Bosu 2015

Global Health Action
ISSN: 1654-9716 (Print) 1654-9880 (Online) Journal homepage: http://www.tandfonline.com/loi/zgha20
The prevalence, awareness, and control of

hypertension among workers in West Africa: a
systematic review
William K. Bosu
To cite this article: William K. Bosu (2015) The prevalence, awareness, and control of
hypertension among workers in West Africa: a systematic review, Global Health Action, 8:1, 26227,
DOI: 10.3402/gha.v8.26227
To link to this article: http://dx.doi.org/10.3402/gha.v8.26227
© 2015 William K. Bosu
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Download by: [University of Florida] Date: 05 August 2017, At: 16:53

Global Health Action æ
REVIEW ARTICLE
The prevalence, awareness, and control of hypertension

among workers in West Africa: a systematic review
William K. Bosu*
Department of Epidemics and Disease Control, West African Health Organisation, Bobo-Dioulasso, Burkina Faso
Background: Interventions in workplace settings are considered to be cost-effective in preventing

cardiovascular diseases. A systematic review was conducted to assess the prevalence of hypertension and
the level of awareness and control among workers in West Africa.
Design: A systematic search for studies on formal and informal sector workers aged ]15 years in West Africa
Downloaded by [University of Florida] at 16:53 05 August 2017
published between 1980 and September 2014 was undertaken using the Ovid Medline, Embase, PubMed,
and Google Scholar databases. Clinical and obstetric studies and studies that did not report prevalence
were excluded. Data on study settings, characteristics of workers, blood pressure (BP) levels, prevalence of
hypertension, and associated demographic factors were extracted.
Results: A total of 45 studies from six countries were identified involving 30,727 formal and informal sector
workers. In 40 studies with a common definition of hypertension, the prevalence ranged from 12.0% among
automobile garage workers to 68.9% among traditional chiefs. In 15 of these studies, the prevalence exceeded
30%. Typically sedentary workers such as traders, bank workers, civil servants, and chiefs were at high risk.
Among health care workers, the prevalence ranged from 17.5 to 37.5%. The prevalence increased with age and
was higher among males and workers with higher socio-economic status. Complications of hypertension,
co-morbidities, and clustering of risk factors were common. The crude prevalence of hypertension increased
progressively from 12.9% in studies published in the 1980s to 34.4% in those published in 20102014. The
proportion of hypertensives who were previously aware of their diagnosis, were on treatment or had their
BP controlled was 19.684.0%, 079.2%, and 012.7%, respectively. Hypertensive subjects, including health
workers, rarely checked their BP except when they were ill.
Conclusions: There is a high prevalence of hypertension among West Africa’s workforce, of which a significant
proportion is undiagnosed, severe or complicated. The clustering of risk factors, co-morbidities, and general
low awareness warrant an integrated and multisectoral approach. Models for workplace health programmes
aiming to improve cardiovascular health should be extended to informal sector workers.
Keywords: West Africa; hypertension; blood pressure; awareness; treatment; control; workers; systematic review
*Correspondence to: William K. Bosu, Department of Epidemics and Disease Control, West African
Health Organisation, 01 BP 153, Bobo-Dioulasso 01, Burkina Faso, Email: [email protected];
[email protected]
Received: 7 October 2014; Revised: 20 November 2014; Accepted: 4 December 2014; Published: 22 January 2015
wo of the earliest post-colonial studies on the tension worsened from the fourth to the third leading
T cardiovascular health of workers in West Africa

