A cross-sectional, facility-based study of the prevalence of

hypertension and diabetes among adults in the greater Masaka

region, Uganda.

A dissertation submitted to The University of Manchester for the

degree of Master of Public Health in the Faculty of Biology,
Medicine, and Health

2020

Student ID:10255822

School of Health Sciences

Word Count: 10,161 words

Student ID:10255822

TABLE OF CONTENTS

LIST OF TABLES .................................................................................................................... 6

LIST OF FIGURES ................................................................................................................... 7

LIST OF APPENDICES ........................................................................................................... 8

LIST OF ABBREVIATIONS/ACRONYMS............................................................................ 9

ABSTRACT ............................................................................................................................ 10

DECLARATION ..................................................................................................................... 11

COPYRIGHT STATEMENT ................................................................................................. 12

ACKNOWLEDGMENT ......................................................................................................... 13

CHAPTER ONE ...................................................................................................................... 14

INTRODUCTION ................................................................................................................... 14

1.1 Background.............................................................................................................. 14

1.2 NCDs definition....................................................................................................... 14

1.3 Global burden of NCDs ........................................................................................... 14

1.4 Uganda’s NCDs burden ........................................................................................... 15

1.5 Diabetes mellitus definition and diagnosis .............................................................. 16

1.6 Hypertension definition and diagnosis .................................................................... 16

1.7 Research question .................................................................................................... 16

1.8 Study aim and objectives ......................................................................................... 16

1.8.1 Study Aim ............................................................................................................ 16
1.8.2 Specific Objectives .............................................................................................. 17

1.9 Conceptual Framework ........................................................................................... 17

CHAPTER TWO ..................................................................................................................... 18

LITERATURE REVIEW ........................................................................................................ 18

2.1 Introduction ............................................................................................................. 18

2.2 Appraisal of existing Literature ............................................................................... 18

2.2.1 Database search results ............................................................................................ 18

2
Student ID:10255822

2.2.2 Research questions addressed.............................................................................. 21

2.2.3 Study Designs ...................................................................................................... 21
2.2.4 Study populations ................................................................................................ 22
2.2.5 Sampling .............................................................................................................. 22
2.2.6 Analysis ............................................................................................................... 23
2.2.7 Results ................................................................................................................. 23
2.2.8 Generalizability of results.................................................................................... 24
2.2.9 Studies gaps ......................................................................................................... 25

2.3 Study justification .................................................................................................... 26

CHAPTER THREE ................................................................................................................. 27

METHODOLOGY .................................................................................................................. 27

3.1 Study design ............................................................................................................ 27

3.2 Study setting ............................................................................................................ 27

3.3 Population ................................................................................................................ 27

3.3.1 Target population................................................................................................. 27
3.3.2 Accessible population .......................................................................................... 27
3.3.3 Study population .................................................................................................. 27

3.4 Data definition of study variable ............................................................................. 28

3.5 Study Variables ....................................................................................................... 28

3.5.1 Outcome variables ............................................................................................... 28
3.5.2 Independent variables .......................................................................................... 29

3.6 Data Collection ........................................................................................................ 29

3.6.1 Hypertension and Diabetes screening process .................................................... 30
3.6.2 Hypertension screening and diagnosis ................................................................ 31
3.6.3 Diabetes screening and diagnosis ........................................................................ 32

3.7 Data management .................................................................................................... 33

3.8 Data storage ............................................................................................................. 33

3.9 Data analysis ............................................................................................................ 33

3.9.1 Analysis of objective one .................................................................................... 33
3.9.2 Analysis of objective two .................................................................................... 34

3
Student ID:10255822

3.9.3 Analysis of objective three .................................................................................. 34

3.9.4 Analysis of objective four ................................................................................... 34

3.10 Ethical considerations .............................................................................................. 35

CHAPTER FOUR ................................................................................................................... 36

RESULTS ................................................................................................................................ 36

4.1 Introduction ............................................................................................................. 36

4.2 Demographic Characteristics of study participants ................................................. 36

4.3 Objective 1: To estimate the individual prevalence of hypertension and diabetes as

NCDs risk factors among adults in the greater Masaka region. .......................................... 37
4.3.1 Prevalence of having at least one disease (hypertension and/or diabetes) .......... 37
4.3.2 Prevalence of hypertension and DM2 ................................................................. 38

4.4 Objective 2: To determine the co-morbidity of hypertension and diabetes, among

adults in the greater Masaka region. .................................................................................... 39
4.4.1 Prevalence of hypertension and DM2 co-morbidity ........................................... 39
4.4.2 Prevalence of diabetic patients with hypertension .............................................. 40

4.5 Objective 3: To assess the association between patients’ aging and hypertension
severity. ............................................................................................................................... 41
4.5.1 Association between patients’ aging and hypertension severity ......................... 41

4.6 Objective 4: To determine the proportion of patients' awareness of their hypertension

and/or diabetes status. .......................................................................................................... 42
4.6.1 Patients awareness about their hypertension and/or diabetes status .................... 42

CHAPTER FIVE ..................................................................................................................... 44

DISCUSSION.......................................................................................................................... 44

5.1. Summary of findings in the context of existing studies .......................................... 44

5.2. Prevalence of hypertension and/or diabetes among the study participants ............. 44

5.3. Hypertension and diabetes co-morbidity among study participants........................ 46

5.4. Association between patients’ aging and hypertension severity ............................. 46

5.5. Study patients’ awareness of their hypertension and/or diabetes status .................. 47

5.6. Strength of the study ................................................................................................ 49

4
Student ID:10255822

5.7. Limitations of the study ........................................................................................... 50

CHAPTER SIX ....................................................................................................................... 52

CONCLUSION AND RECOMMENDATIONS .................................................................... 52

6.1 Conclusion ............................................................................................................... 52

6.2 Recommendations ................................................................................................... 52

REFERENCES ........................................................................................................................ 54

APPENDICES ......................................................................................................................... 67

5
Student ID:10255822

LIST OF TABLES

Table 1: Descriptive summary of the literature review relevant articles ............................. 19

Table 2: Demographic characteristics of 1,441 participants at three study HFs in the greater
Masaka region, January 2018 to January 2019. .................................................................. 37

Table 3: Prevalence of hypertension and/or DM2 by demographic characteristics among

1,441 participants in the greater Masaka region, January 2018 to January 2019. ............... 38

Table 4: Prevalence of hypertension and DM2 by demographic characteristics among 1,441

participants in the greater Masaka region, January 2018 to January 2019. ......................... 39

Table 5: Prevalence of hypertension and DM2 co-morbidity by demographic characteristics

among 1,441 participants in the greater Masaka region, January 2018 to January 2019. ... 40

Table 6: Association between patients’ aging and hypertension severity among 1,441
participants in the greater Masaka region, January 2018 to January 2019. ......................... 41

Table 7: Patients' awareness of their hypertension and/or diabetes status in the greater
Masaka region before data collection, January 2018 to January 2019. ............................... 43

6
Student ID:10255822

LIST OF FIGURES

Figure 1: Literature database search for articles on the prevalence of hypertension, diabetes,
and their co-morbidity among adult Ugandans (Output: Ovid Medline). ........................... 18

Figure 2: Summary of the study HTN and DM2 screening process. .................................. 30

Figure 3: Blood pressure measurement and hypertension diagnosis process...................... 31

Figure 4: Blood sugar (BS) measurement and DM2 diagnosis process. ............................. 32

Figure 5: Flow diagram of the study selection of participants and reasons for non-
participation. ........................................................................................................................ 36

Figure 6: Hypertension stages classified by age-group among the 1,441 participants in the
greater Masaka region, January 2018 to January 2019. ...................................................... 42

7
Student ID:10255822

LIST OF APPENDICES

Appendix 1: Secondary data use permission letter.............................................................. 67

Appendix 2: Literature Database Search Results ................................................................ 68

8
Student ID:10255822

LIST OF ABBREVIATIONS/ACRONYMS

BP Blood Pressure
BS Blood Sugar

CIs Confidence Intervals

CSOs Community Screening Outreaches
CSS Cross-Sectional Study
CVDs Cardiovascular Diseases

DBP Diastolic Blood Pressure

DM1 Type I Diabetes Mellitus

DM2 Type II Diabetes Mellitus
FBS Fasting Blood Sugar
HBP High Blood Pressure
HFs Health Facilities
HTN Hypertension

IQR Interquartile Range

LMICs Low-or-Middle-Income Countries
LN LifeNet International
MeSH Medical Subject Heading

NCDs Non-Communicable Diseases

ORs Odd Ratios
PAF Population Attributable Fraction

RBS Random Blood Sugar

SBP Systolic Blood Pressure
SD Standard Deviation
SRS Simple Random Sampling

SSA Sub-Saharan Africa

STEPS STEPwise approach to Surveillance
WHO World Health Organization

9
Student ID:10255822

ABSTRACT

Introduction: Non-communicable diseases (NCDs) are on the rise in developing countries

with a disproportionate increase in sub-Saharan Africa (SSA). The burden of hypertension and
diabetes in SSA is high and threatens the economic development of these countries by
incapacitating the workforce and adding undo pressure on the already scarce resources. In
Uganda, recent evidence shows that 33% of the adult deaths are caused by NCDs, however,
there are gaps in the measure of hypertension and diabetes across the different regions in the
country.

Objective: To determine the overall prevalence of hypertension, diabetes, and their co-
morbidity, among adults in the greater Masaka region, Uganda.

Methods: This was a facility-based, cross-sectional study involving secondary analysis of data
collected from three rural primary care health facilities (HFs) located in the greater Masaka
region, Uganda. The data was collected from the HFs’ catchment areas through community
screening outreaches (CSOs) and the HFs’ hypertension/diabetes registry between January
2018 and January 2019. The prevalence of the different categorical variables was determined
using percentages while the associations between categorical variables were analyzed using
the chi-square (X2) test.

Results: Of the 1,441 study participants, 35% (95% CI 32.5 – 37.5) had at least one of the two
NCDs risk factors (hypertension and/or diabetes). The crude prevalence of hypertension and
diabetes mellitus was 33.2% and 5.3%, respectively. Of the study participants, 3.5% were co-
morbid and of the diabetic patients, 65.8% were hypertensive. Of the hypertensive participants,
72.4% did not know their status before the CSOs, while 80.3% of the diabetic and 70% of the
co-morbid participants knew their status before the CSOs. Aging of the patients was
significantly associated with hypertension severity (X2 = 195.8, r = 0.37, p < 0.0001).

Conclusion: NCDs are now a high burden of disease in Uganda. Hypertension and diabetes
are on the rise in the country which calls for immediate intervention measures such as
screening, diagnosing, and managing these diseases. Elderly people are at high risk of
hypertension and diabetes which calls for aggressive screening and prevention programmes
targeted with age.

10
Student ID:10255822

DECLARATION

To the best of my knowledge, the work presented in this dissertation is original except where
otherwise acknowledged. There is no portion of the work referred to in this dissertation that
has been submitted in support of an application for another degree or other qualification of this
or any other University or other institutes of learning.

11
Student ID:10255822

COPYRIGHT STATEMENT

1. Copyright in the text of this dissertation rests with the author. Copies (by any process)
either in full or of extracts, may be made only in accordance with instructions given by
the author. Details may be obtained from the Graduate Office of the Faculty of Biology,
Medicine, and Health. This page must form part of any such copies made. Further
copies (by any process) of copies made in accordance with such instructions may not
be made without the permission (in writing) of the author.
2. The ownership of any intellectual property rights which may be described in this
dissertation is vested in the University of Manchester, subject to any prior agreement
to the contrary, and may not be made available for use by third parties without the
written permission of the University, which will prescribe the terms and conditions of
any such agreement.
3. Further information on the conditions under which disclosures and exploitation may
take place is available from the Head of the School of Health Sciences.

12
Student ID:10255822

ACKNOWLEDGMENT

Firstly, I express my sincere and heartfelt gratitude to my supervisor Dr. Isla Gemmell for the
guidance, nurturing, and suggestions rendered to me throughout the dissertation process. From
the beginning, she acknowledged my potential, accepting my Commonwealth Scholarship
application, and has continued to support me through the completion of my dissertation. Thank
you very much.

Secondly, I thank the Uganda Country Director of LifeNet International, Mr. Joshua Guenther,
for granting me access to the secondary data used in this dissertation. To my professional
supervisor at LifeNet, Adriana Verkerk, thank you for always checking in on my academic
progress and providing me extra time to focus on my academic assignments.

I thank my dad for encouraging me to take on an MPH programme and always guiding me on
the balance of work and academics. He motivated me to pursue my Studies. My grandparents
also supported me through prayer and periodic inquiries about the progress of my studies.

To my fellow Ugandan University of Manchester students and alumni, thank you for
encouraging me always to push harder through my academic career. Your guidance and
motivation have surely pushed me this far, we will always keep in touch to push and change
the healthcare and access status quo in our country and the region.

13
Student ID:10255822

CHAPTER ONE

INTRODUCTION
1.1 Background
The high global burden of non-communicable diseases (NCDs) is one of the major public
health challenges in the 21st century(1–3). If not adequately managed, the United Nation’s
Sustainable Development goal number 3.4, of “reducing premature mortality from NCDs by
one third by 2030” may not be realized(4,5).

1.2 NCDs definition

The World Health Organization (WHO) identifies NCDs as chronic diseases, spanning a long
period with slow progression resulting from a combination of genetic, environmental,
physiological, dietary, and behavioural factors(5,6). NCDs mainly include cardiovascular
diseases (CVDs), cancer, diabetes mellitus, and chronic respiratory diseases, which are the
leading causes of morbidity and mortality worldwide(3,5). Higher trends of NCDs potentially
hinders the economic development of many countries due to incapacitation of the main
workforce, which exacerbates the financial burden for NCD patients' care and treatment(7).

1.3 Global burden of NCDs

Globally, NCDs are responsible for more than 70% of all deaths, and over 80% of those who
die reside in low-or middle-income countries (LMICs) and are under the age of 70 years(2,3,8–
10). CVDs are the leading causes of death among the elderly in Africa, accounting for more
than 25% of deaths in people aged 60 years and older(11,12). It is projected that by 2030, 46%
of SSA’s deaths may result from NCDs compared to 28% in 2008(13). The projected
percentage increase in NCDs deaths in SSA ranks the highest compared to other regions across
the globe within the same period (2008-2030)(13). There is an increasingly high burden of risk
factors for NCDs like diabetes and hypertension in sub-Saharan Africa (SSA), which is
troubling considering the majority of the population in these countries can barely afford
adequate care and treatment for these conditions(14–18). Most NCDs result from four main
behavioural risk factors such as tobacco use, physical inactivity, unhealthy diets, and harmful
alcohol use(19). These lead to four key metabolic changes: raised blood pressure,
overweight/obesity, raised blood glucose, and raised cholesterol(3,19,20). Throughout Africa,
an increased number of cases of hypertension, diabetes, obesity, and high cholesterol levels

14
Student ID:10255822

have been linked to an increased number of CVDs(21). This dissertation focuses on the
prevalence of hypertension and diabetes as key risk factors for other NCDs among adults 18
years and older.

