The cascade of care in managing hypertension in the Arab world: a systematic assessment of the evidence on awareness, treatment and control

Abstract

Background: Hypertension is a leading risk factor for mortality and morbidity globally and in the Arab world. We summarize the evidence on awareness, treatment, and control of hypertension, to assess the extent of gaps in the hypertension continuum of care. We also assess the influence of gender and other social determinants at each level of the cascade of care.

Methods: We searched MEDLINE and SSCI databases for studies published between 2000 and 2017, reporting the rates of awareness, treatment or control of hypertension and/or their determinants in the Arab region. We included sources on both general populations and on clinical populations. The review process was based on the PRISMA guidelines. We present rates on the three stages of the care cascade corresponding to (1) awareness (2) treatment and (3) control of blood pressure, and estimated the losses that occur when moving from one stage to another. We also take stock of the evidence on social determinants and assess the statistical significance of gender differences in awareness, treatment and control.

Results: Data from 73 articles were included. Substantial proportions of hypertensives were lost at each step of the hypertension care continuum, with more missed opportunities for care resulting from lack of awareness of hypertension and from uncontrolled blood pressure. More than 40% and 19% of all hypertensive individuals were found to be unaware and to have uncontrolled blood pressure, respectively, but among individuals diagnosed with hypertension, less than 21% were untreated. Awareness rates were higher among women than men but this advantage was not consistently translated into better blood pressure control rates among women.

Conclusions: This analysis of the cascade of care indicates that barriers to proper diagnosis and adequate control are greater than barriers to delivery of treatment, and discusses potential factors that may contribute to the gaps in delivery.

Keywords: Arab world; Awareness; Blood pressure; Cascade of care; Continuum of care; Control; Gender differences; Hypertension; Systematic assessment; Treatment.

Fig. 1

The three stages of the hypertension cascade of care showing losses that occur at different points (adapted from Berry et al, 2017 [16]). *Most studies defined hypertension by a SBP > =140 mmHg; and/or a DBP > =90 mmHg; or by a self-reported treatment with antihypertensive medication. A few studies used different cut-off points for SBP and DBP such as SBP > =140 mmHg and/or DBP > =80 mmHg; or SBP > =160 mmHg and/or DBP > =95 mmHg.

Fig. 2

Studies’ inclusion and exclusion in the review. *SSCI: Social Sciences Citation Index (SSCI).

Fig. 3

The cascade of care: Studies of awareness, treatment and control of hypertension in the Arab World, 2000–2017. Each study is represented by dots for the percent of respondents who are aware, treated, and have controlled blood pressure respectively, out of the study sample of hypertensives (as reported in the original publication). We plot a line to show how these percent decrease from one stage to the next reflecting the missed opportunities for care.