Non-Communicable Disease Risk Factors among Formal Sector Employees in Namibia. PLoS One. 2015;10(7):e0131737. doi:10.1371/journal.pone.0131737. 18. Guariguata L, de Beer I, Hough R, et al. Diabetes, HIV and other health determinants associated with absenteeism among formal sector workers in Namibia. BMC Public Health. 2012;12:44. doi:10.1186/1471-2458-12-44. 19. Huynen MMTE, Martens P, Hilderink HBM. The health impacts of globalization: a conceptual

• framework. Global Health. 2005;1:14. doi:10.1186/1744-8603-1-14.

20. Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health.; 2010. doi:ISBN 978 92 4 150085 2. 21. World Health Organization. Noncommunicable Diseases (NCD) Country Profiles , 2014.; 2014. http://www.who.int/nmh/countries/nam_en.pdf. Accessed September 29, 2017.