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Prevalence of Undiagnosed Hypertension Among Adult Displaced Individuals in Baidoa

Camps, Somalia

Mohamed Jayte

1Internal Medicine Department of Kampala International University Teaching Hospital.,

Kampala, Uganda

Correspondence: Mohamed Jayte, Department of Medicine, Kampala International University,

P.O. Box 7062, Kampala, Uganda. Tel: +256 55272543; Email:
[Link]@[Link]

Abstract

Introduction

Hypertension may be prevalent among internally displaced people who typically do not engage
in sedentary activities throughout the day. However, the prevalence of hypertension in this
population remains poorly understood. In this study, we aimed to determine the prevalence of
undiagnosed hypertension and associated factors among adults living in internally displaced
people (IDP) camps around Baidoa.

Methods

A cross-sectional study was conducted, recruiting displaced persons in camps aged 18 years or
older without a prior diagnosis of hypertension or current use of anti-hypertensive therapy. A
standardized questionnaire was administered, and body mass index (BMI) was calculated.
Hypertension was defined as two consistent measurements of systolic blood pressure
≥140mmHg and/or diastolic blood pressure ≥90mmHg, taken 4 hours apart. Multivariable
logistic regression analysis was performed to identify factors independently associated with
undiagnosed hypertension. Statistical significance was set at p<0.05.

Results:

A total of 240 participants were enrolled, with a mean age of 39.4 ± 12.8 years. The majority
were female (83.3%, n=199) and urban dwellers (88.3%, n=212). The prevalence of undiagnosed
hypertension was 16.7% (n=40). Of the participants with hypertension, 40% (n=16) were
younger than 40 years. Factors associated with undiagnosed hypertension included age >50 years
(adjusted odds ratio (aOR): 7.0, 95% confidence interval (CI): 1.9 to 25.6, p=0.003), male gender
(aOR: 4.2, 95% CI: 1.5 to 11.1, p=0.005), tobacco consumption (aOR: 2.6, 95% CI: 1.1 to 6.0,
p=0.021), and being overweight (aOR: 3.6, 95% CI: 1.5 to 8.8, p=0.005).

NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
medRxiv preprint doi: [Link] this version posted March 26, 2024. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-ND 4.0 International license .

Conclusion:

Approximately one in six adult IDPs living in camps around Baidoa had undiagnosed
hypertension, with a disproportionately high burden among those younger than 40 years. Further
larger multi-centric studies are warranted to validate these findings.

Keywords: hypertension, internally displaced people, physical activity, tobacco, Somalia.

Introduction

Between the years 1975 and 2015, the prevalence of hypertension among adults surged from
approximately 594 million cases to surpass a billion cases worldwide 1. Hypertension, alongside
other non-communicable diseases (NCDs), stands as a primary contributor to premature
mortality in both affluent and impoverished nations 2 NCDs alone are responsible for more than
70% of annual deaths globally, exceeding 41 million cases, with a significant portion—between
75% and 80%—of these fatalities occurring in low- and middle-income countries (LMICs)3 (3).
Recent findings from the World Health Organization reveal that approximately 27% of adults in
sub-Saharan Africa exhibit hypertension, surpassing the global average of 22% 3.

Hypertension exacts a toll of roughly 7% of the global burden of disability-adjusted life years,
and it contributes to nearly 45% of cardiovascular morbidity and mortality worldwide 4. This
condition is implicated in around 9.4 million fatalities, accounting for approximately 17% of all
global deaths. Over the past few decades, the burden of hypertension has surged exponentially)1.
Despite this, a considerable proportion of individuals with hypertension remain undiagnosed,
untreated, or inadequately treated, thereby heightening the risk of hypertension-related
complications, including stroke and myocardial infarction 5.