were described in Nigeria and in Ghana more than
40 years ago. In Nigeria, Akinkugbe and Ojo assessed
risk factor for deaths in West Africa from 1990 to 2010 (5).
Cardiovascular complications are more common and
severe in sub-Saharan Africa, and they occur at younger
arterial blood pressure (BP) levels among 821 workers in a ages (6, 7). With the increasing urbanisation, globalisation,
tobacco factory and a shopping centre in Ibadan in 1968 and associated nutrition transition, NCDs are likely to
(1). In Ghana, Pobee et al. screened 6,900 civil servants increase in the region (811).
in 1973 as part of a World Health Organization Feasibility However, the development of occupational health
Study on the Community Control of Hypertension (2). services has not kept pace with this rapid rise in most
Since these publications, there has been a rapid rise in West African countries. This is in spite of the determi-
cardiovascular diseases (CVDs) and non-communicable nation that workplace health programmes are among the
diseases (NCDs) in West Africa (3, 4). According to the most cost-effective ways to prevent NCDs (12). The United
Global Burden of Disease (GBD), the ranking of hyper- Nations Political Declaration on NCDs also calls on the
Global Health Action 2015. # 2015 William K. Bosu. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0 License 1
(http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and
build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
Citation: Glob Health Action 2015, 8: 26227 - http://dx.doi.org/10.3402/gha.v8.26227
(page number not for citation purpose)
William K. Bosu
private sector to create ‘an enabling environment for bottom 30 of the Human Development Index league
healthy behaviour among workers’ and promote ‘safe of 185 countries. The life expectancy at birth is about 54
and healthy working environment’ (13). A major challenge years, ranging from 45 years in Sierra Leone to 75 years
is that most workers in West Africa are engaged in the in Cape Verde (22). The major health problems include
informal sector without access to any structured occu- malaria, diarrhoeal diseases, acute respiratory infections,
pational health programme to protect or promote their undernutrition, HIV, and hypertensive diseases. There are
health. Even among the formal sector workers who should periodic outbreaks of cholera, meningitis, yellow fever,
have access to pre-employment screening and periodic and Lassa fever.
medical screening, awareness of hypertension is low with While much of West Africa is in the early stages of
consequent low control rates and high levels of target the nutrition transition, three countries Ghana, Cape
organ damage (14). Verde, and Senegal are in the later stages (23). In many
Insufficient attention has been paid to the prevention West African cities, more than 25% of adults have
and control of NCDs in West Africa, particularly pro- hypertension with rates higher than 40% being reported
grammes that target formal and informal sector workers. in Ouagadougou, Accra, and St. Louis (2426). The high
Data are required to guide evidence-informed decisions prevalence of hypertension is not limited to the affluent
and to advocate for change. However, there is a dearth populations. Among urban poor adults in Ouagadougou
of studies on hypertension at the sub-regional level in and Accra, 19 and 28% have hypertension (27, 28).
West Africa. The few regional studies on the prevalence A recent review of diabetes in Africa reported prevalence
of hypertension have been undertaken as part of reviews ranging from 2.5 to 7.9% (29). Among some workers in
in Africa as a whole (15, 16) or limited to a few countries Accra and Dakar, the prevalence exceeds 9.0% (30, 31).
in the sub-region (17, 18). Review studies on hyperten- Obesity rates in West Africa increased by about 115%
sion among workers and identifiable social groups in to reach 15% in the 15-year period from 1990 to 2004
West Africa are notably absent. The present study was (9). Risk factors for NCDs are evident in children and
therefore undertaken to review the prevalence of the adolescents in Africa, about 10.6% of whom are over-
hypertension among workers in the Economic Commu- weight/obese (32). The proportion of West Africans not
nity of West African States (ECOWAS). The review as- engaged in vigorous physical activity varies from 31.0%
sessed the trends and severity of hypertension as well in Sierra Leone to 93.0% in Cote d’Ivoire (33).
as the knowledge, awareness, treatment practices, and
extent of control among the workers. It responds to Search strategy and data extraction
the resolution of the 11th Assembly of the ECOWAS A literature search was conducted on the Ovid Medline,
Ministers of Health in 2010 which calls for a higher Embase, and PubMed databases using the search terms
priority to the prevention and control of NCDs and for for hypertension, Africa, and workers in a systematic
improved surveillance (19). build up. In the combined Ovid Medline and Embase
databases, the terms ‘hypertension’ and ‘occupation’ were
Methods exploded while in PubMed, the Medical Subject Head-
ings (MeSH) ‘sex workers’, ‘social work’, ‘occupations’,
Study area ‘occupational groups’, ‘health personnel’, ‘community
ECOWAS was established in 1975 with the aim of foster- health workers’, ‘agriculture’, and ‘manpower’ as well as
ing regional political and economic integration among ‘hypertension’ were used. In each database, these head-
15 West African Member States. The Member States ings were complemented by a long list of generic terms
comprise eight Francophone countries (Benin, Burkina for workers (artisans, company, corporation, employees,
Faso, Cote d’Ivoire, Guinea, Mali, Niger, Senegal, Togo), employers, enterprise, occupation, ‘occupational groups’,
five Anglophone countries (The Gambia, Ghana, Liberia, profession, staff, ‘blue collar’, ‘green collar’, ‘pink collar’,
Nigeria, Sierra Leone), and two Lusophone countries ‘white collar’, workers, workplace). In order to capture
(Cape Verde, Guinea-Bissau). The 15 Member States have work types that are peculiar to the African setting, more
a combined population of about 320 million, accounting specific search terms (agriculture, ‘agricultural workers’,
for about 43% of the sub-Saharan African (SSA) popula- ‘bank workers’, chiefs, ‘civil servants’, executive, factory,
tion. There has been rapid urbanisation with 42% living ‘factory workers’, farmers, ‘health workers’, industry,
in urban areas in 2010, a two-fold increase over the 19% ‘industrial workers’, laborer, labourer, lecturers, market,
40 years earlier. The population living in urban areas is plantation, teachers, traders, tradesmen, trading) were
projected to reach 63% by 2050 (20). also added.
Poverty in West Africa is among the worst in the world For the disease, the subject headings were comple-
with about 3045% of the population in most countries mented by a search for articles whose title or abstract
living under $1.25 purchasing parity power (PPP) per day contained the terms ‘hypertension’ or ‘blood pressure’.
(21). Eleven of the ECOWAS Member States are in the For the geographical scope, Africa and the names of each
2
Prevalence, awareness, and control of hypertension
of the 15 individual ECOWAS Member States were The proportion of those who were aware of their diag-
used. The various search terms were connected with the nosis and who were on antihypertensive therapy was also
relevant Boolean operators. The Ovid Medline database calculated where available. BP was deemed to be under
search also included a search on related terms. Additional control if it was less than 140/90 mmHg in subjects on
searches were also done in Google Scholar in French medication. No pooled analyses could be performed in
and in English. Manual searches of listed references were view of the heterogeneity of the study population.
done to maximise the number of identified studies.
Duplicate records were removed using the EndNote re- Results
ference manager (34). Then the titles were reviewed, and
articles obviously not related to the subject of interest Description of the studies
were removed. The abstracts or full text of the remain- A total of 45 papers on hypertension were identified from
ing articles was then reviewed, and further articles were six countries Cote d’Ivoire, Ghana, Liberia, Nigeria,
removed if they did not fulfil the inclusion criteria. Senegal, and Togo (Fig. 1). Thirty-three (73.3%) of them
Articles published between 1980 and September 2014 were from Nigeria, four from Ghana, three from Senegal,
were retrieved based on the consideration that 35 years two each from Cote d’Ivoire and Togo, and one from
was long enough duration to allow patterns and trends in Liberia (Table 1 and Fig. 2). Five of the papers were
hypertension among workers to be determined. published in French. The studies covered a wide range
Studies were included if they were conducted among of workers including largely sedentary groups such as
formal or informal workers aged ]15 years, the sample market women (3740) or long-distance drivers (41) and
size was ]75 workers, and they reported an estimate of largely active groups such as farmers (42, 43) or factory
the prevalence of hypertension. Studies conducted among workers (4446).
patients or the general population, those that were ob- The most commonly studied groups were civil servants
stetric, pharmacological, anthropological, review studies, in whom there were 10 studies in three countries, Ghana,
or studies outside the ECOWAS region were excluded. Nigeria, and Togo (30, 4756). The other workers were
Studies involving pre-selection medical examination for university staff (5761), health care workers (6266), office
possible recruitment into jobs were also excluded. Multi- workers (31, 6769), policemen (52), artisans (7072), bank
ple studies among the same set of workers were counted workers (73, 74), civil aviation workers (75), port workers
once, but the separate papers reporting the prevalence of (76), traditional chiefs (77) and miners (78). Eight studies
hypertension were included in the references. involved exclusively male workers (41, 44, 52, 70, 71, 77)
Using a standard data extraction sheet, data on the or female workers (37, 39). Traders and health workers
study location, type of setting, study population, sam- studied were predominantly female while automobile gar-
pling technique, BP measurement technique, mean age, age workers, drivers, railway workers, policemen, factory
sex distribution, prevalence of overweight or obesity, co- workers, civil servants, and chiefs were predominantly
morbidities, mean systolic blood pressure (SBP) and male (Table 1). Except for two studies conducted in rural
diastolic blood pressures (DBP), prevalence of diabetes populations (42, 43), the studies were conducted in urban
mellitus, and the prevalence of hypertension were ob- or mixed settings.
tained. Most of the studies used the threshold 140/90 Thirty-two studies (80.0%) were considered to have
mmHg and/or taking of antihypertensive medication for used an unbiased sampling technique or recruited their
their definition of hypertension, in line with the Seventh entire workforce while a further seven studies (15.5%)
Report of the Joint National Committee on the Preven- provided evidence of high participation (Table 1). Re-
tion, Detection, Evaluation and Treatment of High Blood presentative samples from formal workplaces with staff
Pressure (JNC VII) (35). A few studies used the older lists such as airport authority (75), banks (73, 74), civil
160/95 mmHg cut-off point in line with existing WHO service ministries (51, 53, 55, 82, 84), hospitals (65),
guidelines (36). and universities (57, 59) were obtained through simple
Besides the prevalence of hypertension, the severity random, systematic, cluster, or stratified sampling. Re-
of hypertension was assessed by the prevalence of grade presentative samples were also obtained in studies with
2 (SBP of 160179 mm Hg or DBP of 100109 mmHg) informal sector workers such as port workers (76),
or grade 3 hypertension (SBP of ]180 mm Hg or DBP factory workers (4446), music shop operators (83),
was ]110 mmHg), history of hospitalisation, and the hotel workers (45), traders (3739), and farmers (43, 70)
presence of complications and co-morbidities (35). The through the use of registers or a sampling of their
proportion of hypertensive patients who reported having mapped locations (39, 43). Representativeness was easily
previously been diagnosed by a health professional was obtained in small to medium-sized institutions through
considered to be aware of their diagnosis. The proportion the enrolment of all their workers. For example, in the
of persons with hypertension on treatment was based on study with the smallest sample size in this review, a total
the subjects reporting taking antihypertensive medication. of 75 (68.8%) lecturers (based on a calculated sample
Citation: Glob Health Action 2015, 8: 26227 - http://dx.doi.org/10.3402/gha.v8.26227 3