In recent years, diabetes has maintained its status as one of the most devastating global health
challenges in the 21st century(22). It mainly damages the heart, eyes, kidneys, blood vessels,
and the nervous system, causing disability and premature death(23–25). Over the last thirty
years, the prevalence of diabetes has more than quadrupled with over 420 million people
suffering from the condition worldwide(3,14,26). In 2015, an estimated 1.6 million people died
from complications related to diabetes, ranking it the fourth most deadly NCD across the
globe(5,27,28).

Hypertension, estimated to affect over one billion people worldwide, is also a critical global
public health issue(29). Hypertension also known as high blood pressure (HBP), is a silent,
invisible killer. While it rarely causes symptoms, it is the highest contributor to heart disease,
stroke, kidney failure, disability, and can lead to premature mortality(29–32). It frequently
accompanies diabetes and often present in over two-thirds of diabetic patients(33–36). While
there are safe and effective treatments for this condition, many people still fail to control their
blood pressure in LMICs where health systems are weak(37). Every year, nearly ten million
people die from hypertension and only one out of every seven people with HBP have it under
control(38). This implies that of the estimated 1.4 billion people with HBP, only 200 million
have the disease under control(38).

1.4 Uganda’s NCDs burden

In Uganda, NCDs are less prioritized than infectious diseases yet their burden escalates every
year(39). The recent WHO NCDs profile report estimates a third(33%) of all deaths among
people aged 18 years and older are attributed to NCDs, which is catching up to the devastatingly
high communicable diseases burden rated at 54% in the country(3). Recent studies in Uganda
estimate the prevalence of hypertension and diabetes among people aged 13 years or older to
be above 20% and 7%, respectively(35,40–48). Moreover, hypertension and diabetes were
estimated to be higher in rural (hypertension > 26% , diabetes 3% to 16%) compared to urban
(hypertension 18% to 24%, diabetes 2% to 8%) areas(35,47).

15
Student ID:10255822

1.5 Diabetes mellitus definition and diagnosis

Diabetes mellitus is a chronic disease that results from either the pancreas’ failure to produce
enough insulin (type 1 diabetes) or inability of the body to effectively use the insulin it produces
(type 2 diabetes)(3,23,28). The main function of insulin is to regulate blood sugar in the body,
therefore, both types of diabetes result from raised/high blood sugar/glucose levels which
damage the body when accumulated over time(3). Type 1 diabetes (DM1) onset is most
common in childhood and early adulthood, whereas type 2 diabetes (DM2) mostly occurs
among adults although children too are affected. The majority of diabetic people have
DM2(23,26,46). This study will primarily focus on DM2.

According to the WHO and other studies, an individual is said to have diabetes when fasting
blood sugar (FBS) is ³ 7.0 mmol/l (126 mg/dl), 2-hour post-load plasma glucose is ³ 11.1
mmol/l (200 mg/dl), Hemoglobin A1c (HbA1c) is ³ 48 mmol/mol, or random blood sugar
(RBS) is ³ 11.1 mmol/l (200 mg/dl) in the presence of diabetes signs and
symptoms(1,3,23,26,49–51).

1.6 Hypertension definition and diagnosis

Hypertension is also known as raised/high blood pressure(3,30,52), blood pressure is the force
exerted against the blood vessel walls by the person’s blood when pumped by the heart(30).
This pressure is mostly caused by the blood vessels’ resistance and the force the heart requires
to pump the blood through them. An individual is diagnosed with hypertension when systolic
blood pressure (SBP) is ³ 140 mmHg and/or diastolic blood pressure (DBP) is ³ 90
mmHg(3,31,52–54).

1.7 Research question

What is the prevalence of hypertension, diabetes, and hypertension-diabetes co-morbidity,
among adults in the greater Masaka region in Uganda?

1.8 Study aim and objectives

1.8.1 Study Aim
To determine the overall prevalence of hypertension, diabetes, and their co-morbidity, among
adults in the greater Masaka region, Uganda.

16
Student ID:10255822

1.8.2 Specific Objectives

• To estimate the individual prevalence of hypertension and diabetes as NCDs
risk factors among adults in the greater Masaka region
• To determine the co-morbidity of hypertension and diabetes among adults in
the greater Masaka region
• To assess the association between patients’ aging and hypertension severity
• To determine the proportion of patients' awareness of their hypertension
and/or diabetes status

1.9 Conceptual Framework

The conceptual framework is based on the factors associated with NCDs that determine an
individual’s quality of life. These factors range from demographic factors, such as age, sex,
education level, occupation, place of residence, marital status, and family history of NCDs.
Behavioural risk factors mainly include harmful alcohol use, unhealthy diet, physical
inactivity, and tobacco use. These result in physiological/metabolic changes like
overweight/obesity, raised blood glucose, raised blood pressure, and raised cholesterol(3).

The scope of this study was limited to the prevalence of hypertension, diabetes, and their co-
morbidity, compared with age, sex, and individual awareness about their hypertension and
diabetes status.

17
Student ID:10255822

CHAPTER TWO

LITERATURE REVIEW
2.1 Introduction
The literature search was intended for studies conducted to determine the prevalence of
hypertension, diabetes, and their co-morbidity among adult Ugandans. These studies were
identified through the Medline database using Ovid as the search engine (1946 to January Week
3, 2020). To maximize the search strategy yielding relevant articles to this study, the following
Medical Subject Headings (MeSH) in figure 1 were used. The MeSH were restricted to title,
abstract, or keyword heading. Details of this search are shown in appendix 2 of the dissertation.
Only English language articles were considered.

Figure 1: Literature database search for articles on the prevalence of hypertension, diabetes,
and their co-morbidity among adult Ugandans (Output: Ovid Medline).
The search strategy for relevant articles also included forward citation searching and secondary
sources.
2.2 Appraisal of existing Literature
2.2.1 Database search results
The overall database search strategy line #12 above yielded 54 articles. However, only 22
articles addressed NCDs research questions in Uganda on hypertension and/or

18
Student ID:10255822

DM2. Of these, eight other articles were excluded: five articles included age groups outside this study (< 18 years), one article investigated
behavioural factors associated with hypertension, another article investigated the prevalence and patterns of hypertensive crisis, and the final article
concentrated on the hypertension burden. Therefore, the final literature appraisal included 14 articles relevant to this study as shown in table 1
below.
Table 1: Descriptive summary of the literature review relevant articles
Author(s) (year) Title Journal Age- response/ Ref
/District/ study Period group Sample size No.
Kayima et al (2015)/ Determinants of hypertension in young adult Ugandan BMC Public 18 – 40 3,685/3,920 (32)
Wakiso/ (2012-2013) population in epidemiological transition-the MEPI-CVD Health years
survey
Kavishe et al (2015)/ High prevalence of hypertension and of risk factors for BMC Medicine ³ 18 916 Ugandans (35)
Wakiso & Mpigi/ non-communicable diseases (NCDs): a population-based years
(2012-2013) cross-sectional survey of NCDs and HIV infection in
Northwestern Tanzania and Southern Uganda.
Muddu et al (2018)/ Hypertension among newly diagnosed diabetic patients at Cardiovascular ³ 18 201/206 (36)
Kampala/ (2014/2015) Mulago National Referral Hospital in Uganda Journal of Africa years
Nyombi et al (2016)/ High prevalence of hypertension and cardiovascular BMC Research ³ 18 180/191 (39)
Kampala/ (2013) disease risk factors among medical students at Makerere Notes years
University College of Health Sciences, Kampala, Uganda
Lunyera et al (2018)/ Geographic differences in the prevalence of hypertension PLoS ONE ³ 18 3,416/4,310 (41)
Nationwide/ (2016) in Uganda: Results of a national epidemiological study years

19
Student ID:10255822

Lasky et al (2002)/ Obesity and gender differences in the risk of type 2 Nutrition ³ 35 440 (46)
Mukono & Kampala/N/A diabetes mellitus in Uganda. years
Chiwanga et al (2016)/ Urban and rural prevalence of diabetes and pre-diabetes Global Health ³ 18 417/497 (47)
Wakiso & Bushenyi/N/A and risk factors associated with diabetes in Tanzania and Action years Ugandans
Uganda
Mayega et al (2013)/ Diabetes and pre-diabetes among persons aged 35 to 60 PLoS ONE 35 – 60 1,497/1,656 (48)
Iganga & Mayuge/(2012) years in eastern Uganda: prevalence and associated factors years
Bahendeka et al (2016)/ Prevalence and correlates of diabetes mellitus in Uganda: a Trop. Medicine & 18-69 3,689/3,989 (55)
Nationwide/ (2014) population-based national survey Int. Health years
Guwatudde et al The burden of hypertension in sub-Saharan Africa: a four- BMC Public ³ 18 462 Ugandans (56)
(2015)/Wakiso & country cross-sectional study Health years
Bushenyi/ (2011/2012)
Wamala et al (2009)/ Prevalence factors associated with hypertension in African Health ³ 20 842 (57)
Rukungiri/ (2006) Rukungiri district, Uganda Sciences years
Kotwani et al (2013)/ Epidemiology and awareness of hypertension in a rural BMC Public ³ 18 2,252/3,250 (58)
Mbarara/ N/A Ugandan community: a cross-sectional study Health years
Mondo et al (2013)/ The prevalence and distribution of non-communicable Cardiovascular ³ 25 518/611 (59)
Kasese/ 2011/2012 diseases and their risk factors in Kasese district, Uganda Journal of Africa years
Wandera et al (2015)/ Prevalence and risk factors for self-reported non- Global Health ³ 50 2,382 (60)
Nationwide/ 2010 communicable diseases among older Ugandans Action years
N/A – Study period not available in the paper

20
Student ID:10255822

2.2.2 Research questions addressed

All the selected studies aimed at measuring the prevalence of hypertension and/or diabetes
among adults (³ 18 years) in Uganda. Despite the measure of hypertension among diabetic
patients in one of the studies, it did not independently measure the prevalence of hypertension
or diabetes(36). None of the selected 14 articles investigated hypertension and diabetes co-
morbidity from study participants. Two articles majorly measured the prevalence of diabetes
and pre-diabetes among adult Ugandans and diabetes related risk factors(47,48). Relatedly,
another two studies only focussed on DM2 prevalence and its associated factors among
adults(46,55). Three studies determined the prevalence of hypertension, pre-hypertension, and
their associated factors among adults (³ 18 years)(32,41,56). Another three articles focused on
the prevalence of hypertension, its associated factors, and other risk factors for
NCDs(39,57,58). Finally, three studies measured the prevalence of hypertension, DM, and
other risk factors for NCDs while further investigating their association to varying
degrees(35,59,60). Whereas one study determined the per-capita cost of screening adults for
DM2, none of the studies measured the cost-effectiveness analysis of screening individuals for
NCDs and/or their risk factors(48).

2.2.3 Study Designs

Most of the studies (12/14) were primarily conducted using a cross-sectional study (CSS)
design. One of the studies analyzed data from the Africa/Harvard Partnership for Cohort
Research and Training studies(47). Whereas another article performed a cross-sectional
analysis of the baseline data collected from a cohort study in four SSA countries including
Uganda(56). Although the use of a CSS design in most of the articles is appropriate in
prevalence studies, it does not establish the causal relationship between being hypertensive
and/or diabetic and developing NCDs. Therefore, it is hard to ascertain whether the
development of hypertension and/or diabetes preceded the development of other NCDs or if
these NCDs led to the development of hypertension and/or diabetes. While randomized
controlled trials are typically considered the “gold standard” in the hierarchy of evidence, they
are less useful when determining the prevalence of a disease or its risk factors. The CSS design
was also adopted in this study.

21
Student ID:10255822

2.2.4 Study populations

There were three studies conducted in the western region of Uganda in Kasese, Rukungiri, and
Mbarara districts, they mainly recruited rural population participants(57–59). Six of the studies
were conducted in the central region of Uganda, commonly known as the Kampala
metropolitan area, this population is predominantly urban and peri-urban with some rural
dwellings(32,35,36,39,46,47). Additionally, the analyses by Kavishe et al and Guwatudde et
al compared rural and urban hypertension prevalence(35,56), while Chiwanga et al compared
rural and urban diabetes prevalence(47). One study was conducted in a predominantly rural
setting of Iganga and Mayuge districts in eastern Uganda(48). Three of the selected studies
were conducted nationwide(41,55,60). Noteworthy, none of the identified studies were solely
conducted in the same catchment population as that investigated in this study. This is the
greater Masaka region located in western-central Uganda, approximately 150km west of
Kampala, Uganda's capital.

2.2.5 Sampling
The simple random sampling (SRS) technique of populations was adopted in most of the
studies selected for this review, although many of them accompanied it with other methods.
Stratified multistage sampling was used in six studies(32,35,47,55,57,60). The stages included
randomly sampling the selected local geographical administrative units and thereafter
systematically or randomly sampling study participants from each study unit (stratum).
Relatedly, Wandera et al performed a nested analysis of the Uganda National Household
Survey data which used a two-stage stratified sampling technique(60). Four studies employed
a multi-stage cluster sampling method where study participants were randomly selected from
purposively sampled clusters(41,46,56,59). One study simply used the consecutive sampling
technique whereby the eligible study participants were sent invitations to participate in the
study and enrolled upon accepting, although, the desired sample size was not achieved(39).
This also creates selection bias as the attitude of participation differs between healthy and
diseased individuals. The Mayega et al article was nested into a larger survey where SRS was
performed using the survey database to select the required study sample(48). There was one
study that uniquely conducted a community-wide household census in the entire parish located
in the study district where all adults (³ 18 years) were included in the study(58). Last but not
least, there was one study in which participants were conveniently selected from newly
diagnosed diabetic patients from the national referral hospital that met the study’s inclusion

22
Student ID:10255822

criteria(36). The studies had varying sample sizes as summarized in table 1 above. Whereas
studies with larger sample sizes are deemed capable of providing better estimates of the
population parameters, if the sample is biased then the estimates will be inaccurate regardless
of how big the sample is(61).