In Africa, the estimated prevalence of hypertension has steadily climbed from 54.6 million in
1990 to 92.3 million in 2000—a 70% increase— and further to 130.2 million in 2010, marking a
41% rise from 2000. Projections indicate that this figure will soar to 216.8 million by 2030,
constituting a 66% rise from 2010 6. In sub-Saharan Africa specifically, the total number of
individuals with hypertension was estimated at 75 million in 2008 and is anticipated to reach
125.5 million by 2025 7. Despite this high burden, over three-quarters of cases in Africa are
unaware of their hypertension status 8.

In Somalia, according to the Findings from the Somali Health and Demographic Survey 2018-
2019, the overall prevalence of hypertension was 26%9. This study also found out that the
prevalence of hypertension is high in Advanced age, female gender, urban residence, and
elevated wealth status were associated with higher likelihood of having a chronic disease;
therefore, early identification of subjects with undiagnosed hypertension may prevent or reduce
progression of many of its serious complications. Therefore, we aimed to determine the
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prevalence and factors associated with undiagnosed hypertension among adult Displaced People
in Camps in Baidoa, Somalia.

Study Design and Setting

I conducted a cross-sectional study among adult internally displaced persons (IDPs) residing in
camps situated within a 10 km radius of Baidoa town, South west state, Somalia. The camps
reside approximately 5000 internally displaced persons (IDPs). Notably, the camps lack a health
wellness facility, and all medical services are accessed from nearby health centers or Bay
Regional Referral Hospital, situated approximately 1 kilometer away from the camps.

Study Population

Adults aged 18 years and above living in the selected camps were invited to participate through
home visits and announcements at community centers. Exclusion criteria were pregnancy,
physical disabilities that impair measurement of blood pressure, and severe mental illness.
Participants were enrolled consecutively until the required sample size per camp was reached,
based on probability proportional to size sampling.

Sampling Technique and Procedure

The study employed a systematic sampling approach, ensuring that each individual within the
population had an equal opportunity for selection. However, participants with pre-existing
diagnoses of hypertension, individuals undergoing anti-hypertensive treatment, those with
known heart conditions, pregnant women, and individuals under the age of 18 were
systematically excluded from the study. Subsequently, the next eligible participant in the
sequence was enrolled. This method facilitated the acquisition of samples that accurately
represented the population while concurrently mitigating potential biases and optimizing time
efficiency.

Sample Size Determination

The sample size for this study was determined utilizing the Kish–Leslie formula (1965).
Considering a 95% confidence level (corresponding to a standard value of 1.96), a presumed
prevalence of undiagnosed hypertension set at 50% due to the absence of prior studies, a
maximum acceptable marginal error of 5% (0.05), and a statistical power of 80%, the calculated
minimum sample size was 385 participants. Accounting for the finite population factor due to the
estimated total population of 5000 individuals across all camps in Baidoa town, a final sample
size of 240 participants was determined, accommodating a 10% allowance for non-response.
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Data Collection

A structured questionnaire, translated into Somali, was administered in person to gather socio-
demographic data, encompassing age, gender, educational attainment, marital status, tobacco and
khat usage, duration of displacement, and family history of hypertension. Height, weight, and
blood pressure measurements were acquired utilizing standardized protocols. Blood pressure
readings were obtained in triplicate using a digital sphygmomanometer following a 5-minute
period of rest in a seated position, with the average of the final two readings utilized for analysis.

Weights of the participants were measured employing a calibrated stand-on weighing scale. Each
participant stood upright on the scale without footwear and with no additional weight in their
hands or pockets, and their weight was subsequently recorded. Heights were determined using a
height board, with participants standing barefoot on the height meter in an upright position, head
forward, and arms hanging naturally at their sides. The maximum height was measured and
recorded in meters. Body Mass Index (BMI) was then computed by dividing the weight in
kilograms by the square of the height in meters to ascertain whether the respondent fell into the
obese category.

Operational Definitions:

• Obesity: Defined as a Body Mass Index (BMI) greater than 30 kg/m^2.