William K. Bosu
Fig. 1. The process of selecting articles.
size) were randomly sampled from a total of 109 eligible 15 years old civil servants (85) to 105 years old traders (38).
medical school lecturers in Port Harcourt, Nigeria (59). In 32 reporting studies, the mean ages ranged from 23.2
Some studies that did not report representative sam- years among policemen (52) to 63.0912.6 years among
pling obtained high participation of their workers. For rural farmers (70). Overall, most workers studied were
example, investigators assessing hypertension in civil ser- in their 40s, and the youngest workers were in their 20s
vants in two different studies in separate locations could (52, 83).
not obtain any staff lists as these were not available nor Of the 45 studies, three were published in the 19801989
did they consider it feasible to prepare one (48, 79). decade, 10 in 19901999, 12 in 20002009, and 20 from
Consequently, they achieved high participation through a 2010 to September 2014. The annual rate of production
door-to-door mobilisation of all on-site workers. Without therefore increased progressively from 0.3 in the 1980s
a sampling frame of all eligible workers, they could not through to 1.2 in the 2000s and then sharply to 4.2 in
provide any response rates based on eligible subjects. 20102014.
Incomplete reporting did not permit the assessment
of representativeness of workers in a few studies. For BP measurement
example, a study among long-distance professional drivers Strategies to improve the quality of BP measurements
estimated the needed sample size but did not provide included the use of trained personnel or the self-deployment
adequate information on the sampling procedure (41). of the study researchers in the process, the use of formally-
Studies among automobile garage industry workers (71), certified field workers, ensuring that the subject was
health care workers (80), policemen (52) or mill operators relaxed and seated upright with legs uncrossed and flat
(72) were compelled to recruit a convenient sample of on the floor with the arm supported at the level of the
workers as a sampling frame was unavailable, and it was heart, the use of calibrated equipment with appropriate
not feasible to compile one. In such cases, recruitment was cuff size and the use of multiple measurements.
facilitated through the solicited cooperation of the leader There was a wide variation in the quality of the reported
of these categories of workers. approaches to the measurement of BP (Table 2). Of the
The maximum sample size of 5,200 involved a mixed 35 studies which provided information, 29 measured the
group of civil servants and factory and plantation workers BP during a single visit. In a few studies, subjects with
in South-eastern Nigeria (50). Overall, the mean and total raised BP were advised to make one or two additional
sample size in all 45 studies was about 683 and 30,727 visits for further measurements (30, 43, 64). Other studies
workers, respectively. Reported participation rates ranged required two or three visits for all subjects for BP
from 75 to 100%. The age of the workers ranged from measurements (51, 79). The interval between visits ranged
4
Table 1. Characteristics of studies on prevalence of hypertension among workers
Sample Participation Sampling % Age group Mean