2.2.6 Analysis
The analysis in these studies took multiple directions in the interest of meeting the various
study objectives. Unlike in one study where proportions were used(39), most studies presented
the prevalence of hypertension and/or diabetes as percentages with their confidence intervals
(CIs) and/or p-values. Furthermore, the multivariate analysis technique (linear or logistic) was
used in most of the papers to assess the association between several predictors and hypertension
and/or DM2. Although, in two papers, this association was not determined(46,59). Interactions
were assessed using the Chunk test. These models were fitted mainly to adjust for the
confounders to the association under test. Results from these models were presented as odds
ratios (ORs) accompanied by their CIs. Relatedly, Wandera et al used the multivariate
complementary log-log regression to estimate the odds of reporting NCDs among elderly
Ugandans(60). Two studies used the modified Poisson regression to identify factors associated
with hypertension and diabetes using adjusted prevalence ratios(48,56). Moreover, the diabetes
study determined the per-capita cost of screening adults for DM2. Additionally, only one study
tested for the population attributable fraction (PAF) of hypertension for overweight and
obesity, and central obesity using adjusted ORs in the final model(35). No study investigated
the PAF of DM2 for any of its risk factors. Only one study investigated the association between
hypertension severity and patients’ aging(35). The participants’ awareness about their
hypertension and/or diabetes status was investigated in only 4 of 14 selected papers.

2.2.7 Results
There was a noticeable range in the results of these studies regarding the prevalence of
hypertension and/or DM2, despite the similarity in the study periods in some studies. Five
studies estimated the prevalence of hypertension in Uganda to be between 14% and
19%(32,39,56,58,60), while two studies estimated it between 20% and 22%(35,59). On the
contrary, Wamala et al and Lunyera et al equally estimated the hypertension prevalence at
about 31%(41,57). Six studies found a higher hypertension prevalence among females
compared to males(36,56–60), and three found the opposite(32,35,41). Mondo at al found no

23
Student ID:10255822

significant difference in the hypertension prevalence between the genders(59). The diabetes
prevalence among adult Ugandans was estimated at £ 3% in three studies(35,55,60), whereas,
the other three studies’ estimates range between 7% and 9% (46,48,59). However, Chiwanga
et al estimated it at 10% with higher prevalence in rural Uganda, estimated at 16%(47). Three
studies found a higher prevalence of diabetes among females compared to males(46–48),
except for one paper that determined otherwise(55). Noteworthy, three of these papers found
no significant difference in the prevalence of diabetes between sexes(47,48,55). Most of the
selected studies found more elderly people as diabetic and/or hypertensive than younger adults.
Overall, hypertension/diabetes prevalence rates were higher in the urban compared to rural
areas. There were no studies that investigated hypertension and DM2 co-morbidity, although,
NCDs multimorbidity estimated in two papers(35,60) ranged between 3.8% to 5.6%. These
papers investigated multimorbidity in conditions like hypertension, DM2, Heart disease,
epilepsy, and obstructive lung disease. In the single study that investigated the hypertension
prevalence among diabetic patients, this was estimated at 62%(36). The patients' awareness of
their hypertension and diabetes status had conflicting estimates. Kotwani et al estimated
hypertension awareness at 38%(58), Guwatudde et al estimated it at 14.3% and 31.4% among
rural and peri-urban residents, respectively(56), whereas Kayima et al estimated it at
13.7%(32). Bahendeka et al estimated diabetes awareness among adults at 51%(55). No
assessment among the selected papers was performed to measure co-morbidity awareness
among patients.

2.2.8 Generalizability of results

Overall, most studies used the SRS technique with a mix of rural and urban populations,
however, they had different findings of the prevalence of hypertension and diabetes. This
resulted from the different participants’ response/sample sizes, age-groups, sampling frames
(Table 1), and diagnostic measures for hypertension and diabetes. The variation in results
diminishes their representativeness of the study population and deems them less generalizable
to the wider target population in Uganda and beyond. Some studies’ sampling frames that
mainly included participants selected from Universities, hospitals, offices/businesses, and
religious centers were likely to have biased results due to participant selection bias(36,46). This
is because non-students, non-hospitalized, unemployed, and non-religious participants were
excluded from the studies. Such studies’ samples misrepresent the study population whose

24
Student ID:10255822

analytical findings diminish generalizability to the target population (Ugandan adults ³ 18

years).
2.2.9 Studies gaps
While almost all the studies in this literature review used the CSS design, deemed appropriate
for estimating the prevalence of a disease among populations, they registered some flaws in
their conduct and measure of the desired outcomes.

a) Some studies lacked the potential generalizability of findings given the use of biased
sampling frames whose results restricted their inference to the national target
populations.
b) Some studies adopted limited adult age-groups that sorted and left out potential
participants who are relevant to the study population.
c) The literature search strategy employed in this review did not identify any studies
conducted from the region of interest to this study. This implies that the research topic
under study is new in the literature.
d) Some studies used self-reported responses of whether or not one was hypertensive
and/or diabetic which is prone to recall bias hence underestimating the actual NCD
prevalence(62,63).
e) Furthermore, some studies’ measurements for blood pressure/glucose didn’t follow the
recommended protocols i.e. taking the participant’s blood pressure (BP) after about 5
minutes rest time and averaging at least 2 BP readings to obtain the final reading(64).
For FBS testing, ensuring participants’ adherence to the recommended fasting-period
before testing(49). This led to misclassification of hypertensive and/or diabetic status
of study participants.
f) No study measured hypertension and DM2 co-morbidity, however, hypertension was
measured among only diabetic patients without considering a healthy target population.
This shows a huge gap in knowledge which hinders policy reforms for caring and
managing co-morbid patients. Moreover, the study did not measure patients’ awareness
of their co-morbidity.
g) Only one paper in the review investigated the association between the patients' aging
and hypertension severity.

25
Student ID:10255822

2.3 Study justification

Based on the gaps identified in the literature above, there is a need for more research-based
information and knowledge about hypertension and diabetes burden in Uganda and the
surrounding region. There is limited awareness about hypertension and DM2 prevalence,
symptoms, and adverse effects in developing economies like Uganda(16). In Uganda, NCDs
risk factors sensitization and awareness are mostly in towns and major regional cities, leaving
the rural communities abandoned(65). Moreover, medical professionals rely on limited
evidence about the prevalence and severity of NCDs in LMICs like Uganda compared to
communicable diseases to inform their vigilance and preparedness to take action(65–67). From
this background, this study aimed to expand on the existing knowledge diversity on the
prevalence of hypertension, DM2, and their co-morbidity among rural Ugandan adults,
especially in the greater Masaka region where limited investigations exist. The study also
investigated the association between patients’ aging and hypertension severity as well as
awareness of their hypertension and/or diabetes status. Additionally, Chiwanga et al(47)
recommended future studies investigating co-morbidities of diabetes which further perpetuates
this study's intent.

26
Student ID:10255822

CHAPTER THREE

METHODOLOGY
3.1 Study design
The study used a facility-based cross-sectional design to determine the prevalence of
hypertension, diabetes, and hypertension-diabetes co-morbidity among Ugandan adults (³ 18
years). It was a cross-sectional analysis of secondary data collected from three health facilities’
catchment areas through community screening outreaches (CSOs) and outpatient facility
visitors’ registry between January 2018 and January 2019.

3.2 Study setting

The study was carried out at three rural primary care Health Facilities (HFs) in the greater
Masaka region, Uganda as part of the NCDs pilot project by LifeNet International (LN). LN is
a not-for-profit organization working with faith-based HFs to transform health care in Africa.
The three HFs are private-not-for profit faith-based level III facilities affiliated to the Roman
Catholic Diocese of Masaka located in the greater Masaka region of Uganda. During the study
period, the Masaka district had 297,004 residents (50.5% male and 65% rural)(68). The three
study HFs had an estimated average annual outpatient attendance of 12,000 and a catchment
population of 14,500 people of whom 45% are 18 years and older(68). The pilot project
targeted screening 50% of the adults in the catchment areas of the study HFs.

3.3 Population
3.3.1 Target population
Adult individuals aged 18 years and older living in rural areas in Uganda.

3.3.2 Accessible population

• Adult Ugandans that participated in the CSOs for hypertension (HTN) and DM2 led by
the three study HFs between January 2018 and January 2019.
• Participants that attended hypertension and diabetes clinics at the three rural primary
care HFs in the greater Masaka region, between January 2018 and January 2019.

3.3.3 Study population

The study population was defined by the following inclusion and exclusion criteria;

27
Student ID:10255822

• Inclusion criteria
All adults screened for HTN and DM2 aged 18 years and older, or attended the hypertensive/
diabetic clinic at the three-study rural primary care HFs in the greater Masaka region during
the study period and did not meet any of the exclusion criteria below.

• Exclusion criteria
Pregnant women, screened participants aged < 18 years, or hypertensive/ diabetic clinic
attendants aged below 18 years during the study period.

3.4 Data definition of study variable

a) Hypertension was defined as SBP of at least 140 mmHg and/or DBP of at least 90
mmHg, and/or self-report of the current use of antihypertensive medication.
b) Hypertension stages were defined as follows; normotensive was defined as SBP < 140
mmHg and DBP < 90 mmHg, mild hypertension was defined as SBP of 140-159 mmHg
and/or DBP of 90-99 mmHg; moderate as SBP of 160-179 mmHg and/or DBP of 100-
109 mmHg, and severe as SBP of at least 180 mmHg and/or DBP of at least 110
mmHg(10,53).
c) Diabetes was defined as FBS of ³ 7.0 mmol/l (126 mg/dl) (fasting for at least 10 hours
without food but water), or RBS of ³ 11.1 mmol/l 200mg/dl) in the presence of diabetes
signs and symptoms, or self-report of the current use of anti-diabetic medication.
d) HTN-DM2 co-morbidity was defined as patients with both hypertension and diabetes.
e) Awareness status was defined as being aware that one is hypertensive and/or diabetic
at the time of screening.

3.5 Study Variables

3.5.1 Outcome variables
The study outcome variables include.
• Having hypertension: This was a binary categorical variable measuring whether
participants had hypertension or not.
• Having DM2: This was a binary categorical variable measuring whether participants
had DM2 or not.
• Having a co-morbidity: This was a binary categorical variable measuring whether
participants had both hypertension & DM2 or not.

28
Student ID:10255822

• Hypertension stage: This was an ordinal four-stage categorical variable measuring

whether participants had normotensive, mild, moderate, or severe hypertension.
• Hypertension awareness: This was a binary categorical variable measuring whether
patients with hypertension at the time of screening knew they had the condition or not.
• DM2 awareness: This was a binary categorical variable measuring whether patients
with diabetes at the time of screening knew they had the condition or not.
• Co-morbidity awareness: This was a binary categorical variable measuring whether co-
morbid patients at the time of screening knew they had both hypertension and DM2 or
not.

3.5.2 Independent variables

The Independent variables in this study include demographic factors like;
• Sex: This was a binary categorical variable identifying participants as either male or
female.
• Age: This was a continuous variable of participants’ age in years.
• Age-group: This was a categorical variable identifying the participants’ age into the
following categories of (18–29, 30–39, 40–49, 50–59, 60–69, and 70+).
• HF category: This was a categorical variable that included three categories of study
health facilities (Facility 1, Facility 2, and Facility 3).

3.6 Data Collection

The study utilized secondary data collected by the three study HFs. The data was mainly
collected through CSOs led by the study HFs within their catchment population areas. Other
participants were recruited through routine screening for outpatient visitors to the HFs’
hypertension and DM2 clinics. Clinical officers with a minimum of three years of medical
training led the screening events in each HF, they were responsible for data recording and
preliminary interviews with the study participants.

29
Student ID:10255822

3.6.1 Hypertension and Diabetes screening process

Figure 2: Summary of the study HTN and DM2 screening process.

Figure 2: Study hypertension and DM2 screening process (Source: LifeNet archives).

The CSOs are large public health community engagement initiatives that provide rapid
diagnostic services for people in rural areas where health services are minimal. Before the
outreaches, community health workers and village local leaders mobilize community members
through mobile loudspeakers, posters/banners, and local radio announcements. Community
gatherings such as church/mosque services, weddings/parties, and universities were also
leveraged to maximize participation at the CSOs. At least one outreach was conducted by each
HF per month. The screening process involved adults ³ 18 years from the community
catchment areas of the three study rural HFs. Upon screening, the clinical officer performed a
short survey and recorded the name, address, sex, and age of each participant in the HF
screening register. Furthermore, the participants were asked whether they knew their
hypertension or DM status and whether or not they were on treatment. Participants who were
on treatment or screened positive before for HTN/DM2 were exempted from screening but
recorded in the screening register as 'known HTN/DM2'. Participants were then screened for

30
Student ID:10255822

hypertension and DM2 if did not know their status and neither on any form of HTN/DM2
treatment.
The information on pregnancy was self-reported by the participants during the survey. Those
pregnant were tested for pre-eclampsia and gestational diabetes and if found positive provided
treatment or referred to higher-level HFs for further management. But these were excluded
from analysis in this study.

3.6.2 Hypertension screening and diagnosis

Figure 3: Blood pressure measurement and hypertension diagnosis process.

Figure 3: Blood pressure measurement and hypertension diagnosis (Source: LifeNet archives).

Before BP measurement, the participant was made to rest for at least five minutes. For each
participant, at least two BP readings 30 minutes apart were taken in the sitting position with
arms resting on the table. The average BP reading was recorded as final for each participant. If
the average BP was ³ 140/90 mmHg, the participant was diagnosed with hypertension. The
practice was similar for the participants screened at HFs’ HTN/DM2 clinics. Using the highest

31
Student ID:10255822

number, either SBP or DBP, the participant’s hypertension stage was determined as shown in
figure 3 above.

3.6.3 Diabetes screening and diagnosis

Figure 4: Blood sugar (BS) measurement and DM2 diagnosis process.

Figure 4: Blood sugar measurement and DM2 diagnosis (Source: LifeNet archives).

During the CSOs before the BS measurement, the participants were assessed for typical DM2
symptoms like polyuria, polydipsia, and unexpected weight loss, thereafter their RBS readings
were taken. If the RBS was ³ 11.1 mmol/l and the common symptoms are positive, the
participant was diagnosed with DM2 and referred to the respective HF to begin treatment. This
referral was intended to link the participant to the HF clientele since CSOs where not conducted
at the HF premises but in the community. However, if the RBS was ³ 11.1 mmol/l but the
client did not exhibit the common DM2 symptoms, they were referred to the HF laboratory for
confirmatory FBS diagnostic tests. These referred suspected participants were encouraged to
present to the HF after fasting for about 10 hours (eat/drink nothing except water, the test was

32
Student ID:10255822

usually preferred in the morning before breakfast). If the participant’s FBS was ³ 7 mmol/l,
they were diagnosed with DM2. Nonetheless, if the client who had RBS ³ 11.1 mmol/l without
DM2 symptoms and FBS < 7 mmol/l, they were diagnosed with pre-diabetes and advised on
behavioural change to prevent diabetes.