• Overweight: Defined as a Body Mass Index (BMI) falling between 25 and 29.9 kg/m^2.

• Hypertension: Defined as a systolic blood pressure (SBP) measurement of at least 140

mmHg and/or a diastolic blood pressure (DBP) measurement of at least 90 mmHg, with
readings taken at least 4 hours apart.

Statistical analysis

The data underwent initial cleaning and preparation using Microsoft Excel 2016 before being
imported into STATA Software Version 17.0 for analysis. Continuous variables, such as age and
blood pressure, were re-categorized into categorical outcomes following established guidelines.
Subsequently, a bi-variable logistic regression analysis was performed to examine the association
between undiagnosed hypertension and sociodemographic characteristics, as well as other risk
factors. The results were presented as crude odds ratios (cOR) along with their respective 95%
confidence intervals (CI) and p-values.

Independent variables demonstrating some evidence of association with the dependent variable
at the bi-variable analysis level (p < 0.2) were incorporated into the multi-variable logistic
regression model, alongside known risk factors of hypertension with borderline outcomes. Step-
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wise logistic regression analysis was then conducted, adjusting for all recognized confounders.
The outcomes of the multi-variable logistic regression are delineated as adjusted odds ratios
(aOR) accompanied by their respective 95% CI and p-values. A significance level of p < 0.05
was considered indicative of a robust association between the independent and dependent
variables.

Variables with fewer than five outcomes were excluded from the multi-variable regression due to
data sparseness, and collinearity among all variables in the model was assessed. Collinearity was
deemed present if the variables exhibited a variance inflation factor (VIF) exceeding 3.

In this study, a total of 240 respondents were enrolled. The mean age of all study participants
was 39.4 ± 12.8 years. The majority of participants were female, constituting 83.3% (n=199),
and the predominant marital status among participants was married, accounting for 63.8%
(n=153). Regarding residential distribution, 11.67% of participants resided in rural areas, while
the majority, 88.33%, lived in urban areas (Table 1).

Table 1

Demographic Characteristics of the Study Participants

Socio-Demographic Characteristics N=240 %

Age, years <29 62

30–39 73
40–49 59
>50 46
Sex Male 40
Female 199
Marital Status Single 57
Married 153
Divorced/Separated 30
Education Level None 35
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Socio-Demographic Characteristics N=240 %

Primary 105
Secondary/Tertiary 100
Residence Rural 28
Urban 212

Behavioral and Socio-Economic Characteristics of the Participants

A substantial proportion, 57.5% (n=138), of the study participants reported a larger household
size. Additionally, 30.8% (n=74) of participants engaged in agriculture alongside market sales.
The majority, comprising 75.4% (n=181) of participants, reported no history of smokeless
tobacco consumption, while only 0.8% (n=2) reported smoking cigarettes. Positive family
history of hypertension was documented for 28.3% (n=68) of participants, whereas 4.2% (n=10)
reported a family history of diabetes mellitus (Table 2)

Table 2

Behavioral and Socio-Economic Characteristics of the Participants

Variable Category Frequency Percent

Household size ≤5 102 42.5

≥6 138 57.5
Other occupation None 149 62.08
Agriculture 74 30.83
Others 17 7.08
smokeless tobacco No 181 75.42
Yes 59 24.58
Duration usage of smokeless tobacco Never 181 75.42
<1 year 40 16.67
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Variable Category Frequency Percent

>1 year 19 7.92

smokeless tobacco quantity Never 181 75.42
1 box 34 14.17
>1 box 25 10.42
Smoking history No 238 99.17
Yes 2 0.83
Smoking duration Never 238 99.17
<1 year 2 0.83
>1 year 0 0
Daily cigarettes smoked 0 238 99.17
≥10 sticks 2 0.83
Physical activity No 99 41.25
Yes 141 58.75
Family history of hypertension No 172 71.67
Yes 68 28.33
Family history of diabetes mellitus No 230 95.83
Yes 10 4.17

Body Mass Indices of the Participants

Among the 240 participants, 49.6% (n=119) exhibited a normal BMI, while 32.9% (n=79) were
classified as overweight. Additionally, 17.5% (n=42) of participants fell into the obese category
(table 3).