No. Country References Study population Location Setting Year of study size rate representativeness Female (years) age9sd
1 Cote d’Ivoire Konin et al. (64) Health workers Abidjan Urban 821 Probable 59.4 2858 42.9
2 Cote d’Ivoire Koffi et al. (76) Port workers Abidjan Urban 1995 202 Yes 13.4 3055 46.096.0
3 Ghana Addo et al. (30) Civil servants Accra Urban 2006 1,015 82.7 Yes 39.4 2568 44.0910.1
4 Ghana Gunga et al. (78) Goldminers and Tropical Urban 1986, 1988 495 Yes
rubber company rainforest
workers
5 Ghana Amidu et al. (71) Male automobile Kumasi Urban JanuaryMarch 200 No/ND 0.0 30.297.8
garage workers 2009
6 Ghana Aryeetey & University staff Accra Urban June 2009 141 99.3 Yes 32.6 40.5910.8
Ansong (60)
7 Liberia Giles et al. (43) Rubber plantation Rural September 3,588 83.5 Yes 44.3 2055years
workers November 1989
8 Nigeria Abidoye et al. (75) Airport Authority Lagos Urban JulyAugust 2000 380 Yes 37.1
workers
9 Nigeria Kadiri et al. (73) Bank workers Ibadan Urban 917 95 Yes 33.7 1864 Men 34.397.7;
women 32.397.0
10 Nigeria Abidoye et al. (74) Bank workers Lagos Urban 530 Yes 2059
11 Nigeria Bunker et al. (79) Civil servants Sokoto Urban Summer 1990 539 Probable 13.5 2054
12 Nigeria Huston et al. (51) Civil servants Benin City, Edo Urban 1992 766 84.3 Yes 37.1 2064 41
State
13 Nigeria Olatunbosun Civil servants Ibadan Urban 998 Yes 41.8 1970 40.098.3
et al. (53)
14 Nigeria Oyeyemi & Civil servants and Maiduguri Urban 292 79.8 Yes 34.9 2065 44.898.5

Adeyemi (55) health workers
15 Nigeria Bunker et al. (47); Civil servants from Bendel State Urban 1987 and 1988 559 Probable 21.6 2554 Men 37.8; women
Bunker et al. (48) State Ministries 34.9
16 Nigeria Ekpo et al. (50) Civil servants, Calabar, Cross Urban 5,200 98 Yes 15.7 16 years and
factory and River State above
plantation workers
17 Nigeria Olugbile & Farmers and Badeku, Rural 276 78.9 Yes 2170 97.8% of industrial
Oyemade (42) industrial workers Ewereko workers and

villages 55.7% of farmers
B50 years
18 Nigeria Balogun & Female traders Sango Market, Urban April 2003 281 Yes 100 37.3912.8
Owoaje (37) Ibadan, Oyo
State
19 Nigeria Odugbemi et al. Female traders Tejuosho Urban August 400 Yes 100 Men 45.5911.9;
(39) market, Lagos September 2006 women 42.3911.0
5
William K. Bosu
Table 1 (Continued )
6

20 Nigeria Uwanuruochi Health care workers Umuahia, Abia Urban October 2010 299 No/ND 72.6 4060 47.795.4
et al. (80) State
21 Nigeria Funke & Ibrahim Health workers Jos City, Urban JuneSeptember 340 100 Yes 62.9 2460
(62) Plateau State 2005
22 Nigeria Owolabi et al. (65) Health workers Ogbomoso, Urban 324 92.3 Yes 55.9 2065 41.1910.1
Oyo State
23 Nigeria Adeoye et al. (66) Health workers in a Urban 352 Probable 63.6 42.0399.4
tertiary hospital
24 Nigeria Ogunlesi et al. Male battery factory Ibadan Urban November 1989 404 100 Yes 0.0 1854
(44) workers
25 Nigeria Ofuya (81) Male commercial Port Harcourt, Urban 200 Yes M1656 years; Men23.1;
motorcyclists; Rivers State F1654 years women 25.0
market women
26 Nigeria Oviasu & Okupa Male office clerks, Isiuwa village Rural and RuralJuneJuly 1,263 Rural male Yes Rural 0.0; 1560
(54); Oviasu & male field labourers and Benin City, Urban 1976; Urban 98.8; Urban
Okupa (82) (rural); civil servants Bendel State September Urban 95.0 27.5
(urban) November 1977