3.7 Data management

The data were retrospectively transcribed from the HF screening and outpatient logs/registers
by the LN NCDs project officer with support from one research assistant working on the same
project. It was entered in a Microsoft Excel spreadsheet, coded to protect the clients’ and HFs’
identities. All the study data were checked for accuracy, completeness, and consistency by the
study principal investigator, and any errors identified where corrected in consultation with the
LN NCDs project officer.

3.8 Data storage

All data hard copies of registers/logs were stored in the study HFs’ records offices with door-
locks only accessible to the responsible qualified clinical staff. The Microsoft Excel data
transcripts were stored in a password protected external drive only accessible to the
organization project staff and higher management. A back-up copy of the data was also stored
on an external hard drive locked in the safe of the organization monitoring and evaluation
department.

3.9 Data analysis

All data analyses were performed using StatsDirect statistical software version 3.2.8. All the
continuous variables were summarized using medians, means, and standard deviation, while
the categorical variables were summarized using proportions or percentages.

3.9.1 Analysis of objective one

To estimate the individual prevalence of hypertension and diabetes as NCDs risk factors among
adults in the greater Masaka region.
o The overall prevalence of at least one disease (hypertension and/or diabetes) was
determined as the proportion of study participants with at least one of the conditions.
This was reported with a 95% confidence interval (CI).

33
Student ID:10255822

o The individual prevalence of hypertension and DM2 were determined as proportions of

study participants with hypertension and the proportion of study participants with DM2,
respectively. These were also reported with a 95% CI.
3.9.2 Analysis of objective two
To determine the co-morbidity of hypertension and diabetes among adults in the greater
Masaka region.
o The prevalence of co-morbidity was determined as the proportion of study participants
with both hypertension and DM2. This was also reported with a 95% CI.
o Moreover, the prevalence of diabetic patients with hypertension was also determined
as the proportion of diabetic patients with hypertension. This was reported with a 95%
CI.

3.9.3 Analysis of objective three

To assess the association between patients’ aging and hypertension severity.
o The association between patients’ aging and hypertension severity was determined
using cross-tabulations and analyzed using the Chi-square test. Because the Chi-square
(X2) test measures associations between categorical variables, the patients’ age-group
and the hypertension stage variables were used to test for this association(61,69). The
association was reported with a p-value to measure the statistical significance of results.
o Because the hypertension stage is an ordinal categorical variable, and the association
between hypertension stages and the patients’ age-group was proven to be statistically
significant (p < 0.0001), the Chi-square test for trend was determined. This was
intended to ascertain whether as a patient grows older, their hypertension severity also
increases. The results were also reported with a p-value to measure statistical
significance.

3.9.4 Analysis of objective four

To determine the proportion of patients' awareness of their hypertension and/or diabetes status.
o The patients’ awareness of their hypertension status was determined as the proportion
of hypertensive patients who knew they had the condition at the time of screening. This
was reported with a 95% CI.

34
Student ID:10255822

o The patients’ awareness of their DM2 status was determined as the proportion of
diabetic patients who knew they had the condition at the time of screening. This was
also reported with a 95% CI.

o The patients’ awareness of their co-morbidity status was determined as the proportion
of co-morbid patients who knew they had both HTN and DM2 at the time of screening.
This was also reported with a 95% CI.

3.10 Ethical considerations

Written permission to use the secondary data for the study was sought from LifeNet
International, the main data custodian (See appendix 1). The study participants' details, such as
names, phone numbers, or physical addresses that would disclose their identity were not
included in the data extraction for this study. Furthermore, unique personal identification
numbers were assigned to each enrolled participant and HF sites to protect their identity.

35
Student ID:10255822

CHAPTER FOUR

RESULTS
4.1 Introduction
This chapter presents the results and findings of the study.

4.2 Demographic Characteristics of study participants

A total of 1,470 adults (³ 18 years) attended the CSOs and hypertensive/diabetic clinics and
answered a short screening survey for hypertension and DM2 at the three study HFs between
January 2018 and January 2019. Of the adult study participants, two percent (29/1,470)
reported to be pregnant and were excluded from data analysis. The included participants (1441)
represented 22% of the 6,525 (45% of 14,500) adults (3,295 males and 3,230 females) residing
in the catchment areas of the three study HFs (Figure 5). Overall, 60.2% (867/1441) of the
participants were female and 60.5% (872/1441) were aged under 50 years. The median age of
the participants was 42.5 years for males (Interquartile range (IQR): 30 – 58), 45 years for
females (IQR: 30 – 58), and 44 years overall (IQR: 30 – 58). Facility two constituted the highest
number of study participants 37.6% (542/1441) compared to facilities one and three (Table 2).

Figure 5: Flow diagram of the study selection of participants and reasons for non-participation.

Number of eligible participants in the catchment area 6,525 (45% of 14,500)

1,470 (22.5%) attended CSOs Number of participants who failed

and the hypertensive/diabetic to attend CSOs and the hypertensive
clinics at the study HFs or diabetic clinics 5,055 (77.5%)

1,441 (98%) included Number of pregnant

in the study for the final women excluded from the
phase of data analysis study analysis 29 (2%)

Number of participants Number of participants Number of participants

with blood pressure with blood glucose
surveyed 1,441 (100%)
measured 1,441 (100%) measured 1,441 (100%)

36
Student ID:10255822

Table 2: Demographic characteristics of 1,441 participants at three study HFs in the greater
Masaka region, January 2018 to January 2019.
Variable Number (N = 1,441) Percentage (%)
Sex
Male 574 39.8
Female 867 60.2

Age-group
18 – 29 332 23.0
30 – 39 273 18.9
40 – 49 267 18.5
50 – 59 235 16.3
60 – 69 191 13.3
70 + 143 10.0
Mean age ± SD* (overall) 44.8 ± 17.1
Median age (IQR**) overall 44 (30 – 58)
Median age (IQR**) (Males) 42.5 (30 – 58)
Median age (IQR**) (Females) 45 (30 – 58)

HF+ Category
Facility 1 470 32.6
Facility 2 542 37.6
Facility 3 429 29.8
SD* - standard deviation, IQR** - Interquartile range, HF+ - Health Facility

4.3 Objective 1: To estimate the individual prevalence of hypertension and diabetes as

NCDs risk factors among adults in the greater Masaka region.
4.3.1 Prevalence of having at least one disease (hypertension and/or diabetes)
Overall, 504 of the 1,441 adult participants (35%, 95% CI 32.5 – 37.5) had at least one of the
two NCD risk factors (hypertension and/or DM2). The prevalence increased by more than
seven percentage points for every 10-year increase in age after the 18-29 age-group. Whereas
the prevalence was slightly higher among females 37.3% (95% CI 34.0 – 40.6) compared to
males 31.5% (95% CI 27.7 – 35.5), it was relatively similar between the catchment areas of
the three study HFs but slightly higher in facility three at 38.0% (95% CI 33.4 – 42.8) (Table
3).

37
Student ID:10255822

Table 3: Prevalence of hypertension and/or DM2 by demographic characteristics among 1,441

participants in the greater Masaka region, January 2018 to January 2019.
Variable Total (N=1,441) Frequency (n) Prevalence (%) 95% CI
Overall* 1,441 504 35.0 32.5–37.5

Sex
Male 574 181 31.5 27.7 – 35.5
Female 867 323 37.3 34.0 – 40.6

Age-group
18 – 29 332 50 15.1 11.4 – 19.4
30 – 39 273 53 19.4 14.9 – 24.6
40 – 49 267 86 32.2 26.6 – 38.2
50 – 59 235 111 47.2 40.9 – 53.6
60 – 69 191 104 54.5 47.1 – 61.7
70 + 143 100 69.9 61.7 – 77.3
HF
Category
Facility 1 470 162 34.5 30.2 – 39.0
Facility 2 542 179 33.0 29.1 – 37.2
Facility 3 429 163 38.0 33.4 – 42.8
* - Participants with at least one of the NCDs risk factors (hypertension and/or DM2)

4.3.2 Prevalence of hypertension and DM2

The overall crude prevalence of hypertension among adults was 33.2% (95% CI 30.7 – 35.7).
The crude hypertension prevalence was 30% (95% CI 26.2 – 33.9) among men and 35.3%
(95% CI 32.1 – 38.6) in women. Of the 1,441 participants screened, 265 (18.4%), 127 (8.8%),
and 86 (6%) had mild, moderate, and severe stages of hypertension, respectively. Hypertension
prevalence increased with age from 14.5% to 17.6% to 29.6% to 44.7% to 51.8%, and to 69.2%
in the 18 – 29, 30 – 39, 40 – 49, 50 – 59, 60 – 69, and 70 + years age-groups, respectively. The
crude prevalence was nearly similar among the catchment areas of the three study HFs although
slightly higher in facility three at 36.4% (95% CI 31.4 – 41.1) (Table 4).

Type II diabetes was registered in 5.3% (95% CI 4.2 – 6.6) of the study participants, the DM2
crude prevalence among males was 3.5% (95% CI 2.1 – 5.3), and 6.5% (95% CI 4.9 – 8.3)
among females. Similar to hypertension, the DM2 prevalence was higher among older
participants aged 50 years and above compared to the younger counterparts below 50 years.

38
Student ID:10255822

Diabetes was highest among participants in the catchment area of Facility one at 7.2% (95%
CI 5.1 – 10.0) compared to those in facilities two and three (Table 4).

Table 4: Prevalence of hypertension and DM2 by demographic characteristics among 1,441

participants in the greater Masaka region, January 2018 to January 2019.
Variable Total Hypertension (n = 478) DM2 (n = 76)
N=1,441
n Prevalence 95%CI n Prevalence 95%CI
(%) (%)
Overall 1,441 478 33.2 30.7 – 35.7 76 5.3 4.2 – 6.6

HTN stages
Normotensive 963 66.8 64.3 – 69.3
Mild 265 18.4 16.4 – 20.5
Moderate 127 8.8 7.4 – 10.4
Severe 86 6.0 4.8 – 7.3

Sex
Male 574 172 30.0 26.2 – 33.9 20 3.5 2.1 – 5.3
Female 867 306 35.3 32.1 – 38.6 56 6.5 4.9 – 8.3

Age-group
18 – 29 332 48 14.5 10.9 – 18.7 2 0.6 0.1 – 2.2
30 – 39 273 48 17.6 13.3 – 22.6 6 2.2 0.8 – 4.7
40 – 49 267 79 29.6 24.2 – 35.5 15 5.6 3.2 – 9.1
50 – 59 235 105 44.7 38.2 – 51.3 18 7.7 4.6 – 11.8
60 – 69 191 99 51.8 44.5 – 59.1 20 10.5 6.5 – 15.7
70 + 143 99 69.2 61.0 – 76.7 15 10.5 6.0 – 16.7
HF Category
Facility 1 470 150 31.9 27.8 – 36.3 34 7.2 5.1 – 10.0
Facility 2 542 172 31.7 27.3 – 35.8 21 3.9 2.4 – 5.9
Facility 3 429 156 36.4 31.4 – 41.1 21 4.9 3.1 – 7.4

4.4 Objective 2: To determine the co-morbidity of hypertension and diabetes, among

adults in the greater Masaka region.
4.4.1 Prevalence of hypertension and DM2 co-morbidity
The overall crude prevalence of hypertension and DM2 co-morbidity was 3.5% (95% CI 2.6 –
4.5), females experienced these diseases more frequently at 4.5% (95% CI 3.2 – 6.1), compared
to males at 1.9% (95% CI 1.0 – 3.4). While the co-morbidity prevalence progressively
increased with age, none of the screened participants aged under 30 years had both

39
Student ID:10255822

hypertension and diabetes. The co-morbidity prevalence was relatively lower in facility two at
2.6% (95% CI 1.4 – 4.3) compared to facilities one and three catchment areas (Table 5).

4.4.2 Prevalence of diabetic patients with hypertension

As shown in table 5, among the 76 diabetic patients in the study, 50 (65.8%, 95% CI 54.0 –
76.3) were hypertensive.

Table 5: Prevalence of hypertension and DM2 co-morbidity by demographic characteristics

among 1,441 participants in the greater Masaka region, January 2018 to January 2019.
Variable Total (N = 1,441) Co-morbid (n = 50) Prevalence (%) 95% CI
Overall 1,441 50 3.5 2.6 – 4.5

Sex
Male 574 11 1.9 1.0 – 3.4
Female 867 39 4.5 3.2 – 6.1

Age-group
18 – 29+ 332 0 - -
30 – 39 273 1 0.4 0 – 2.0
40 – 49 267 8 3.0 1.3 – 5.8
50 – 59 235 12 5.1 2.7 – 8.7
60 – 69 191 15 7.9 4.5 – 12.6
70 + 143 14 9.8 5.5 – 15.9
HF Category
Facility 1 470 22 4.7 3.0 – 7.0
Facility 2 542 14 2.6 1.4 – 4.3
Facility 3 429 14 3.3 1.8 – 5.4
Variable DM2 (N = 76) Prevalence (%) 95% CI

Have HTN++ 50 65.8 54.0 – 76.3

+ - No co-morbid participants aged 18-29years, ++ - Number of hypertensive diabetic patients.

40
Student ID:10255822

4.5 Objective 3: To assess the association between patients’ aging and hypertension
severity.
4.5.1 Association between patients’ aging and hypertension severity
From the bivariate analysis in table 6, the chi-square test showed that hypertension severity
was statistically significantly associated with the patients’ aging (X2 = 234.2, 15-df, p <
0.0001). A further test for trend showed that there was a statistically significant positive
correlation between hypertension stages and the patients’ age-group, implying that as the
patient grows older their hypertension severity increases (X2 = 195.8, 1-df, r = 0.37, p <
0.0001).

Table 6: Association between patients’ aging and hypertension severity among 1,441
participants in the greater Masaka region, January 2018 to January 2019.
Variable Hypertension Stage Test statistic
Normal Mild Moderate Severe Chi- P-value
(N=963) (N=265) (N=127) (N=86) square
Age- n (%) n (%) n (%) n (%) X2
group
18 – 29 284 (29.5) 34 (12.8) 8 (6.3) 6 (7.0) 234.2, p<0.0001
30 – 39 225 (23.4) 36 (13.6) 8 (6.3) 4 (4.6) 15 – df*
40 – 49 188 (19.5) 44 (16.6) 24 (18.9) 11 (12.8)
50 – 59 130 (13.5) 52 (19.6) 33 (26.0) 20 (23.3)
60 – 69 92 (9.5) 45 (17.0) 33 (26.0) 21 (24.4)
70 + 44 (4.6) 54 (20.4) 21 (16.5) 24 (27.9)
Total 964 100 264 100 127 100 86 100
Test for Linear Trend
Chi-square for linear trend X2 Correlation (r) P-value
Value 195.8, 1 – df* 0.37 p < 0.0001
df* - degrees of freedom

Figure 6 shows the proportions of hypertension stages by age-group. Normotensive participants

were much younger compared to their hypertensive counterparts; moreover, there was a
statistically significant trend towards increased hypertension severity among aging patients (p

41
Student ID:10255822

< 0.0001). On the contrary, it is important to note that the prevalence of hypertension among
youth is reasonably high, which calls for adequate attention.
Figure 6: Hypertension stages classified by age-group among the 1,441 participants in the
greater Masaka region, January 2018 to January 2019.