Body Mass Indices of the Participants

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Table 3

BMI Category Frequency (n) Percentage

Normal BMI 119 49.6%
Overweight 79 32.9%
Obese 42 17.5%

Prevalence of undiagnosed Hypertension

Overall, 40 (16.7%) participants had undiagnosed hypertension

Figure 2
The prevalence of hypertension among the study
participants.
90% 83%
80%
70%
60%
50%
40%
30%
17%
20%
10%
0%
Figure 2 The prevalence of
hypertension among the
study participants.
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Factors Associated with Undiagnosed Hypertension

The factors significantly associated with undiagnosed hypertension included age >50 years
(adjusted odds ratio [aOR]: 7.0, 95% confidence interval [CI]: 1.9–25.6, p=0.003), male gender
(aOR: 4.2, 95% CI: 1.5–11.1, p=0.005), alcohol use (aOR: 2.6, 95% CI: 1.1–6.0, p=0.021), and
overweight status (aOR: 3.6, 95% CI: 1.5–8.8, p=0.005) (Table 3).

Table 3

Multivariable Analysis of Factors Associated with Undiagnosed Hypertension

Independent Variables Adjusted OR 95% CI p-value

Age
<29 years Reference
30–39 years 1.76 0.51 6.07 0.374
40–49 years 2.32 0.66 8.18 0.190
>50 years 7.02 1.93 25.55 0.003
Sex
Male Reference
Female 0.24 0.09 0.65 0.005
Other occupation
No Reference
Yes 1.27 0.59 2.77 0.541
Tobacco use
No Reference
Yes 2.64 1.15 6.02 0.021
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Independent Variables Adjusted OR 95% CI p-value

Physical activity
Yes Reference
No 1.84 0.85 3.97 0.119
Family history of hypertension
Yes Reference
No 0.55 0.24 1.25 0.151
Diabetes mellitus
No Reference
Yes 0.31 0.03 2.96 0.311
Body mass index
Normal weight Reference
Overweight 3.59 1.46 8.82 0.005
Obese 2.46 0.81 7.45 0.113

Discussion

In this cross-sectional study conducted among adult internally displaced persons (IDPs) residing
in camps in Baidoba, the prevalence of hypertension was approximately 17%. Our investigation
revealed that older age, male gender, tobacco use, and being overweight were significantly
associated with hypertension. These findings underscore a noteworthy proportion of adult
internally displaced persons (IDPs) living with undiagnosed hypertension, highlighting potential
gaps in awareness of blood pressure status within this population. The observed prevalence of
hypertension of around 17% aligns closely with findings from a previous study conducted in
Northern Somalia 10, which reported a hypertension prevalence of 22.6%. This consistency
underscores the pervasive nature of hypertension as a silent ailment, with numerous individuals
harboring the condition within the community without receiving a formal diagnosis.
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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
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The prevalence of hypertension observed in the current study aligns with previous reports from
Ethiopia (12.3%) 11 and Uganda (16.7%) 2 concerning participants who were hypertensive but
unaware of their condition. However, our findings diverge from a study conducted in Nakivale
refugee camp, Uganda, which reported a lower prevalence of undiagnosed hypertension at 8.8%.
This discrepancy may be attributed to differences in the study populations, as our investigation
focused specifically on internally displaced persons, whereas the study in Nakivale refugee camp
encompassed a diverse population representing individuals from various sub-Saharan African
countries 12.

