The uneven road to controlling hypertension

Education, wealth shape disparities in diagnosis and treatment, studies find

Bangladesh is among 14 countries where hypertension diagnosis rates differ by at least 10 percentage points across educational groups, according to a World Health Organization report released on Tuesday.

Using Bangladesh’s 2018 STEPS survey, the WHO found that hypertension diagnosis was more common among adults aged 30-69 with secondary or higher education than those with less than primary schooling. The comparison is part of an assessment of 32 countries with education-disaggregated data.

The report, State of inequality: noncommunicable diseases and their risk factors, is the WHO’s first global assessment of within-country inequalities in the burden, detection and treatment of major chronic diseases. It draws on nine international datasets and examines 35 indicators.

A Bangladesh study published three days earlier found a substantial education gap even among patients receiving treatment.

Blood pressure was controlled in only 35.8 percent of treated patients without formal schooling, compared with 59.4 percent of those with higher education, according to the paper published on October 17 in the Journal of Epidemiology and Global Health.

The researchers analysed 13,760 adults aged 18 and above from the 2022 Bangladesh Demographic and Health Survey (BDHS). They found that patients with higher education had just over twice the odds of achieving blood pressure control. 

However, the association does not prove that education itself caused better outcomes.

Hypertension affected 20.7 percent of adults in the analysis. Of those with the condition, 54.8 percent knew they had it, and 45.1 percent were receiving treatment.

Among treated patients, 43.6 percent had controlled blood pressure. As fewer than half of those with hypertension were receiving medication, only 19.7 percent of all adults with the condition had their blood pressure under control.

A separate study published in June, also based on the 2022 BDHS, found that access to diagnosis and treatment varied by wealth.

Among adults with hypertension, 66.3 percent of those from the wealthiest 20 percent of households had been diagnosed, compared with 53.6 percent of those from the poorest 20 percent.

Among those diagnosed, 79.5 percent of the richest group received treatment, against 61.7 percent of the poorest.

Published in PLOS Global Public Health, the study also found that hypertension prevalence was higher among the wealthiest 20 percent of households, at 27.1 percent, than the poorest 20 percent, at 17.3 percent. The poorer group’s disadvantage lay in diagnosis and treatment, rather than a higher measured prevalence.

Another analysis of the 2022 BDHS, published in July, found that blood pressure control among people with hypertension improved from 12.5 percent in 2017–18 to 19.3 percent in 2022. Treatment coverage rose from 37.0 percent to 44.6 percent over the same period.

The June, July and October studies use overlapping samples from the 2022 BDHS, while the WHO report relies on older STEPS data.

Organised hypertension treatment programmes in Bangladesh have reported higher control rates among enrolled patients.

At a seminar in May, Dr Syed Zakir Hossain, former line director of the Non-Communicable Disease Control programme under DGHS, said 446 NCD corners had been established, and over 918,000 patients with hypertension had been registered digitally.

“Through our digital system, blood pressure is now being successfully controlled among 58 percent of patients under treatment,” he said.

The figure applies to patients enrolled in the programme, not everyone with hypertension. Population-level estimates also include people who have never been diagnosed or started treatment.

The October study’s authors called for community screening, continuous access to affordable medicines, and the integration of patient education and follow-up into primary care, particularly for people with limited education.