27a Nigeria Kaufman et al. Male rural farmers Idere village, Rural 1994 108 Yes 0.0 45 years and 63.0912.6
(70) Ibarapa above
district,
Oyo State
27b Nigeria Kaufman et al. Retired railway Ibadan Urban 1994 203 0.0 45 years and 60.298.5
(70) workmen above
28 Nigeria Ulasi et al. (40) Market workers Ogbete Urban May 2006 688 No/ND 48.5 38.0913.3
market, Enugu
State
29 Nigeria Ordinioha (59) Medical school Port Harcourt Urban 75 75 Yes 34.7 46.199.6
lecturers
30 Nigeria Ebare et al. (83) Musical shop Benin City, Edo Urban 250 83.3 Yes 12.0 26.997.6
operators State
31 Nigeria Shittu et al. (46) Pharmaceutical Urban 750 Yes 58.0
industry workers
32 Nigeria Idahosa (52)a Policemen and male Benin City, Urban May 1983 1,115 No/ND 0.0 Policemen 20 Policemen 23.2
civil servants Bendel State 63; civil servants years; civil servants
2062 years 28.6 years
33 Nigeria Amoran et al. (41) Professional drivers Sagamu Local Urban FebruaryMarch 400 Probable 0 2162 41.196.1
Government 2008
Area, Ogun
State

34 Nigeria Okojie et al. (68) Senior executives of Benin City, Edo Urban 202 Yes 23.3 2564
industries and State
companies
35 Nigeria Oghabon et al. Staff of a Illorin Urban 281 Probable 24.9 40.399.6
(67) government
organisation and
private industry
36 Nigeria Charles-Davies Traders Bodija market, Urban 534 Yes 68.2 18105
et al. (38) Ibadan
37 Nigeria Ordinioha & Traditional chiefs Rivers State Urban; 106 Yes 0.0 56.594.1
Brisibe (77) semi-urban
38 Nigeria Emerole et al. (57) University staff Owerri, Imo Urban October 2003 241 Yes 49.4
State
39 Nigeria Ige et al. (58) University staff Ibadan Urban 525 96.0 Yes 48.8 37.499.5
40 Nigeria Omokhodion & Vegetable, cereal Bodija market, Urban 120 No/ND 45.8 1865 41
Kolude (72) and tuber mill Ibadan
operators
41 Senegal Lang et al. (45) Factory and hotel Dakar Urban 1,869 97 Yes 29.6 1664 Men 39.399.7;
workers women 35.498.8
42 Senegal Seck et al. (31) Information Dakar Urban September 402 100 Yes 33.8 46.297.6
technology workers November 2010
43 Senegal Mbaye et al. (69) Telecommunication Not stated Urban 2006 1,229 Probable 29.8 2158 41.899.1
workers

44 Togo Atatsi et al. (61) University staff Lome Urban MayJune 2006 640 No/ND 36.1 2160 Men41;
women 43
45 Togo Yayehd et al. (56) Civil servants Lome Urban June 2010 207 97.6 Yes 32.9 2460 42.799.8
a
Benin City was located in Bendel State but the State was divided up into Edo State and Delta State in 1991, with the capital remaining in the former.
SD standard deviation; NDnot determined.
7
William K. Bosu
Fig. 2. Map of West Africa showing distribution of selected studies.
from 1 day to 3 weeks. Most studies took two or three BP (23% vs. 93%) or smoke (5% vs. 25%). Overweight or obese
measurements and used the mean of at least two of them chiefs were 2.25 times as likely as those with normal weight
for analysis. Of 12 studies which took three BP readings, to be hypertensive (78.3% vs. 34.8%).
six used the mean of the latter two readings for analysis. Young age did not automatically mean lower prevalence
Four studies measured the BP only once or used only one of hypertension. Among music shop operators in Benin
reading (after rejecting the first reading) in their analyses City, Edo State, Nigeria, with a mean age 26.997.6 years,
(50, 53, 54, 81). One-third of the studies reviewed did 55% were hypertensive (83). Most of the shop operators
not provide adequate information on how the BP was were exposed to high noise levels 90 dB for more than
measured. 8 h daily.
There were also variations in the device used for the BP Of the 40 studies, the prevalence of hypertension in
measurement. Of the 33 studies reporting their measure- workers was ]20% in 30 studies (15.0%), ]30% in 15
ment device, 25 employed a mercury sphygmomanometer studies (37.5%), and ]40% in 6 studies (15.0%) (Table 3).
while eight employed an electronic monitor. One study
The prevalence was high among both formal and infor-
validated their electronic BP monitor using a manual
mal sector workers. A slightly higher proportion of studies
sphygmomanometer (52). Only 25 studies reported the
among informal sector workers reported a prevalence
part of the body to which the cuff of the BP device was
]30% than those among formal sector workers (6/15 vs.
applied. BP was taken in both arms in the same subjects
9/23 studies). High prevalence (]30%) informal sector
in three studies, on the left arm in seven studies, and on
the right arm in six studies. workers included traders (38, 39), market workers (86),
music shop operators, and chiefs (77). Among formal
sector workers, they included civil servants (30, 48, 56),
Prevalence of hypertension
health workers (62, 80), university staff (60), port workers
The prevalence of hypertension among the workers was
generally high, the wide diversity of workers notwithstand- (76), factory workers (46), senior executives (68), and tele-
ing. In 40 studies which used the 140/90 mmHg threshold, communications workers (69). There were variations in
the prevalence ranged from 12% among automobile the prevalence of hypertension within a particular group
garage workers in Ghana (71) to 69% among traditional of workers. For example, the prevalence was 17.5% among
chiefs in the oil-rich Ogba land in the Rivers State, Nigeria health workers in Abidjan, Cote d’Ivoire (64), but was
(77) (Table 3). These two extreme groups prevalence were twice as much among health workers in Jos City (36.5%)
quite different in terms of socio-demographic character- (62) or Umuahia, Nigeria (37.5%) (80). Similarly, the
istics and risk factors. The artisans were younger (mean prevalence among civil servants in Accra in 2006 (30) or
ages 30 years vs. 57 years), less affluent, less likely to Bendel State in 1988 (48) was twice that among civil
be obese (2% vs. 26%), and less likely to drink alcohol servants in the Bendel State in 1992 (51) (30% vs. 16%).
8
Table 2. Blood pressure (BP) measurement techniques in studies among workers in West Africa
Frequency of Initial Interval between