We discovered that the likelihood of hypertension escalated with age, with individuals aged
between 30–39 years exhibiting 76% higher odds of hypertension compared to those under 29
years, and those aged 40–49 years displaying more than double the odds compared to the
younger age group. The highest odds of hypertension were observed among participants aged
over 50 years. Furthermore, our findings indicated that male gender, history of khat
consumption, and overweight status were associated with increased odds of hypertension,
consistent with a study conducted in Hargeisa, Northern Somalia10

Similarly, the aforementioned study on hypertension in Hargeisa, Somalia, revealed associations

between male sex, higher BMI, and advancing age with hypertension, consistent with findings
from studies conducted in sub-Saharan Africa, which identified older age as strongly associated
with hypertension. These observations are supported by scientific evidence indicating that as
individuals age, they are more prone to developing hypertension due to increased vascular
resistance.

In light of these findings, there is a pressing need to promote healthy lifestyle practices among
the elderly to mitigate the risks associated with hypertension, as evidenced by previous studies.
Therefore, encouraging and implementing interventions aimed at fostering healthy behaviors
among older individuals is strongly recommended.

The study further unveiled those men are at a higher risk of having undiagnosed hypertension
compared to women, corroborating findings from a study conducted in a refugee camp in
Uganda12 and results from a national survey in Kenya on the prevalence, awareness, treatment,
and control, as well as determinants of hypertension Prevalence, awareness, treatment and
control of hypertension and their determinants: results from a national survey 13. These studies
demonstrated that men were less likely to be aware of their hypertension status.

This disparity in awareness between genders underscores the importance of targeted

interventions aimed at improving hypertension awareness and detection among men. Efforts to
enhance health education, increase access to screening services, and promote regular blood
pressure monitoring among men are imperative to address this gap and facilitate timely diagnosis
and management of hypertension in this papulation.
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This study found out that the odds of developing undiagnosed hypertension was higher in those
who use smokeless tobacco products. Our finding is also in agreement with that of a study
carried out in Ethiopia14 which revealed that, use smokeless tobacco products among other
factors like older age, were factors associated with hypertension. Our study also identified that
overweight participants had nearly four times higher odds of developing undiagnosed
hypertension compared to those with normal weight, followed by obese participants who had 2.5
times higher odds of developing undiagnosed hypertension. This finding is consistent with
results from other studies conducted in Uganda 2.

This study has several limitations. Firstly, I was unable to investigate other laboratory factors
such as cholesterol levels, which are known risk factors for hypertension. Additionally, while the
study sample size was deemed adequate for our analysis, it is possible that certain subgroups
within the population may not have been adequately represented. Furthermore, this study focused
specifically on a population with limited literature, as most previous studies included both
individuals who were hypertensive and those who were unaware of their blood pressure levels.
This could potentially limit the generalizability of our findings to other populations with
different characteristics. Despite these limitations, our study contributes valuable insights into
the prevalence and risk factors associated with undiagnosed hypertension among internally
displaced persons, shedding light on an important public health concern in this population .

Conclusion

In this study, I had observed that approximately one in six of adult IDPs living in camps around
Baidoa had undiagnosed hypertension. Our findings corroborate existing evidence indicating that
age, weight, sex, and Tobacco intake are significantly associated with hypertension. Notably, the
highest odds of hypertension were observed among participants aged over 50 years. Given these
findings, it is imperative to implement routine screening and management protocols for
hypertension within this displaced population. Early detection and effective management of
hypertension are crucial for reducing the burden of hypertension-related complications and
improving overall health outcomes among internal displaced persons living in camps around
Baidoa.

Acknowledgments:

The author expresses his gratitude to Dr Maryan Dahir and ICR Baidoba Office for their
contribution to this research.

Funding Statement:

There is no funding to report for this study.

Data Sharing Statement:

All supporting data are included within the manuscript.

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Informed Consent:

Participating students provided both written and verbal consent.

Ethical approval

The research has been approved by the Somali International University Research Board with
Approval number SIU-REB-2024-001, demonstrating adherence to ethical standards.

Disclosure:

The authors declare no conflicts of interest regarding this work.

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