40
Normal Mild Moderate Severe

30
Proportion

20

10

0
18–29 30–39 40–49 50–59 60–69 70+

Age-group

4.6 Objective 4: To determine the proportion of patients' awareness of their

hypertension and/or diabetes status.
4.6.1 Patients awareness about their hypertension and/or diabetes status
A large proportion of patients were not aware of being hypertensive 346/478 (72.4%, 95% CI
68.1 – 76.3) and received their first diagnosis during the CSOs. The awareness was poor among
men 27/172 (15.7%, 95% CI 10.6 – 22.0) compared to women 105/306 (34.3%, 95% CI 29.0
– 39.9). Facility one population catchment area had a higher hypertensive patients’ awareness
proportion of 58/150 (38.7%) compared to Facility two 30/172 (17.4%) and Facility three
44/156 (28.2%) catchment areas. The awareness of hypertension was higher in the older age-
groups compared to the younger age-groups (Table 7).

On the contrary, 80.3% (61/76) of the diabetic patients were aware of their condition before
the CSOs (95% CI 67.5 – 88.5). The awareness was not significantly different between the
participants’ genders and relatively similar among the three study HF catchment areas. Seven
in ten of the co-morbid patients knew their status before the CSOs, similarly, there was no
significant difference between males and females (Table 7).

42
Student ID:10255822

Table 7: Patients' awareness of their hypertension and/or diabetes status in the greater Masaka
region before data collection, January 2018 to January 2019.
Variable HTN (N=478) DM2 (N=76) Co-morbid (N=50)
Aware+ n % 95%CI n % 95%CI n % 95%CI
Yes 132 27.6 23.7–31.9 61 80.3 67.5–88.5 35 70 55.4–82.1
No 346 72.4 68.1–76.3 15 19.7 11.5–30.5 15 30 17.9–44.6

Sex M=172, F=306 M=20, F=56 M=11, F=39

Male (M) 27 15.7 10.6–22.0 17 85 62.1–96.8 8 72.7 39.0–94.0
Female (F) 105 34.3 29.0–39.9 44 78.6 65.6–88.4 27 69.2 52.4–83.0

Age-
group
18 – 29 3 6.3 1.3–1.7 1 50 2.3–98.7 0 - 0
30 – 39 4 8.3 2.3–20.0 3 50 11.8–88.2 1 100 2.5–1.0
40 – 49 17 21.5 13.1–32.2 11 73.3 44.9–92.2 4 50 15.7–84.3
50 – 59 26 24.8 16.9–34.1 12 66.7 41.0–86.7 7 58.3 27.7–84.8
60 – 69 41 41.4 31.6–51.8 20 100 83.2–1.0 11 73.3 44.9–92.2
70 + 41 41.4 31.6–51.8 14 93.3 68.1–99.8 12 85.7 57.2–98.2

HF
Category
Facility 1 58 38.7 30.8–47.0 27 79.4 62.1–91.3 16 72.7 49.8–89.3
Facility 2 30 17.4 12.1–24.0 17 81.0 58.1–94.6 7 50 23.0–77.0
Facility 3 44 28.2 21.3–36.0 17 81.0 58.1–94.6 12 85.7 57.2–98.2
+ - Patients aware of their hypertension, diabetes, or co-morbid status.

43
Student ID:10255822

CHAPTER FIVE

DISCUSSION

5.1. Summary of findings in the context of existing studies

Overall, 35% of the study participants had at least one of the two NCDs risk factors
(hypertension and/or diabetes). The individual prevalence of hypertension and DM2 among
study participants was 33.2% and 5.3%, respectively. Of the study participants, 3.5% were co-
morbid and 65.8% of diabetic patients were hypertensive. Hypertension severity of patients
was statistically significantly associated with aging. Among the hypertensive participants,
27.6% knew their status before the CSOs, compared to 80.3% of the diabetic counterparts.
Similarly, 70% of the co-morbid patients knew their status before the CSOs.

5.2. Prevalence of hypertension and/or diabetes among the study participants

The prevalence of 35% of participants with at least one of the two NCDs risk factors is
consistent with findings from other studies carried out in the country. Kavishe et al estimated
that 36.7% of rural Ugandan adults have at least one NCD including hypertension, diabetes,
heart failure, obstructive lung disease, and epilepsy(35). Relatedly, in a nationally
representative survey to assess the key NCDs risk factors among Ugandan adults, 38.6% of
respondents exhibited one or two risk factors(70). However, the study looked at several NCDs
risk factors including physical activity, tobacco smoking, body mass index, high blood
pressure, and dietary feeding. This high prevalence implies that one in every three people has
at least one NCDs risk factor. This indicates that NCD risk factors are on the rise in LMICs
which threatens the NCDs’ rise imminence in these countries. There is a skewed concentration
of public health interventions towards the control and treatment of infectious diseases like HIV,
malaria, and tuberculosis in LMICs like Uganda. This has resulted in neglecting prevention
measures for NCDs and their risk factors which could be a major facilitator of the high
prevalence of NCD risk factors in this study(39,45).

The hypertension prevalence of 33.2%, 95% CI (30.7 – 35.7) estimated in our study is
consistent with other literature reports on Uganda that estimated hypertension prevalence to
fall between 31% and 32% (41,57). Moreover, the result falls within the range of the
hypertension prevalence in sub-Saharan Africa and other LMICs in Africa such as Ethiopia,

44
Student ID:10255822

Kenya, Namibia, Mozambique, Malawi, Tanzania, Angola, Cameroon, Zimbabwe, South

Africa, Tunisia, Benin, Ghana, and Nigeria which is 20% to 40%(17,71,80–87,72–79). The
finding is also consistent with the existing literature of evidence which suggests that
hypertension prevalence in SSA is approaching estimates in the developed countries(88–92).
Mild, moderate, and severe hypertension were estimated at 18.4%, 8.8%, and 6%, respectively.
This is consistent with the previous research studies in the country where severe hypertension
ranged between 3% to 8% (32,35,58).

Related to the study literature in Uganda, the hypertension prevalence was more pronounced
among the elderly compared to the younger adults. This emanates from the increased weakness
of the body due to aging prone to multimorbidity including hypertension(32,35,36,40,41,43–
45,56,58). The hypertension prevalence was slightly higher in females (35.3%, 95% CI 32.1 –
38.6) compared to males (30%, 95% CI 26.2 – 33.9), consistent with other reports in the
country(36,56–60). However, there was no significant difference between the genders due to
the overlap between the 95% CIs of both sexes consistent with the finding by Mondo et al(59).

The DM2 prevalence was 5.3%, 95%CI (4.2 – 6.6), which was consistent with the estimate
from the Mayega et al study carried out in eastern Uganda where the diabetes prevalence of
adult rural dwellers stood at 6.8%(48). There have been several mixed estimates of type 2
diabetes prevalence among rural and urban adult Ugandans, some literature study findings
estimated the prevalence to be £ 3%(35,55,60) while others between 8% to 16%(46,47,59).
However, our study finding is in range with the diabetes prevalence estimates in the different
populations in SSA which is between 2% and 10%(21,85,101–104,93–100). The DM2
prevalence increased with an increase in age, similar to other studies in the
country(47,48,55,60). The study also showed a higher DM2 prevalence in females (6.5%, 95%
CI 4.9 – 8.3) than in males (3.5%, 95% CI 2.1 – 5.3) consistent with other literature estimates
in the country and other Sub-Saharan African populations(47,48,63,100,101,105,106).
Nonetheless, there was no significant difference in the DM2 prevalence between the genders
due to the overlap between the 95% CIs of both genders which is consistent with the previous
reports(47,48,55,65,100,101).

45
Student ID:10255822

5.3. Hypertension and diabetes co-morbidity among study participants

Knowledge of hypertension and DM2 co-morbidity is important for any health sector to foster
proper planning and adequate allocation of the already scarce resources. This will ease the
treatment and management of these patients since hypertension is statistically significantly
associated with diabetes(32,46,47,58,103,105,107,108). The co-morbidity for hypertension
and DM2 was found at 3.5%, 95% CI (2.6 – 4.5). While literature estimating this co-morbidity
in Uganda is scarce, the results are similar to the NCDs multimorbidity estimate of 4.1% from
a nationally representative self-reported household survey(60). Although, the survey
investigated the prevalence of hypertension, DM2, and heart diseases. Relatedly, the
HTN/DM2 co-morbidity prevalence was similar to that estimated in Angola and India at 3%
and 4.5%, respectively(93,103). The prevalence of hypertension among diabetic patients was
estimated at 65.8%, 95% CI (54.0 – 76.3) which is consistent with the previous literature
estimates in Uganda that ranged between 60% and 62%(35,36). The results are also well
matched with the prevalence estimates of hypertension among diabetic patients among SSA
populations as estimated in Cameroon and South Africa at 66.7% and 65.4%,
respectively(107,109). Overall, the co-morbidity prevalence increased with an increase in the
age of the participants ranging from 0% among 18-29 year-olds to 9.8% among 70+-year-olds.
This was expected because when people grow older, their bodies become weaker and more
susceptible to NCDs(35,36,60,93,94,110–113).

Overall, the NCDs’ comorbidities and multimorbidities are increasing in SSA and LMICs,
therefore, intervention strategies to promote early diagnosis and treatment need be encouraged
and intensified.

5.4. Association between patients’ aging and hypertension severity

In a bivariate analysis using the chi-square test, the patients’ age-group was statistically
significantly associated with hypertension stages (X2 = 234.2, 15df, p < 0.0001). A further test
for linear trend revealed a statistically significant positive correlation (r = 0.37) between the
patients’ age-group and hypertension stages. This implies that as the patients grow older, their
hypertension severity increases. This is because aging is associated with common
cardiovascular system changes such as increased vascular stiffness and weight increase(114–
117). Since increased weight is associated with cardiovascular risks like fat accumulation and
deposition in the blood vessels, this eventually leads to blood pressure elevation which

46
Student ID:10255822

culminates in hypertension severity(118–120). The results are consistent with the findings from
a population-based WHO STEPS survey conducted by Kavishe et al in Uganda and
Tanzania(35). Furthermore, the finding concurs with other studies that found a significant
association between patients’ aging and hypertension severity in the late 20th century(120–
122).

5.5. Study patients’ awareness of their hypertension and/or diabetes status

The prevalence of awareness of hypertension status among hypertensive patients before the
CSOs was 27.6%, 95% CI (23.7 – 31.9). This is similar to findings from a community-based
survey in Uganda which estimated the hypertensive patients’ awareness at 28.2%(40) despite
surveying people aged ³ 15 years. This study finding is consistent with reports from other SSA
populations such as Senegal, Tanzania, Comoros, Zimbabwe, Angola, Cameroon, Benin,
Ghana, and Nigeria whose hypertension awareness range between 21% and 35%
(74,75,126,77,78,80,81,84,123–125). Our study finding further concurs with the Addo et
al(127) review which reported that hypertension awareness among hypertensive patients in
SSA was mostly less than 40%. The hypertension awareness in our study was more than double
among females (34.3%, 95% CI 29.0 – 39.9) compared to males (15.7%, 95% CI 10.6 – 22.0)
as revealed in other findings in the country(40,58). This may be attributed to the higher health-
seeking behaviour among women compared to men in the region. Due to pre-conceived
traditional male gender norms associated with exercising toughness and control, men view
health seeking as a sign of weakness and vulnerability in the community which deters them
from routine health check-ups(128–130). Because women are the primary caretakers for
children in households, they utilize the opportunity during routine maternal and child health
programme visits to the health facilities and get their BP checked(131,132).

The awareness increased with an increase in age, consistent with other findings in Uganda and
other populations in SSA(32,40,87,103,123,126,133). Generally, hypertension awareness rates
are low in Uganda and the region. This could be attributed to the limited priority and the low
health systems capacity in the LMICs to promote community health education campaigns and
provide individual and community level awareness strategies on NCDs and their risk factors
like hypertension(133,134). The Ugandan healthcare system has overly concentrated on
prevention, treatment, and control of communicable diseases such as HIV, Tuberculosis,
malaria, and pneumonia, leaving NCDs with less attention(39,45,135). However, it is

47
Student ID:10255822

important to strengthen the health systems to increase the population awareness of NCDs and
their risk factors to prevent their adverse effects coupled with high morbidity and mortality
rates. The Uganda Health Sector Development Plan 2015/16 – 2019/20 set out to promote
NCDs prevention, build the capacity of health workers on NCDs, and enhance NCD
management and control(136). However, in a recent assessment to determine the Ugandan
public sector HFs’ capacity to prevent and control NCDs, all the sampled HFs reported
significant resource gaps and deficiencies in NCD screening and management(137). This is
very dangerous in the battle to combat the emerging NCD burden in the country.

Among diabetic patients, eight in ten were aware of their status before the CSOs. This is higher
than the 2014 national population-based survey estimates of about 51%(55). However, there is
limited literature on DM2 awareness rates among diabetic patients in Uganda. The high
awareness rate could be a result of the higher symptomatic nature of DM2 even in the early
stages prompting earlier diagnosis compared to hypertension(23,26). The finding could be a
reflection of increased education, sensitization, and screening for diabetes in the country since
it is the fourth cause of death across the globe among NCDs, after chronic respiratory diseases,
cancers, and cardiovascular diseases(3,9). Based on our results, the Uganda diabetic population
is considered more aware of their condition than other countries in the region such as Angola,
Seychelles, and Kenya whose awareness is estimated at 11%, 54%, and 64%, respectively
(98,103,138). Similar to the gender DM2 awareness prevalence in Angola, the DM2 awareness
in the study was slightly higher among males (85% 95% CI 62.1 – 96.8) compared to females
(79% 95% CI 65.6 – 88.4)(103). However, based on the CIs, there was no significant difference
in the DM2 prevalence between both sexes. Generally, diabetes awareness among patients
increased with an increase in age, i.e. 50% among 18 – 29 year-olds to 93% among adults aged
70 years and older, this is also observed among other populations in SSA(103,138). Because
the elderly people are weaker and susceptible to multimorbidity, they occasionally visit the
HFs and are often tested for elderly-linked conditions like hypertension and diabetes. This
increases their awareness of having these conditions compared to the younger
counterparts(35,60,94,110,112,113).

