A systematic review of the burden of hypertension, access to services and patient views of hypertension in humanitarian crisis settings

Abstract

Introduction: Globally, a record number of people are affected by humanitarian crises caused by conflict and natural disasters. Many such populations live in settings where epidemiological transition is underway. Following the United Nations high level meeting on non-communicable diseases, the global commitment to Universal Health Coverage and needs expressed by humanitarian agencies, there is increasing effort to develop guidelines for the management of hypertension in humanitarian settings. The objective was to investigate the prevalence and incidence of hypertension in populations directly affected by humanitarian crises; the cascade of care in these populations and patient knowledge of and attitude to hypertension.

Methods: A literature search was carried out in five databases. Grey literature was searched. The population of interest was adult, non-pregnant, civilians living in any country who were directly exposed to a crisis since 1999. Eligibility assessment, data extraction and quality appraisal were carried out in duplicate.

Results: Sixty-one studies were included in the narrative synthesis. They reported on a range of crises including the wars in Syria and Iraq, the Great East Japan Earthquake, Hurricane Katrina and Palestinian refugees. There were few studies from Africa or Asia (excluding Japan). The studies predominantly assessed prevalence of hypertension. This varied with geography and age of the population. Access to care, patient understanding and patient views on hypertension were poorly examined. Most of the studies had a high risk of bias due to methods used in the diagnosis of hypertension and in the selection of study populations.

Conclusion: Hypertension is seen in a range of humanitarian settings and the burden can be considerable. Further studies are needed to accurately estimate prevalence of hypertension in crisis-affected populations throughout the world. An appreciation of patient knowledge and understanding of hypertension as well as the cascade of care would be invaluable in informing service provision.

Keywords: epidemiology; health policy; hypertension; public health; systematic review.

Figure 1

PRISMA flow diagram. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097. For more information, visit www.prisma-statement.org.

Figure 2

Risk of bias. External validity questions: Was the sampling frame a true or close representation of the target population?, Was some form of random selection used to select the sample, or was a census undertaken?, Was the likelihood of non-response bias minimal? Internal validity questions: Were data collected directly from the subjects (as opposed to a proxy)?, Was an acceptable case definition used?, Was the study instrument that measured the parameter of interest shown to have reliability and validity?, Was the same mode of data collection used for all subjects?, Was the length of the shortest prevalence period for the parameter of interest appropriate?, Were the numerator and denominator for the parameter of interest appropriate?

Figure 3

Map showing the number of papers by country of origin of study population. Map created using R. Granada is missing from the map and featured in one paper.