Personnel Interval readings per rest time multiple readings Reading used in Body part
No. References taking BP No. of visits between visits visit (min) (mins) analysis cuff size Posture for cuff Device
1 Konin et al. (64) 13. Those with 1015 Manual

raised BP on 1st
visit and known
hypertensives
made 2
additional visits
2 Koffi et al. (76) 1 2 Supine
3 Addo et al. (30) Trained 12, BP 3 weeks 3 ]10 1 Mean of 2nd & 3rd Appropriate Seated Right arm Electronic Omron
interviewers repeated at a readings cuff size M51
later visit if
initially 140/
90 mmHg
without
treatment
4 Gunga et al. (78)
5 Amidu et al. (71) Qualified nurses 1 2 ]5 5 Mean of 2 readings Left arm Manual
6 Aryeetey & Ansong Trained personnel 1 2 5 10 Mean of 2 readings Left arm Manual Accoson
(60) MK.3
7 Giles et al. (43) 12, 2nd visit for 2 readings at 5 Mean of 3 readings Left arm Electronic
those with 1st visit, 3 Dynamap 8100
raised BP at 1st readings at
visit 2nd visit
8 Abidoye et al. (75)

9 Kadiri et al. (73) Trained physicians 1 3 1 Mean of 3 readings Appropriate Manual
cuff sizes
10 Abidoye et al. (74) Seated Manual
11 Bunker et al. (79) Trained observers 2 1 ]5 Mean of the 2 readings Appropriate Seated Arm Manual
from each visit cuff size Baumanometer
12 Huston et al. (51) Certified 3 2 days after 1st 3 5 1 Mean of latter 2 Arm Manual
technicians visit and 1 day readings over all the
after 2nd visit three visits
13 Olatunbosun et al. (53) 1 1 Single reading Left arm Manual

14 Oyeyemi & Adeyemi 1 3 5 35 Mean of 3 readings Left arm Electronic
(55) Dinamap 8100/8101
15 Bunker et al. (47) Certified medical 1 3 ]5 Mean of latter 2 Appropriate Seated Arm Manual
students readings cuff size Baumanometer
16 Ekpo et al. (50) Trained observers 1 2 ]5 Only the 2nd reading Appropriate Arm Manual
analysed cuff size
17 Olugbile & Oyemade
9
(42)
William K. Bosu
10
Frequency of Initial Interval between

Personnel Interval readings per rest time multiple readings Reading used in Body part
No. References taking BP No. of visits between visits visit (min) (mins) analysis cuff size Posture for cuff Device
18 Balogun & Owoaje 1 2 5 5 Appropriate Seated Right arm Electronic OMRON

(37) cuff size
19 Odugbemi et al. (39) Trained observers 1 2 2 Mean of 2 readings Seated Right arm Manual
20 Uwanuruochi et al. Physicians 1 1225 cm Manual Accoson
(80)
21 Funke & Ibrahim (62) Physicians 1 3 ]3 Mean of 3 readings Appropriate Seated First 2 measured Manual
cuff size on left arm and
3rd on right arm
22 Owolabi et al. (65) 1 2 5 5 Mean of 2 readings Cuff size Seated Left arm
12.5 cm
23 Adeoye et al. (66) Manual Accoson
24 Ogunlesi et al. (44) 1 3 5 Mean of 3 readings One of three Right arm Electronic
cuff sizes
used as
appropriate
25 Ofuya (81) 1 1 ]5 Single reading Seated arM Electronic OMRON
Hem-412C
26 Oviasu & Okupa (54) 1 1 5 Single reading 1222 cm Seated Left arm Manual
27 Kaufman et al. (70) Trained observers 1 3 510 Appropriate Manual
cuff sizes
28 Ulasi et al. (40) 1 3 10 5 Mean of 3 readings Appropriate Non-dominant Manual Accoson
cuff size arm
29 Ordinioha (59) 1 3 ]3 Mean of latter 2 Appropriate Seated Arm Manual
readings cuff size
30 Ebare et al. (83) 1 2 15 Mean of 2 readings Seated Right arm Manual
31 Shittu et al. (46)
32 Idahosa (52) Two staff nurses 1 2 ]5 Mean of 2 readings 1452 cm Seated Right arm Electronic UEADA
who cross- 8000 validated against
checked unusual Accoson mercury
BP readings device
33 Amoran et al. (41) Trained health
workers
34 Okojie et al. (68) 1 2 Mean of 2 readings Seated Arm Manual
35 Oghabon et al. (67) 12, subjects 1 day 2 510 Seated Both arms in Manual
with raised BP same subject
re-evaluated
36 Charles-Davies et al.
(38)
37 Ordinioha & Brisibe 1 3 Mean of latter 2 Appropriate Seated Arm Manual
(77) readings cuff size
Among the informal sector workers, the prevalence

