Determinants of High Blood Pressure and Quality of Management in Three Regions of Benin

Objective: The aim of this work was to determine the prevalence, associated factors and quality of high blood pressure (HBP) management in three regions of Benin in 2015. Methodology: This was a cross-sectional study, with two components. The first component included adults aged from 18 to 69 years, selected using a three-stage random sampling within the households. Data were collected thanks to the French version of the WHO STEPS instrument. Anthropometric data, including blood pressure, capillary fasting glucose and total cholesterol were measured according to standard procedures. The second component included Public Health Centers (PHC) selected by a random stratified multi-stage sampling. Data were collected on the structures and the processes of HBP management using the standardized tool for assessing the capacities of management of non-communicable diseases in peripheral health centers provided by the World Health Organization. Results: A total of 4816 participants were included in the first component. The mean age was 35.8 ± 12.7 level of community involvement in the management of HBP was noted. Conclusion: This study confirms the high prevalence of HBP and shows inadequacies in its management in the targeted PHC. More appropriate prevention and control measures for HBP should be implemented.


Introduction
High blood pressure (HBP) is one of the major risk factors for cardiovascular disease. It is one of the leading causes of death in the world where it caused about 10 million deaths and 218 million disability-adjusted life-years (DALYs) in 2015 [1] [2]. More than one third of the world adult populations suffer from HBP [3]. Sub-Saharan Africa is the region with the highest prevalence [3], ranging from 18% to 50% among adults [1] [4] [5] [6] [7]. The factors associated with HBP vary according to the epidemiological studies [5] [6] [7]. High-income countries have begun to reduce the prevalence of HBP in their populations through collective prevention measures and the provision of widely accessible diagnosis and treatment services. In sub-Saharan Africa, however, few people know their blood pressure status and few hypertensive patients are under treatment [8] [9] [10]. This may be due to inadequacies in the availability and accessibility of basic technologies and essential medicines in the health facilities, coupled with beliefs, low educational level and low economic status of some patients. Adequate and low-cost treatment of HBP patients is a challenge for health systems in sub-Saharan Africa. For World Health Organization (WHO) experts', attention should be paid to improve the quality of primary care at the peripheral level [11]. Among the nine targets of the global plan of action for the fight against noncommunicable diseases (NCDs) 2013-2020, there are three directly linked to the treatment of HBP.
Today, the world objectives called Sustainable Development Objectives (SDO) take into account NCDs [12]. However, the lack of reliable periodic epidemiological data would lead to the implementation of inappropriate interventions, leading not only to the failure to achieve the SDO but also to the wastage of already limited resources. In Benin, according to data from the national STEPS survey on the main risk factors (RF) of NCDs carried out in 2008, nearly 30% of the population aged 25 to 64 years had HBP [13]. This situation confirms the

Objectives
The objective of this work was to determine the prevalence of HBP in 2015 among adults aged from 18 to 69 years living in the departments of Mono, Couffo and Donga, to identify associated factors and to assess the quality of HBP management in the PHC of these regions. and commune health centers (CHC). The DHC has a dispensary run by a nurse.

Study Framework
The CHC is led by a medical doctor who also supervises the activities of the DHC of his commune.

Study Design
It was a cross-sectional study with a descriptive and analytical purpose. It included two components. The first part dealt with the prevalence and the associated factors to HBP and the second part evaluated the treatment of HBP.

Study Population, Sampling, Data Collection and Analysis
Component I: The study population was constituted of all adults aged from 18 to 69 years Open Journal of Epidemiology living in the PIS for at least six months, were excluded from the study, all those who had not given their consent, those who had been given two unsuccessful visits, and anyone with a medical condition that prevented the administration of the questionnaire as: speech and language understanding problems, major mental problems.
Participants were selected using a three-stage random sampling technique.  [16]. Individual face-to-face interviews provided sociodemographic data, behavioral risk factors and data on the history of NCDs (STEP 1). Anthropometric measurements were then taken (STEP 2). The biological measurements were carried out the following morning after a fasting of at least 8 hours (STEP 3).
The weight of each participant was measured using an electronic scale of 0.1 kg (Model 753 E, Seca, Hamburg, Germany). The height was measured in a standing position with SECA gauge to within 0.1 cm. The Body Mass Index (BMI) was calculated using the formula BMI = weight (in kg)/height 2 (in square meter). Waist circumference (WC) was measured at 0.1 cm using a non-elastic tape measure and WHO standards were used (<102 cm for men, <88 cm for women) [17]. The food evaluation was carried out using food models (standard glass, bowl, standard portions of fruits) to assess the food consumption of the subjected persons.
Blood pressure was measured three times in a row at 5-minute intervals while sitting in the left arm after a rest period of at least 15 minutes and using an electronic blood pressure device (Boso medicus, Germany). The average of the last two measures represented the systolic and diastolic blood pressures.
Blood glucose and cholesterol were measured on capillary blood using a read-Open Journal of Epidemiology Component II: The population of quality care component was constituted of the PHC of the target areas. The PHC were selected using a stratified multi-stage random sampling. The Departments hospitals and health zone hospitals were systematically retained. In each of target department, 25% of the CHC were selected randomly.
In each of the communes selected, 10% of the DHC were selected randomly.
The quality of care was evaluated through three dimensions: the structures, the care process and the results.
A team of two investigators visited each of the selected PHC. Data were collected through interviews with health center managers and health care providers, direct visits observation; review of records and/or care registers, and face-toface interviews with HBP patients. The standardized tool for assessing NCDs management capacity at the peripheral health center level developed by WHO was adapted for the study [18]. It included four sections on: the structures (availability of equipment, protocol of care, care providers, clinical and paraclinical examinations, essential medicines, community participation in the HBP management ...); the visit observation; the review of 12-months HBP patients' data concerning the care process (taking anthropometric measurements, prescribing biological exams, treatments, health and diet advice, setting up a follow-up appointment, blood pressure level during follow-up); and a questionnaire on the satisfaction of visited patients.
The number of observations and records has been reasonably defined. Ten patients present in each PHC at the time of the survey that were consulted for HBP, were randomly selected for the observation and the satisfaction survey.
The data analysis was made using the Epi Info 7 software. The qualitative variables were expressed as percentages. Missing data related to failure to keep files and care records books by health workers have not been able to evaluate the effectiveness of the HBP management in PHC.