Hypertension and DM2 co-morbidity awareness in this study was 70%. The literature
estimating hypertension and DM2 co-morbidity awareness among patients in Uganda is scarce.
Nevertheless, the study’s results are related to the awareness prevalence of hypertension among
diabetic patients in SSA which stands at 87%(107). Because hypertension is statistically

48
Student ID:10255822

associated with diabetes, many diabetic patients are most likely screened for hypertension
which increases awareness of their HTN/DM2 co-morbidity(32,46,47,103,105).

5.6. Strength of the study

The study was conducted from the community screening outreaches of three rural primary care
health facilities in the greater Masaka region with an estimated adult catchment population of
6,525 (45% of 14,500) people. Of the 1,470 study participants, 29 were excluded due to
pregnancy leaving the sample size at 1441 (22% of the adult population). This is a substantial
sample size representing the study population.

The primary data collection process involving data recording and preliminary participant
interviews were led by qualified medical clinical officers at the respective study HFs with
practical knowledge and experience in screening for HTN and DM2. Moreover, the study
screening employed the internationally recommended procedures and techniques such as
taking at least two BP measurements thirty minutes apart and conducting FBS tests which
further fine-tuned the quality of the data collected in the study. Hence, increasing the validity
of the prevalence estimates.

There was no other study in Uganda that investigated HTN and DM2 co-morbidity and
patients’ awareness of this condition, yet these two conditions are statistically significantly
associated. Moreover, there was no identified study examining the association of patients’
aging and hypertension severity. This study managed to set these findings on record which
have the potential to inform future research, public health policies and health systems
strengthening mechanisms in the country and the region to promote NCD care, management,
and control.

The study period of about 13 months was long enough to capture even one-time participant
attendees to the CSOs and/or HTN/DM2 clinics at the study health facilities which increased
the potential participation rate of the community members in the study.

Finally, the study included a good balance of study participants from each of the study HFs’
communities with approximately a third from each HF’s catchment area. This shows a good

49
Student ID:10255822

balance in the participation of community adults and therefore the study results are
generalizable to similar communities across the country.

5.7. Limitations of the study

Since the participants were not randomly sampled from the study population, there was
selection bias in the study sample. For example, the study participants involved 39.6% of adults
aged over 50 years compared to 16.5% of the same age group in the target population(68). This
implies that the HTN/DM2 prevalence could have been overestimated by more than double
since the HTN/DM2 prevalence is associated with age. Therefore, the study sample could be
less representative of the study population and the results less generalizable to the target
population. Hence, the study estimates could be less informative in planning for HTN/DM2
interventions in the study population.

The study was conducted from only three rural faith-based health facility catchment population
areas in the greater Masaka region. Therefore, the study results could not be used to infer to
the urban facilities’ populations, or catchment populations served by non-religious or
government health facilities.

The study participants were recruited through screening at CSOs and outpatient visitors at the
study HFs’ HTN/DM2 clinics. This would leave out participants who did not attend any of
these stations, moreover, severely hypertensive and diabetic patients referred and admitted for
specialized care and treatment in hospitals would be excluded. Hence, the study findings are
not entirely representative of all the adults in the study population.

The study did not measure the prevalence of NCDs behavioural risk factors among the
participants such as tobacco use, physical inactivity, unhealthy diets, and harmful alcohol use.
This undermines the study’s power and ability to inform health policy and intervention
strategies to combat the future risk of NCDs in the country and other LMICs.

The study only estimated the crude prevalence of hypertension and/or diabetes and did not
adjust for the potential confounding effects of age. This could lead to the overestimation of the
true prevalence in the study population because HTN/DM2 prevalence is associated with age.

50
Student ID:10255822

The study adopted the cross-sectional study design; therefore, it could not assess the causality
concerning hypertension and type 2 diabetes and their association with different NCDs as risk
factors. It could only estimate the prevalence of HTN and DM2 which leaves the questions on
causality unanswered.
There was limited data to measure the prevalence among the different socio-demographics in
the study population. Hence, the study falls short of determining the HTN/DM2 prevalence by
the different population characteristics such as marital status, education levels, employment
status, family history, and more. This limits the ability of the study findings to guide health
policy reforms and intervention strategies that would adequately promote NCD services to
different population groups.

Due to limitations of the secondary data used, the study did not investigate the prevalence of
hypertensive and diabetic patients aware of their conditions who were on treatment, and those
with controlled hypertension and diabetes among those on treatment. This leaves a gap in the
use of this study to inform proper health resources allocation to address NCDs' challenges in
the country.

There was no mention of the calibration of BP machines used by the health workers from the
three HFs during BP measurement. This could result in calibration bias which could register
different BP results between different participants. Hence, the hypertension prevalence could
be under/overestimated in the study.

There were no known biochemical tests carried out to participants to distinguish between DM1
and DM2. Therefore, there is a possibility of having some DM1 participants included in the
study which could lead to misclassification bias. In turn, this could result in the overestimation
of the true DM2 prevalence in the study population.

51
Student ID:10255822

CHAPTER SIX

CONCLUSION AND RECOMMENDATIONS

6.1 Conclusion
Non-communicable diseases are now a high burden in Uganda and the region and are a
potential threat to small and struggling economies in sub-Saharan Africa. The occurrence of
NCDs is easily reversible if LMICs pay close attention to addressing the commonly known
metabolic and behavioural risk factors. Hypertension and diabetes are a significant burden in
rural Uganda which is consistent with other sub-Saharan African countries. The awareness rate
among hypertensive patients is still very poor compared to diabetic patients. The battle against
NCDs in SSA needs to begin with prevention measures mainly focusing on the diagnosis,
management, and control of the key risk factors like hypertension and diabetes. This study
leveraged the CSOs and information from the outpatient departments’ registry from rural
clinics to determine the prevalence of hypertension and diabetes. The study provides
demographic stratified findings by age and sex that could be used to inform hypertension and
diabetes treatment and management intervention decisions in rural Uganda.

6.2 Recommendations
To policy-makers, Ministry of Health and health care providers
Since hypertension awareness among patients was low in the study, there is a need to train and
empower community health workers with information and education materials to support
awareness campaigns on NCDs and their risk factors, like HTN and DM2 in the communities
they serve. This will inform the population on the possible burden of NCDs and their risk
factors, which will culminate into routine voluntary testing, timely enrollment on treatment and
control of these conditions before they are exacerbated.

Hypertension, diabetes, and other NCDs screening services need to be integrated into the
already existing government healthcare promotion programmes such as HIV testing and
treatment, immunization of children, plus sexual and reproductive health services. This will
ensure increased NCD awareness, treatment, and control at a low additional cost of service
delivery because it averts instituting new infrastructure for NCD services which promotes
efficient use of the already scarce healthcare resources in the country.

52
Student ID:10255822

Male participation at CSOs was slightly lower than the females in this study. Therefore, CSOs
should be conducted near male concentration points like community alcohol drinking points,
factories, carpentry and wood workshop centers, and construction sites, to ease and prompt
male participation in screening services.

Furthermore, hypertension and diabetes were commonly prevalent among older age-groups
compared to younger adults. Therefore, prevention intervention strategies like dietary feeding,
regular physical activity, tobacco smoking cessation, and limited alcohol consumption should
target this group. It is also common knowledge that elderly people are physically weaker and
less likely to attend routine CSOs. Thus, the use of mobile clinics needs to be devised to reach
out to remote areas where these people could be located to screen them for HTN and DM2.

To researchers

More research is needed on hypertension and diabetes co-morbidity prevalence, awareness,

and cost-effectiveness analysis of the various prevention and treatment measures for these
conditions. This will support policy-makers and healthcare professionals in the decision-
making process on efficient and effective interventions to control and manage NCDs given the
scarce healthcare resources.

There was limited literature available on the association between patients’ aging and
hypertension severity in the region. Hence, more research on this association and its causality
is needed to guide healthcare professionals on providing appropriate NCD treatment regimen
to their patients.

Future studies need to use randomly sampled participants who are well matched to the study
population age-group composition. Moreover, the BP machines need to be calibrated to provide
uniform BP results to eliminate calibration bias. It would also be important to perform
biochemical tests to distinguish DM1 and DM2 participants to eliminate misclassification bias.
The study could also measure the prevalence of diabetic and hypertensive participants on
treatment and those with controlled hypertension and/or diabetes to guide planning for NCD
services.

53
Student ID:10255822

REFERENCES
1. World Health Organization. Global Status Report on noncommunicable diseases:
"Attaining the nine global noncommunicable diseases targets; a shared responsibility."
WT 500. [Internet]. 2014 [cited 2019 Sep 18]. Available from:
https://apps.who.int/iris/bitstream/handle/10665/148114/9789241564854_eng.pdf
2. World Health Organization. Noncommunicable Diseases Progress Monitor. [Internet].
2017 [cited 2019 Sep 18]. Available from:
https://www.who.int/publications/i/item/9789241513029
3. World Health Organization. Noncommunicable diseases country profiles. [Internet].
2018 [cited 2019 Sep 18]. Available from:
https://www.who.int/publications/i/item/9789241513029
4. United Nations. Transforming our World: The 2030 Agenda for Sustainable
Development, A/RES/70/1. [Internet]. 2016 [cited 2019 Sep 18]. Available from:
http://wedocs.unep.org/bitstream/handle/20.500.11822/11125/unep_swio_sm1_inf7_s
dg.pdf?sequence=1
5. World Health Organization. Noncommunicable diseases. [Internet]. 2018 [cited 2019
Sep 18]. Available from: https://www.who.int/news-room/fact-
sheets/detail/noncommunicable-diseases
6. Christian N. Five Non-communicable Diseases, $47 Trillion Global Burden Over Next
Two Decades. Medical News Today. [Internet]. 2011 Sep 18. Available from:
https://www.medicalnewstoday.com/articles/234590.php
7. Allen L, Williams J, Townsend N, Mikkelsen B, Roberts N, Foster C, et al.
Socioeconomic status and non-communicable disease behavioural risk factors in low-
income and lower-middle-income countries: a systematic review. Lancet Glob Heal.
[Internet] 2017 [cited 2020 Apr 17] ;5(3):e277–89. Available from:
doi: 10.1016/S2214-109X(17)30058-X
8. World Health Organization. Noncommunicable diseases | Major NCDs and their risk
factors. [Internet]. 2016 [cited 2019 Sep 18]. Available from:
https://www.who.int/health-topics/noncommunicable-diseases#tab=tab_1
9. Yach D, Hawkes C, Gould CL, Hofman KJ. The global burden of chronic diseases:
overcoming impediments to prevention and control. Jama. 2004, Jun, 2;291(21):2616–
22.
10. Price AJ, Crampin AC, Amberbir A, Kayuni-Chihana N, Musicha C, Tafatatha T, et

54
Student ID:10255822

al. Prevalence of obesity, hypertension, and diabetes, and cascade of care in sub-
Saharan Africa: a cross-sectional, population-based study in rural and urban Malawi.
Lancet Diabetes Endocrinol. 2018, Mar;6(3):208–22.
11. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional
burden of disease and risk factors, 2001: systematic analysis of population health data.
Lancet. [Internet]. 2006 [cited 2019 Sep 18];367(9524):1747–57. Available from:
https://www.sciencedirect.com/science/article/pii/S0140673606687709
12. Jamison DT, Feachem RG, Makgoba MW, Bos ER, Baingana FK, Hofman KJ, Rogo
KO, editors. Disease and mortality in sub-Saharan Africa. [Internet]. 2nd ed.
Washington, DC: World Bank; 2006 [cited 2019 Sep 18]. Available from:
http://documents.worldbank.org/curated/en/431831468211449561/pdf/363050Disease
0101OFFICIAL0USE0ONLY1.pdf
13. World Bank. The growing danger of non-communicable diseases: acting now to
reverse course. [Internet]. 2011 [Cited 2019 Nov 20]. Available from:
http://documents.worldbank.org/curated/en/196871468336643958/pdf/657850WP0Bo
x360C00WBDeepeningCrisis.pdf
14. Byonanebye D, Bainomujuni B, Black D, Chamie G, et al. Evaluating linkage to care
for hypertension after community- based screening in rural Uganda. Trop Med Int
Health. 2015, Apr, 1;19(4):459–68.
15. Labhardt ND, Balo J, Ndam M, Grimm J, Manga E. Task shifting to non-physician
clinicians for integrated management of hypertension and diabetes in rural Cameroon :
a programme assessment at two years. BMC Health Serv Res. [Internet]. 2010 [cited
2019 Nov 20];10(1):339-48. Available from: http://www.biomedcentral.com/1472-
6963/10/339
16. Murphy GA V, Asiki G, Ekoru K, Nsubuga RN, Nakiyingi-Miiro J, Young EH, et al.
Sociodemographic distribution of non-communicable disease risk factors in rural
Uganda: a cross-sectional study. Int J Epidemiol. 2013, Nov, 4;42(6):1740–53.
17. De Ramirez SS, Enquobahrie DA, Nyadzi G, Mjungu D, Magombo F, Ramirez M, et
al. Prevalence and correlates of hypertension: a cross-sectional study among rural
populations in sub-Saharan Africa. J Hum Hypertens. 2010, Mar, 11;24(12):786–95.
18. Gouda HN, Charlson F, Sorsdahl K, Ahmadzada S, Ferrari AJ, Erskine H, et al.
Burden of non-communicable diseases in sub-Saharan Africa, 1990–2017: results from
the Global Burden of Disease Study 2017. Lancet Glob Heal. [Internet]. 2019 [cited
2020 May 7];7(10):e1375–87. Available from:

55
Student ID:10255822

https://www.sciencedirect.com/science/article/pii/S2214109X19303742
19. World Health Organization. WHO | Risk factors. [Internet]. 2019 [cited 2019 Dec 20].
Available from: https://www.who.int/gho/ncd/risk_factors/en/
20. Htet AS, Bjertness MB, Sherpa LY, Kjøllesdal MK, Oo WM, Meyer HE, et al. Urban-
rural differences in the prevalence of non-communicable diseases risk factors among
25-74 years old citizens in Yangon Region, Myanmar: A cross sectional study. BMC
Public Health. 2016, Dec, 5;16(1):1225-36.
21. Mathenge W, Foster A, Kuper H. Urbanization, ethnicity and cardiovascular risk in a
population in transition in Nakuru, Kenya: A population-based survey. BMC Public
Health. 2010, Sep, 22;10(1):569–80.
22. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global
estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin
Pract. 2014, Feb, 1;103(2):137–49.
23. World Health Organization. Global Report on Diabetes. WK 810. [Internet]. 2016
[cited 2019 Sep 18]. Available from:
https://apps.who.int/iris/bitstream/handle/10665/204871/9789241565257_eng.pdf
24. Rwegerera GM, Molefe-Baikai OJ, Masaka A, Shimwela M, Rivera YP, Oyewo TA,
et al. Prevalence of chronic kidney disease using estimated glomerular filtration rate
among diabetes patients attending a tertiary clinic in Botswana. Hosp Pract. 2018,
Aug, 14;46(4):214–20.
25. Ahlqvist E, Storm P, Käräjämäki A, Martinell M, Dorkhan M, Carlsson A, et al. Novel
subgroups of adult-onset diabetes and their association with outcomes: a data-driven
cluster analysis of six variables. lancet Diabetes Endocrinol. [Internet]. 2018 [cited
2020, May, 25];6(5):361–369. Available from: https://www-sciencedirect-
com.manchester.idm.oclc.org/science/article/abs/pii/S2213858718300512
26. World Health Organization. Classification of Diabetes Mellitus. [Internet]. 2019 [cited
2019 Sep 18]. Available from:
https://apps.who.int/iris/bitstream/handle/10665/325182/9789241515702-eng.pdf
27. World Health Organization. Guidelines on second-and third-line medicines and type of
insulin for the control of blood glucose levels in non-pregnant adults with diabetes
mellitus. [Internet]. 2018 [cited 2019 Sep 18]. Available from:
doi: 10.1192/bjp.111.479.1009-a
28. Buhule OD, Odwee JO, Atuhaire LK. Determinants of recovery time of diabetic
patients in Uganda. Makerere Univ Res J. 2007, Sep, 13;2(2):1–10.