of hypertension was lower among jobs that were more
Device physically demanding such as automobile workers (12.0%)
Electronic
(71), industrial workers (12.3%) (42), plantation workers
Manual
Manual
Manual
(12.5%) (43), and mill operators (19.2%) (72) and plan-
tation workers (12.5%) (43). However, these workers
Both arms in the

also tended to be younger. In contrast, the prevalence
Body part
same subject
for cuff
was generally higher among largely sedentary workers

such as traders (39, 86), office executives (68, 69), and civil
servants (30, 48, 56).
In 10 studies that used the higher cut-off point of 160/
Posture
Seated
Seated
Seated
95 mmHg, the prevalence of hypertension ranged from
5.9% in Sokoto civil servants (79) to 16.3% among Benin
City civil servants in 1987/1988 (47, 48). Among men,
cuff size
the prevalence of hypertension ranged from 2.8% in

rural farmers to 17.8% among Benin City civil servants
(Table 3). Among women, the prevalence ranged from
2nd measurement used
measurement is raised
3.5% among civil servants and factory workers in Calabar

Reading used in
in the analysis, if 1st

Mean of 2 readings
(50) to 12.8% among senior executives in Benin City (68).

analysis
Mean of latter 2
In 26 studies with available data, the prevalence

of hypertension based on the 140/90 mmHg cut-off point
readings
in male workers ranged from 11.2 to 68.9% while in the

22 studies with available data, it ranged from 9.9 to 43.5%
multiple readings
Interval between
among female workers (Table 3). It was consistently

higher in males than in females in 16 studies. The dif-
(mins)
]5
]5
15
ferences were not insignificant in 12 cases, the pre-

valence was more than five percentage points higher in
males. The greatest sex differences of 1821% were
rest time
Initial
(min)
observed in three studies among university workers at

the University of Ghana, Accra (60), among civil servants
in the Bendel State in Nigeria (48), and workers at the
repeated if 1st
Frequency of
measurement
readings per
is raised
12, BP
Port of Abidjan, Cote d’Ivoire (76). In these three studies,

visit
the prevalence of hypertension among males was about

two to three times that among women. In the other three
between visits
studies in which there was a reversal, the prevalence of

Interval
hypertension in females was 1.22.0 times that in male

and the percentage points difference ranged from 5.0 to
22.2% (38, 55, 61).
The sex differences in the prevalence of hypertension
No. of visits
were less pronounced but also mostly higher in male

1
1
1
workers than female workers when the BP cut-off point

of 160/95 mmHg was used. Five studies reported a higher
prevalence among males (48, 50, 53, 73, 79) with a 2.1
8.7% points difference while two studies reported higher
Skilled doctors
Personnel
taking BP
Researchers
prevalence among females (45, 68).

and nurses
Physicians
Physicians
Almost all the studies with available data consistently

showed a direct relationship between age and mean
systolic and diastolic BP and hypertension irrespective
of sex or geographical setting (Table 4) (37, 74, 80, 87).
Emerole et al. (57)
Yayehd et al. (56)

Mbaye et al. (69)
References
Atatsi et al. (61)

Seck et al. (31)
Lang et al. (45)
Omokhodion &
In the few studies conducted in mixed settings, the mean

Ige et al. (58)
Kolude (72)
SBP, mean DBP, and the prevalence of hypertension

were higher in urban than in rural areas (70, 82). The
prevalence of hypertension was higher among senior staff
than among junior staff (30, 57, 60, 88), even after
No.
38
39
40
41
42
43
44
45
adjusting for age (48, 79). For example, the age-adjusted

William K. Bosu
Table 3. Mean systolic and DBPs and prevalence of hypertension among workers using the 140/90 and 160/95 mmHg BP cut-off points
12
Prevalence BP 140/90 mmHg % Prevalence BP 160/95 mmHg %
No. Study population Mean age9sd Males Females Total sample Males Females Total sample Mean SBP Mean DBP
1 Airport authority workers SHT 21.7; Severe

(75)a DHT18.2 SHT3.9;
severe
DHT0.7
2 Bank workers (73) Men 34.397.7; 22.2 14.2 19.5 10.4 7.1 9.3 Men 118.2917.3; Men 76.1911.5;
women 32.397.0 women 113.7916.7 women 72.4911.4