Ethical Considerations
The study protocol received the agreement of the National Committee for Ethics in Health Research (NCEHR). The agreements of the departmental directors of Open Journal of Epidemiology health, the chief medical officers of the health zone, the directors of the hospitals, the responsibles of the health centers, the heads of districts, the heads of the home towns and villages, were obtained before the beginning of the investigation. The free, enlightened and written consent of each participant was required.
The personal data of the participants were protected and the anonymity of the information collected was strictly respected during the investigation. The information related to main NCDs risk factors is presented in Table 2.

Component
Nearly one-tenth of the participants were smokers. Approximately 3% of them consume abusively alcohol. Nearly a quarter of them had a low level of physical activity and more than one-tenth of them added salt to a cooked food. The majority of participants (87.5%) had insufficient consumption of fruits and vegetables of less than 5 servings or 400 g per day. The prevalence of obesity was estimated at 6.7%, that of hyperglycemia at 8.7% and that of hypercholesterolemia at 3.5%.

Prevalence of HBP and Associated Risk Factors
The information related to the diagnosis, measurement and previous treatment of blood pressure is given in  Table 3). It was higher in males compared to females (adjusted OR = 1.13; 95% CI [1.11 -1.15)]) (see Table 4).     Table 4).  Less than one-fifth of the health workers in the PHC have received specific, recent, continuing professional training on HBP (Table 5).  Basic materials for blood pressure measurement and for obesity screening were available in most of the PHC (Table 5). Inversely, care protocols and education materials for the prevention of cardiovascular diseases were scarcely available in these PHC, especially in the DHC (

Discussion
The study population was relatively young with an average age of 35 years.
About one-tenth smoked tobacco. More than one-fifth of the participants were sedentary. Less than one fifth consumed a sufficient quantity of fruits and vegetables. One in four participants had high blood pressure or a history of HBP under treatment and was classified HBP patient. The prevalence of HBP was similar to that observed in the national STEPS 2008 survey (27.9%) [12]. years (17.6%) [19]. However, it is significantly lower than that reported in South Africa in the province of Limpopo by Ntuli (41%) out of a size of 1281 people aged 15 years and over [7].
The prevalence of HBP increased with age as classically reported in the literature. Urban residents had higher prevalence of HBP compared to those living in rural areas. These findings are consistent with the results of the national STEPS 2008 survey [12] as well as those reported by other African authors [8] [20] [21].
This difference in risk was explained in Benin by the higher incidence of poor diet, lack of physical activity and inadequate consumption of fruit and vegetables in the cities compared to the countryside [22]. This explanation still seems valid; further analysis of the database study will confirm this.

Strengths and Limits
The study is one of the first in Benin and sub-Saharan Africa to evaluate both the prevalence and the management of HBP. The results of this study constitute the baseline data for the local response plan against HBP evaluation. The first part of the study was conducted using the STEPS methodology recommended by the WHO for the surveillance of NCDs risk factors, thus ensuring comparability with other studies from STEPS surveys. A three-stage random sampling technique was applied for the selection of people, a number of subjects required were predetermined and a response rate greater than 90% was obtained. A representative sample was thus constituted.
The collection of behavioral variables was based on statements; information biases, in particular social desirability, may have been introduced, which may underestimate the proportions observed. The blood pressure standards used correspond to the WHO criteria [19]. However, the operational definition used for HBP may lead to an overestimation of the prevalence of HBP, as it is based Open Journal of Epidemiology on point measurements.
Regarding the quality of HBP management, in particular the follow-up visits of hypertensive patients may have been underestimated by default in recording data because their collection was based on the retrospective files. In addition, patient satisfaction in hospitals may have been overestimated as it is based on reports collected within the hospital. Additionally, the study concerned only three departments among twelve. The results are not applicable to all the public health centers in Benin. The management of HBP in a department like Cotonou (economic capital of Benin) could be better.

Conclusion
This work allows updating the data on the HBP in general population in Benin, particularly in the area studied. It confirms earlier findings on the importance of HBP in Benin. They also show the low availability of essential medicines and supplementary balance sheets for adequate minimal management of HBP in peripheral PHC. It is necessary to carry out more efficient actions in Benin, in particular in the SIP, for better prevention and adequate and low-cost treatment of HBP in these populations.