56
Student ID:10255822

29. World Health Organization. A global brief on hypertension | A global brief on Hyper
tension. [Internet]. 2013 [cited 2019 Sep 19]. Available from: www.who.int
30. Felman A. Hypertension: Causes, symptoms, and treatments. Medical News Today.
[Internet]. 2019 Jul 22. Available from:
https://www.medicalnewstoday.com/articles/150109.php
31. Vedanthan R, Kamano JH, Naanyu V, Delong AK, Were MC, Finkelstein EA, et al.
Optimizing linkage and retention to hypertension care in rural Kenya (LARK
hypertension study): Study protocol for a randomized controlled trial. Trials. 2014,
Apr, 27;15(1):143–52.
32. Kayima J, Nankabirwa J, Sinabulya I, Nakibuuka J, Zhu X, Rahman M, et al.
Determinants of hypertension in a young adult Ugandan population in epidemiological
transition—the MEPI-CVD survey. BMC Public Health. 2015, Aug, 28;15(1):830–
838.
33. Grossman E, Messerli F. Hypertension and diabetes. Adv Cardiol. 2008, Jan
29;45(1):82-106.
34. Ferrannini E, Cushman WC. Diabetes and hypertension: The bad companions. Lancet.
2012, Aug, 11;380(9841):601-10.
35. Kavishe B, Biraro S, Baisley K, Vanobberghen F, Kapiga S, Munderi P, et al. High
prevalence of hypertension and of risk factors for non-communicable diseases
(NCDs): a population based cross-sectional survey of NCDS and HIV infection in
Northwestern Tanzania and Southern Uganda. BMC Med. 2015, May, 29;13(1):126–
46.
36. Muddu M, Mutebi E, Ssinabulya I, Kizito S, Mondo CK. Hypertension among newly
diagnosed diabetic patients at Mulago National Referral Hospital in Uganda: a cross
sectional study. South African J Diabetes Vasc Dis. 2018, Apr, 5;15(2):57–63.
37. Palafox B, Seguin ML, McKee M, Dans AL, Yusoff K, Candari CJ, et al. Responsive
and equitable health systems-partnership on noncommunicable diseases (RESPOND)
study: A mixed-methods, longitudinal, observational study on treatment seeking for
hypertension in Malaysia and the Philippines. BMJ Open. [Internet] 2018 [cited 2019
Sep 18];8(7):e024000. Available from: doi:10.1136/ bmjopen-2018-024000
38. LINKS. A global community for cardiovascular health. [Internet]. New York: Links
Community; [updated 2019; cited 2019 Nov 27]. Available from:
https://www.linkscommunity.org/about

57
Student ID:10255822

39. Nyombi K V, Kizito S, Mukunya D, Nabukalu A, Bukama M, Lunyera J, et al. High

prevalence of hypertension and cardiovascular disease risk factors among medical
students at Makerere University College of Health Sciences, Kampala, Uganda. BMC
Res Notes. 2016, Feb, 17;9(1):110-15.
40. Musinguzi G, Nuwaha F. Prevalence, awareness and control of hypertension in
Uganda. PLoS One. [Internet] 2013 [cited 2019 Sep 19];8(4):e62236. Available from:
doi:10.1371/ journal.pone.0062236
41. Lunyera J, Kirenga B, Stanifer JW, Kasozi S, van der Molen T, Katagira W, et al.
Geographic differences in the prevalence of hypertension in Uganda: Results of a
national epidemiological study. PLoS One.[Internet] 2018 [cited 2020 Jan
7];13(8):e0201001. Available from: https://doi.org/10.1371/journal.pone.0201001
42. Katende G, Groves S, Becker K. Hypertension education intervention with Ugandan
nurses working in hospital outpatient clinic: a pilot study. Nurs Res Pract. 2014, Dec,
8;2014(1):1-6.
43. Musinguzi G, Van Geertruyden J, Bastiaens H, Nuwaha F. Uncontrolled Hypertension
in Uganda: A Comparative Cross-Sectional Study. J Clin Hypertens. 2015,
Jan;17(1):63–9.
44. Mayega RW, Makumbi F, Rutebemberwa E, Peterson S, Östenson C-G, Tomson G, et
al. Modifiable socio-behavioural factors associated with overweight and hypertension
among persons aged 35 to 60 years in eastern Uganda. PLoS One. [Internet] 2012
[cited 2020 Jan 8];7(10):e47632. Available from: doi:10.1371/journal.pone.0047632
45. Maher D, Waswa L, Baisley K, Karabarinde A, Unwin N. Epidemiology of
hypertension in low-income countries: a cross-sectional population-based survey in
rural Uganda. J Hypertens. 2011, Jun, 1;29(6):1061–8.
46. Lasky D, Becerra E, Boto W, Otim M, Ntambi J. Obesity and gender differences in the
risk of type 2 diabetes mellitus in Uganda. Nutrition. 2002, May, 1;18(5):417–21.
47. Chiwanga FS, Njelekela MA, Diamond MB, Bajunirwe F, Guwatudde D, Nankya-
Mutyoba J, et al. Urban and rural prevalence of diabetes and pre-diabetes and risk
factors associated with diabetes in Tanzania and Uganda. Glob Health Action. 2016,
May, 23;9(1):31440–31447.
48. Mayega RW, Guwatudde D, Makumbi F, Nakwagala FN, Peterson S, Tomson G, et al.
Diabetes and pre-diabetes among persons aged 35 to 60 years in eastern Uganda:
prevalence and associated factors. PLoS One. [Internet] 2013 [cited 2020 Jan
7];8(8):e72554. Available from: https://doi.org/10.1371/journal.pone.0072554

58
Student ID:10255822

49. World Health Organization. Definition and diagnosis of diabetes mellitus and
intermediate hyperglycaemia : report of a WHO/IDF consultation. [Internet]. 2006
[cited 2019 Nov 19]. Available from: https://apps.who.int/iris/handle/10665/43588
50. Zafar TA. Characteristics of monitored diabetic patients by glycated haemoglobin
(HbA1c). Int J Bioassays. 2016, Apr, 21;5(5):4563–6.
51. D’Emden M. Glycated haemoglobin for the diagnosis of diabetes. Aust Prescriber.
2014, Jun;37(3):98–100.
52. Adler AJ, Laar A, Prieto-Merino D, Der RMM, Mangortey D, Dirks R, et al. Can a
nurse-led community-based model of hypertension care improve hypertension control
in Ghana? Results from the ComHIP cohort study. BMJ Open. [Internet] 2019 [cited
2019 Dec 2];9(4):e026799. Available from: doi:10.1136/ bmjopen-2018-026799
53. National High Blood Pressure Education Program. The seventh report of the joint
national committee on prevention, detection, evaluation, and treatment of high blood
pressure, 04-5230. [Internet]. 2004 [cited 2019 Sep 25]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK9630/
54. World Health Organization. Noncommunicable Diseases Country Profiles. [Internet].
2014 [cited 2019 Sep 18]. Available from: https://www.who.int/nmh/publications/ncd-
profiles-2014/en/Diseases Country Profiles 2014.
55. Bahendeka S, Wesonga R, Mutungi G, Muwonge J, Neema S, Guwatudde D.
Prevalence and correlates of diabetes mellitus in Uganda: a population-based national
survey. Trop Med Int Heal. 2016, Mar;21(3):405–16.
56. Guwatudde D, Nankya-Mutyoba J, Kalyesubula R, Laurence C, Adebamowo C, Ajayi
I, et al. The burden of hypertension in sub-Saharan Africa: a four-country cross
sectional study. BMC Public Health. 2015, Dec, 5;15(1):1211-18.
57. Wamala JF, Karyabakabo Z, Ndungutse D, Guwatudde D. Prevalence factors
associated with hypertension in Rukungiri district, Uganda-a community-based study.
Afr Health Sci. 2009, Sep, 3;9(3):153-160.
58. Kotwani P, Kwarisiima D, Clark TD, Kabami J, Geng EH, Jain V, et al. Epidemiology
and awareness of hypertension in a rural Ugandan community: a cross-sectional study.
BMC Public Health. 2013, Dec, 9;13(1):1151-60.
59. MONdO CK, Otim MA, Musoke R, Akol G, Orem J. The prevalence and distribution
of non-communicable diseases and their risk factors in Kasese district, Uganda.
Cardiovasc J Afr. 2013, Apr;24(3):52-57.
60. Wandera SO, Kwagala B, Ntozi J. Prevalence and risk factors for self-reported non-

59
Student ID:10255822

communicable diseases among older Ugandans: a cross-sectional study. Glob Health

Action. 2015, Dec, 1;8(1):27923-33.
61. Kirkwood BR, Sterne JAC. Essential medical statistics. 2nd ed. Goodgame F, Moore K,
editors. Oxford: Blackwell; 2003.
62. Peltzer K, Phaswana-Mafuya N. Depression and associated factors in older adults in
South Africa. Glob Health Action. 2013, Jan, 18;6(1):18871-18880.
63. Minicuci N, Biritwum RB, Mensah G, Yawson AE, Naidoo N, Chatterji S, et al.
Sociodemographic and socioeconomic patterns of chronic non-communicable disease
among the older adult population in Ghana. Glob Health Action. 2014, Apr,
15;7(1):21292–21305.
64. Chobanian A V, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL, et al. The
seventh report of the joint national committee on prevention, detection, evaluation, and
treatment of high blood pressure: the JNC 7 report. Jama. 2003, May,
21;289(19):2560–71.
65. Ministry of Health [MoH]. Non-Communicable Disease Risk Factor Baseline Survey.
Kampala, Uganda: MoH; 2014.
66. Islam SMS, Purnat TD, Phuong NTA, Mwingira U, Schacht K, Fröschl G. Non-
Communicable Diseases (NCDs) in developing countries: a symposium report. Global
Health. 2014, Mar, 22;10(1):81–87.
67. Haregu TN, Setswe G, Elliott J, Oldenburg B. Integration of HIV/AIDS and
noncommunicable diseases in developing countries: rationale, policies and models. Int
J Healthc. 2015, Aug, 7;1(1):21–27.
68. Uganda Bureau of Statistics. The national population and housing census 2014–main
report. Kampala: UBOS Kampala, Uganda; 2016.
69. Swinscow TD. Statistics at square one. XV--The chi-squared tests (continued). BMJ.
1976, Aug, 28;2(6034):513.
70. Wesonga R, Guwatudde D, Bahendeka SK, Mutungi G, Nabugoomu F, Muwonge J.
Burden of cumulative risk factors associated with non-communicable diseases among
adults in Uganda: evidence from a national baseline survey. Int J Equity Health. 2016,
Dec, 1;15(1):195–204.
71. Awoke A, Awoke T, Alemu S, Megabiaw B. Prevalence and associated factors of
hypertension among adults in Gondar, Northwest Ethiopia: a community based cross-
sectional study. BMC Cardiovasc Disord. 2012, Nov, 28;12(1):113–118.
72. Tesfaye F, Byass P, Wall S. Population based prevalence of high blood pressure

60
Student ID:10255822

among adults in Addis Ababa: uncovering a silent epidemic. BMC Cardiovasc Disord.
2009, Aug, 23;9(1):39–48.
73. Damasceno A, Azevedo A, Silva-Matos C, Prista A, Diogo D, Lunet N. Hypertension
prevalence, awareness, treatment, and control in Mozambique: urban/rural gap during
epidemiological transition. Hypertension. 2009, Jul, 1;54(1):77–83.
74. Bovet P, Ross AG, Gervasoni J-P, Mkamba M, Mtasiwa DM, Lengeler C, et al.
Distribution of blood pressure, body mass index and smoking habits in the urban
population of Dar es Salaam, Tanzania, and associations with socioeconomic status.
Int J Epidemiol. 2002, Feb, 1;31(1):240–7.
75. Matenga JA, Allain TJ, Wilson AO, Adamchak DJ, Senzanje B, Mushangi E, et al.
Hypertension management in Zimbabwe-awareness, treatment and blood pressure
control. South African Med J. 1997, Feb, 25;87(10):1371–1373.
76. Romdhane H Ben, Ali S Ben, Skhiri H, Traissac P, Bougatef S, Maire B, et al.
Hypertension among Tunisian adults: results of the TAHINA project. Hypertens Res.
2012, Dec, 1;35(3):341–7.
77. Houinato DS, Gbary AR, Houehanou YC, Djrolo F, Amoussou M, Segnon-Agueh J, et
al. Prevalence of hypertension and associated risk factors in Benin. Rev Epidemiol
Sante Publique. 2012, Apr, 1;60(2):95–102.
78. Addo J, Amoah AGB, Koram KA. The changing patterns of hypertension in Ghana: a
study of four rural communities in the Ga District. Ethn Dis. 2006, Sep, 1;16(4):894–9.
79. Hendriks ME, Wit FWNM, Roos MTL, Brewster LM, Akande TM, De Beer IH, et al.
Hypertension in sub-Saharan Africa: cross-sectional surveys in four rural and urban
communities. PLoS One. [Internet]. 2012 [cited 2020 Apr 22];7(3):e32638. Available
from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0032638
80. Pires JE, Sebastião Y V, Langa AJ, Nery S V. Hypertension in Northern Angola:
prevalence, associated factors, awareness, treatment and control. BMC Public Health.
2013, Jan, 31;13(1):90–99.
81. Kamadjeu RM, Edwards R, Atanga JS, Unwin N, Kiawi EC, Mbanya JC. Prevalence,
awareness and management of hypertension in Cameroon: findings of the 2003
Cameroon Burden of Diabetes Baseline Survey. J Hum Hypertens. 2005, Sep,
15;20(1):91–2.
82. Maepe LM, Outhoff K. Hypertension in goldminers. SAMJ South African Med J.
2012, Jan;102(1):30–3.
83. Malhotra R, Puoane T, Hoyo C, Hughes G, Ostbye T. Prevalence and awareness of

