The Association of Socioeconomic Status With Hypertension in 76 Low- and Middle-Income Countries

Tabea K Kirschbaum¹, Nikkil Sudharsanan², Jennifer Manne-Goehler³, Jan-Walter De Neve¹, Julia M Lemp¹, Michaela Theilmann¹, Maja E Marcus⁴, Cara Ebert⁵, Simiao Chen⁶, Moein Yoosefi⁷, Abla M Sibai⁸, Mahtab Rouhifard⁷, Sahar Saeedi Moghaddam⁹, Mary T Mayige¹⁰, Joao S Martins¹¹, Nuno Lunet¹², Jutta M A Jorgensen¹³, Corine Houehanou¹⁴, Farshad Farzadfar⁷, Albertino Damasceno¹⁵, Pascal Bovet¹⁶, Silver K Bahendeka¹⁷, Krishna K Aryal¹⁸, Glennis Andall-Brereton¹⁹, Justine I Davies²⁰, Rifat Atun²¹, Sebastian Vollmer⁴, Till Bärnighausen¹, Lindsay M Jaacks²², Pascal Geldsetzer²³

Affiliations

¹ Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.
² Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany; Professorship of Behavioral Science for Disease Prevention and Health Care, Technical University of Munich, Munich, Germany.
³ Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁴ Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany.
⁵ RWI - Leibniz Institute for Economic Research, Berlin, Germany.
⁶ Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
⁷ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
⁸ Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
⁹ Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
¹⁰ National Institute for Medical Research, Dar es Salaam, Tanzania.
¹¹ Faculty of Medicine and Health Sciences, Universidade Nacional Timor Lorosae, Dili, Timor-Leste.
¹² Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
¹³ D-Tree International, Boston, Massachusetts, USA.
¹⁴ Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin.
¹⁵ Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.
¹⁶ University Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland; Ministry of Health, Victoria, Republic of Seychelles.
¹⁷ Saint Francis Hospital, Nsambya, Kampala, Uganda.
¹⁸ Monitoring Evaluation and Operational Research Project, Abt Associates, Kathmandu, Nepal.
¹⁹ Independent consultant, Port of Spain, Trinidad and Tobago.
²⁰ Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom; Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
²¹ Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
²² Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA; Global Academy of Agriculture and Food Security, The University of Edinburgh, Midlothian, United Kingdom; Public Health Foundation of India, New Delhi, India.
²³ Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, USA; Chan Zuckerberg Biohub, San Francisco, California, USA. Electronic address: pgeldsetzer@stanford.edu.

PMID: 35981824
DOI: 10.1016/j.jacc.2022.05.044

Free article

The Association of Socioeconomic Status With Hypertension in 76 Low- and Middle-Income Countries

Tabea K Kirschbaum et al. J Am Coll Cardiol. 2022.

Free article

. 2022 Aug 23;80(8):804-817.

doi: 10.1016/j.jacc.2022.05.044.

Authors

Affiliations

¹ Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.
² Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany; Professorship of Behavioral Science for Disease Prevention and Health Care, Technical University of Munich, Munich, Germany.
³ Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁴ Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany.
⁵ RWI - Leibniz Institute for Economic Research, Berlin, Germany.
⁶ Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
⁷ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
⁸ Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
⁹ Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
¹⁰ National Institute for Medical Research, Dar es Salaam, Tanzania.
¹¹ Faculty of Medicine and Health Sciences, Universidade Nacional Timor Lorosae, Dili, Timor-Leste.
¹² Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
¹³ D-Tree International, Boston, Massachusetts, USA.
¹⁴ Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin.
¹⁵ Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.
¹⁶ University Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland; Ministry of Health, Victoria, Republic of Seychelles.
¹⁷ Saint Francis Hospital, Nsambya, Kampala, Uganda.
¹⁸ Monitoring Evaluation and Operational Research Project, Abt Associates, Kathmandu, Nepal.
¹⁹ Independent consultant, Port of Spain, Trinidad and Tobago.
²⁰ Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom; Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
²¹ Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
²² Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA; Global Academy of Agriculture and Food Security, The University of Edinburgh, Midlothian, United Kingdom; Public Health Foundation of India, New Delhi, India.
²³ Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, USA; Chan Zuckerberg Biohub, San Francisco, California, USA. Electronic address: pgeldsetzer@stanford.edu.

PMID: 35981824
DOI: 10.1016/j.jacc.2022.05.044

Abstract

Background: Effective equity-focused health policy for hypertension in low- and middle-income countries (LMICs) requires an understanding of the condition's current socioeconomic gradients and how these are likely to change in the future as countries develop economically.

Objectives: This cross-sectional study aimed to determine how hypertension prevalence in LMICs varies by individuals' education and household wealth, and how these socioeconomic gradients in hypertension prevalence are associated with a country's gross domestic product (GDP) per capita.

Methods: We pooled nationally representative household survey data from 76 LMICs. We disaggregated hypertension prevalence by education and household wealth quintile, and used regression analyses to adjust for age and sex.

Results: We included 1,211,386 participants in the analysis. Pooling across all countries, hypertension prevalence tended to be similar between education groups and household wealth quintiles. The only world region with a clear positive association of hypertension with education or household wealth quintile was Southeast Asia. Countries with a lower GDP per capita had, on average, a more positive association of hypertension with education and household wealth quintile than countries with a higher GDP per capita, especially in rural areas and among men.

Conclusions: Differences in hypertension prevalence between socioeconomic groups were generally small, with even the least educated and least wealthy groups having a substantial hypertension prevalence. Our cross-sectional interaction analyses of GDP per capita with the socioeconomic gradients of hypertension suggest that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

Keywords: education; household wealth; hypertension; low- and middle-income countries; socioeconomic gradient.

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Conflict of interest statement

Funding Support and Author Disclosures Drs De Neve and Bärnighausen were supported by the Alexander von Humboldt Foundation, funded by Germany’s Federal Ministry of Education and Research. Dr Jaacks has received funding from the Harvard McLennan Family Fund. Dr Geldsetzer is a Chan Zuckerberg Biohub investigator. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Harvard McLennan Family Fund, Chan Zuckerberg Biohub, or Alexander von Humboldt Foundation. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Comment in

Hypertension-A Silent Killer Without Global Bounds: What Next?
Pokharel Y, Karmacharya BM, Neupane D. Pokharel Y, et al. J Am Coll Cardiol. 2022 Aug 23;80(8):818-820. doi: 10.1016/j.jacc.2022.05.043. J Am Coll Cardiol. 2022. PMID: 35981825 No abstract available.

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The Association of Socioeconomic Status With Hypertension in 76 Low- and Middle-Income Countries

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The Association of Socioeconomic Status With Hypertension in 76 Low- and Middle-Income Countries

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