61
Student ID:10255822

hypertension in an urban township of South Africa: compelling need for action. Ethn
Dis. 2008, Sep, 1;18(4):401–2.
84. Ekwunife OI, Udeogaranya PO, Nwatu IL. Prevalence, awareness, treatment and
control of hypertension in a Nigerian population. SciRes. 2010, Mar, 26;7(2):731-735.
85. Oladapo OO, Falase AO, Salako L, Sodiq O, Shoyinka K, Adedapo K. A prevalence
of cardiometabolic risk factors among a rural Yoruba south-western Nigerian
population: a population-based survey. Cardiovasc J Afr. 2010, Feb;21(1):26–31.
86. Addo J, Smeeth L, Leon DA. Prevalence, detection, management, and control of
hypertension in Ghanaian civil servants. Ethn Dis. 2008, Jan, 1;18(4):505–11.
87. Mohamed SF, Mutua MK, Wamai R, Wekesah F, Haregu T, Juma P, et al. Prevalence,
awareness, treatment and control of hypertension and their determinants: results from a
national survey in Kenya. BMC Public Health. 2018, Nov, 7;18(3):1–10.
88. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden
of hypertension: analysis of worldwide data. Lancet. 2005, Jan, 15;365(9455):217–23.
89. Twagirumukiza M, Van Bortel LM. Management of hypertension at the community
level in sub-Saharan Africa (SSA): towards a rational use of available resources. J
Hum Hypertens. 2011, Jan;25(1):47–56.
90. Rodgers A, Ezzati M, Vander Hoorn S, Lopez AD, Lin R-B, Murray CJL, et al.
Distribution of major health risks: findings from the Global Burden of Disease study.
PLoS Med. [Internet]. 2004 [cited 2020 May 4];1(1):e27. Available from: doi:
10.1371/journal.pmed.0010027
91. Unwin N, Setel P, Rashid S, Mugusi F, Mbanya J-C, Kitange H, et al.
Noncommunicable diseases in sub-Saharan Africa: where do they feature in the health
research agenda? Bull World Health Organ. 2001;79(10):947–53.
92. Murray CJL, Lopez AD. Measuring the global burden of disease. N Engl J Med. 2013,
Aug, 1;369(5):448–57.
93. Tripathy JP, Thakur JS, Jeet G, Jain S. Prevalence and determinants of comorbid
diabetes and hypertension: Evidence from non communicable disease risk factor
STEPS survey, India. Diabetes Metab Syndr Clin Res Rev. 2017, Nov, 1;11(1):S459–
65.
94. Boutayeb A, Boutayeb S, Boutayeb W. Multi-morbidity of non communicable
diseases and equity in WHO Eastern Mediterranean countries. Int J Equity Health.
2013, Aug, 20;12(1):60-72.
95. Sobngwi E, Mbanya JCN, Unwin NC, Kengne AP, Fezeu L, Minkoulou EM, et al.

62
Student ID:10255822

Physical activity and its relationship with obesity, hypertension and diabetes in urban
and rural Cameroon. Int J Obes. 2002, Jun, 25;26(7):1009–16.
96. Amoah AGB, Owusu SK, Adjei S. Diabetes in Ghana: a community based prevalence
study in Greater Accra. Diabetes Res Clin Pract. 2002, Jun, 1;56(3):197–205.
97. Baldé N-M, Diallo I, Baldé M-D, Barry I-S, Kaba L, Diallo M-M, et al. Diabetes and
impaired fasting glucose in rural and urban populations in Futa Jallon (Guinea):
prevalence and associated risk factors. Diabetes Metab. 2007, Mar, 23;33(2):114–20.
98. Christensen DL, Friis H, Mwaniki DL, Kilonzo B, Tetens I, Boit MK, et al. Prevalence
of glucose intolerance and associated risk factors in rural and urban populations of
different ethnic groups in Kenya. Diabetes Res Clin Pract. 2009, Apr, 9;84(3):303–10.
99. Nyenwe EA, Odia OJ, Ihekwaba AE, Ojule A, Babatunde S. Type 2 diabetes in adult
Nigerians: a study of its prevalence and risk factors in Port Harcourt, Nigeria. Diabetes
Res Clin Pract. 2003, Jul, 31;62(3):177–85.
100. Alberts M, Urdal P, Steyn K, Stensvold I, Tverdal A, Nel JH, et al. Prevalence of
cardiovascular diseases and associated risk factors in a rural black population of South
Africa. Eur J Cardiovasc Prev Rehabil. 2005, Aug, 12;12(4):347–54.
101. Motala AA, Esterhuizen T, Gouws E, Pirie FJ, Omar MAK. Diabetes and other
disorders of glycemia in a rural South African community: prevalence and associated
risk factors. Diabetes Care. 2008, Sep, 1;31(9):1783–8.
102. Aspray TJ, Mugusi F, Rashid S, Whiting D, Edwards R, Alberti KG, et al. Rural and
urban differences in diabetes prevalence in Tanzania: the role of obesity, physical
inactivity and urban living. Trans R Soc Trop Med Hyg. 2000, Nov, 1;94(6):637–44.
103. João MP, Miguel B, João MP, Henrique B, Miguel B, Henrique B. Prevalence,
awareness, treatment and control of hypertension, diabetes and hypercholesterolaemia
among adults in Dande municipality, Angola. Cardiovasc J Afr. 2018, Mar, ;29(2):73–
81.
104. Azevedo M, Alla S. Diabetes in sub-saharan Africa: kenya, mali, mozambique,
Nigeria, South Africa and zambia. Int J Diabetes Dev Ctries. 2008, Oct;28(4):101–
108.
105. Namusisi O, Sekandi JN, Kasasa S, Wasswa P, Kamara NT, Medard B, et al. Risk
factors for non-communicable diseases in rural Uganda: a pilot surveillance project
among diabetes patients at a referral hospital clinic. Pan Afr Med J. 2011, Nov,
29;10(1):47-57.
106. Kamara NT, Asiimwe S. Dyslipidaemia and hypertension among adults with diabetes

63
Student ID:10255822

in rural Uganda. Trop Doct. 2010, Jan;40(1):41–2.

107. Choukem SP, Kengne AP, Dehayem YM, Simo NL, Mbanya JC. Hypertension in
people with diabetes in sub-Saharan Africa: revealing the hidden face of the iceberg.
Diabetes Res Clin Pract. 2007, Jan;77(2):293–9.
108. Kengne AP, Amoah AGB, Mbanya J-C. Cardiovascular complications of diabetes
mellitus in sub-Saharan Africa. Circulation. 2005, Dec, 6;112(23):3592–601.
109. Rotchford AP, Rotchford KM. Diabetes in rural South Africa-an assessment of care
and complications. South African Med J. 2002, Jul;92(7):536–41.
110. Ekpenyong CE, NE U, Akpan EE, Samson TK. Double burden, non-communicable
diseases and risk factors evaluation in sub-Saharan Africa: The Nigerian experience.
Eur J Sustain Dev. 2012, Jun, 1;1(2):249–270.
111. Muka T, Imo D, Jaspers L, Colpani V, Chaker L, van der Lee SJ, et al. The global
impact of non-communicable diseases on healthcare spending and national income: a
systematic review. Eur J Epidemiol. 2015, Apr, 1;30(4):251–77.
112. Magodoro IM, Esterhuizen TM, Chivese T. A cross-sectional, facility based study of
comorbid non-communicable diseases among adults living with HIV infection in
Zimbabwe. BMC Res Notes. 2016, Aug, 2;9(1):379–88.
113. Haregu TN, Oldenburg B, Sestwe G, Elliott J, Nanayakkara V. Epidemiology of
comorbidity of HIV/AIDS and non-communicable diseases in developing countries: a
systematic review. J Glob Heal Care Syst. 2012;2(1):1–12.
114. Patil RR, Garg BS. Prevalence of hypertension and variation in blood pressure among
school children in rural area of Wardha. Indian J Public Health. 2014, Jun,
16;58(2):78–83.
115. Mengistu MD. Pattern of blood pressure distribution and prevalence of hypertension
and prehypertension among adults in Northern Ethiopia: disclosing the hidden burden.
BMC Cardiovasc Disord. 2014, Mar, 5;14(1):33–40.
116. Arnett DK, Boland LL, Evans GW, Riley W, Barnes R, Tyroler HA, et al.
Hypertension and arterial stiffness: the Atherosclerosis Risk in Communities Study.
Am J Hypertens. 2000, Apr;13(4):317–23.
117. Agmon Y, Khandheria BK, Meissner I, Schwartz GL, Petterson TM, O’Fallon WM, et
al. Independent association of high blood pressure and aortic atherosclerosis: a
population-based study. Circulation. 2000, Jun, 8;102(17):2087–93.
118. Williams CL, Hayman LL, Daniels SR, Robinson TN, Steinberger J, Paridon S, et al.
Cardiovascular health in childhood: a statement for health professionals from the

64
Student ID:10255822

Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of

the Council on Cardiovascular Disease in the Young, American Heart Association.
Circulation. 2002, Jul, 2;106(1):143–60.
119. Boodai SA, Cherry LM, Sattar NA, Reilly JJ. Prevalence of cardiometabolic risk
factors and metabolic syndrome in obese Kuwaiti adolescents. Diabetes, Metab Syndr
Obes targets Ther. 2014, Oct;7(1):505–511.
120. Franklin SS, Gustin IV W, Wong ND, Larson MG, Weber MA, Kannel WB, et al.
Hemodynamic patterns of age-related changes in blood pressure: the Framingham
Heart Study. Circulation. 1997, Jul, 1;96(1):308–15.
121. Sokolow M, Werdegar D, KAIN HK, HINMAN AT. Relationship between level of
blood pressure measured casually and by portable recorders and severity of
complications in essential hypertension. Circulation. 1966, Aug;34(2):279–98.
122. Kannel WB, Gordan T. Evaluation of cardiovascular risk in the elderly: the
Framingham study. Bull N Y Acad Med. 1978, Jun;54(6):573–591.
123. Duboz P, Boëtsch G, Gueye L, Macia E. Hypertension prevalence, awareness,
treatment and control in Dakar (Senegal). J Hum Hypertens. 2014, Jan, 16;28(8):489–
93.
124. Solet J-L, Baroux N, Pochet M, Benoit-Cattin T, De Montera A-M, Sissoko D, et al.
Prevalence of type 2 diabetes and other cardiovascular risk factors in Mayotte in 2008:
the MAYDIA study. Diabetes Metab. 2011, Jun, 1;37(3):201–7.
125. Agyemang C, Bruijnzeels MA, Owusu-Dabo E. Factors associated with hypertension
awareness, treatment, and control in Ghana, West Africa. J Hum Hypertens. 2006,
Jan;20(1):67–71.
126. Dzudie A, Kengne AP, Muna WFT, Ba H, Menanga A, Kouam CK, et al. Prevalence,
awareness, treatment and control of hypertension in a self-selected sub-Saharan
African urban population: a cross-sectional study. BMJ Open. [Internet]. 2012 [cited
2020 Apr 22];2(4):e001217. Available from: doi:10.1136/bmjopen-2012-001217
127. Addo J, Smeeth L, Leon DA. Hypertension in sub-saharan Africa: a systematic review.
Hypertension. 2007, Dec, 1;50(6):1012–8.
128. Cornell M. Gender inequality: Bad for men’s health. South Afr J HIV Med. 2013, Mar,
11;14(1):12–14.
129. Shand T, Thomson-de Boor H, van den Berg W, Peacock D, Pascoe L. The HIV blind
spot: men and HIV testing, treatment and care in sub-Saharan Africa. IDS Bull. 2014,
Jan;45(1):53–60.

65
Student ID:10255822

130. Türmen T. Gender and HIV/aids. Int J Gynecol Obstet. 2003, Sep, 1;82(3):411–8.
131. Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature
review. J Adv Nurs. 2005, Mar, 26;49(6):616–23.
132. Antai D, Ghilagaber G, Wedrén S, Macassa G, Moradi T. Inequities in under-five
mortality in Nigeria: differentials by religious affiliation of the mother. J Relig Health.
2009, Sep, 1;48(3):290–304.
133. Kayima J, Wanyenze RK, Katamba A, Leontsini E, Nuwaha F. Hypertension
awareness, treatment and control in Africa: a systematic review. BMC Cardiovasc
Disord. 2013, Aug, 2;13(1):54–64.
134. Pereira M, Lunet N, Azevedo A, Barros H. Differences in prevalence, awareness,
treatment and control of hypertension between developing and developed countries. J
Hypertens. 2009, May, 1;27(5):963–75.
135. Maher D, Waswa L, Baisley K, Karabarinde A, Unwin N, Grosskurth H. Distribution
of hyperglycaemia and related cardiovascular disease risk factors in low-income
countries: a cross-sectional population-based survey in rural Uganda. Int J Epidemiol.
2011, Feb, 1;40(1):160–71.
136. Ministry of Health, Health Sector Development Plan 2015/16 - 2019/20. 2015.
Kampala, Uganda. [Internet]. 2015 [cited 2020 Jun 15]. Available from:
https://health.go.ug/sites/default/files/Health Sector Development Plan 2015-16_2019-
20.pdf
137. Rogers HE, Akiteng AR, Mutungi G, Ettinger AS, Schwartz JI. Capacity of Ugandan
public sector health facilities to prevent and control non-communicable diseases: an
assessment based upon WHO-PEN standards. BMC Health Serv Res. 2018, Aug,
6;18(1):606–618.
138. Faeh D, William J, Tappy L, Ravussin E, Bovet P. Prevalence, awareness and control
of diabetes in the Seychelles and relationship with excess body weight. BMC Public
Health. 2007, Jul, 19;7(1):163–161.

66
Student ID:10255822

APPENDICES
Appendix 1: Secondary data use permission letter

67
Student ID:10255822

Appendix 2: Literature Database Search Results

68
Student ID:10255822

69
Student ID:10255822

70
Student ID:10255822

71
Student ID:10255822

72
Student ID:10255822

73
Student ID:10255822

74
Student ID:10255822

75
Student ID:10255822

76
Student ID:10255822

77
Student ID:10255822

78
Student ID:10255822

79
Student ID:10255822

80
Student ID:10255822

81
Student ID:10255822

82
Student ID:10255822

83