3 Bank workers (74)b SHT 17.9;
DHT21.1
4 Civil servants (30)c 44.0910.1 31.7 28.0 30.2 128.5 79
5 Civil servants (79) 19.3 13.7 18.6 6.2 4.1 5.9 Men (2054 years) 124.7910.9; Men (2054 years) 73.4910.9;
women (2044 years) 121.5915.6 women (2044 years) 73.899.7
6 Civil servants (51) 41 19.3 9.9 15.8 117.4917.6 76.1913.5
7 Civil servants (53)d 40.098.3 13.9 5.3 10.3
8 Civil servants and health 44.898.5 20.5 25.5 23.3 129.2916.8 81.3910.5
workers (55)
9 Civil servants (47, 48) Men 37.8; 34.2 16.5 30.4 17.8 10.7 16.3 Men 127.9917.7; Men 82.2912.6;
women 34.9 women 116.4915.1 women 75.4911.3
10 Civil servants, factory 8.9 3.5 8.1
and plantation workers
(50)d
11 Civil servants (56) 42.799.8 54.1
12 Factory and hotel Men 39.399.7; 21.9 19.9 21.3 7.4 10.1 8.2 Men 126.7917.5; Men 75.2911.6;
workers (45) women 35.498.8 women 123.3920.2 women 74.6911.7
13 Farmers and industrial 97.8% of industrial 12.3
workers (42)d workers and 55.7%
of farmers B50 years
14 Female traders (37) 37.3912.8 19.9 19.9 6.8 6.8 122.0920.0 78.0913.0
15 Female traders (39) Men 45.5911.9; 34.8 34.8
women 42.3911.0
16 Goldminers and rubber 8.9
company workers (78)d,e
17 Health workers (80) 47.795.4 37.5 128.0916.8 80.5910.5
18 Health workers (64) 42.9 17.7 17.4 17.5
19 Health workers (62) 36.5
20 Health workers (65)d 41.1910.1 20.1
21 Health workers (66) 42.0399.4 34.9
22 Male automobile garage 30.297.8 12.0 12.0 122.3917.5 75.9911.6
workers (71)d
Prevalence BP 140/90 mmHg % Prevalence BP 160/95 mmHg %
No. Study population Mean age9sd Males Females Total sample Males Females Total sample Mean SBP Mean DBP
23 Male battery factory 20.3 20.3 8.4 8.4 128.0913.4 69.6911.0

workers (44)
24 Male commercial Men23.1; 16 12 Men 136; women 122 Men 81 women 83.4
motorcyclists; market women 25.0
women (81)
25 Male civil servants, male 14.4 10.4 13.3 Rural clerks 127.7917.1; Rural clerks 83.4911.6;
field labourers (54, 82)d,e rural labourers 124.9921.4 rural labourers 80.3911.6
26a Male rural farmers (70) 63.0912.6 13.9 13.9 2.8 2.8 121.1917.9 70.6910.9
26b Retired railway workmen 60.298.5 29.1 29.1 13.8 13.8 127.0924.2 76.1913.5
(70)
27 Market workers (40) 38.0913.3 46.3 37.7 42.2 129.2920.8 84.5914.5
28 Medical school lecturers 46.199.6 24.5 15.4 21.3
(59)d
29 Musical shop operators 26.997.6 55.6 134.7914.3 88.499.7
(83)d
30 Pharmaceutical industry 51.3 43.5 48.0
workers (46)d
31 Policemen and male civil Policemen 23.2 28.7 28.7 8.5 8.5 Policemen 130.0915.3; Policemen 76.0914.4;
servants (52)d years; civil servants civil servants 134.0918.8 civil servants 75.0914.9
28.6 years
32 Port workers (76) 46.096.0 32.6 11.1 29.7
33 Professional drivers (41)d 41.196.1 22.5 22.5
34 Rubber plantation 12.5 Men 125.6; women 123.0 Men 72.4; women 71.9

workers (43)
35 Senior executives of 36.1 29.8 34.7 5.8 12.8 7.4 Men 129.8; women 127.4 Men 82.6; women 80.1
industries and
companies (68)d
36 Staff of a government 40.399.6 28.4 22.9 27.0 130.4920.5 83.3912.0
organisation and private
factory (67)d
37 Traders (38)d 43.9912.7 21.2 43.4 36.3 8.2 18.1 15.0 128.9923.5 80.5912.7
38 Traditional chiefs (77)d 56.594.1 68.9 68.9
39 University staff (60) 40.5910.8 40.0 21.7 34.0
40 University staff (57)d 29.0
41 University staff (58)f 37.499.5 21.5
42 University staff (61) Men41; 11.2 17.3 13.4
women 43
13
William K. Bosu
Based on SHT; bbased on DHT; cmean BP: Addo et al. (30) uses median SBP and DBP; ddefinition of HTN: based on measurement only; eBP threshold 160/100 mmHg; fbased on self-
reported previous diagnosis of HTN. BPblood pressure; HTN hypertension; SBP systolic blood pressure; DBP diastolic blood pressure; SHTsystolic hypertension; DHT diastolic
prevalence in senior and junior staff was 43% vs. 23%,
respectively, among male civil servants in Benin City
Mean DBP (48). In multivariate analyses, the major determinants of
97.199.1
hypertension included older age group, male sex, and
higher socio-economic status (30, 44, 48, 53, 62, 79).
When analyses are restricted to the 32 studies with
representative samples of workers, the patterns of hyper-
tension changed very little. As before, the prevalence
ranged from 12.3 to 68.9% in the 27 studies using the 140/
90 mmHg BP threshold. The prevalence was ]20% in 22
studies (81.5%), ]30% in 10 studies (37.0%), and ]40%
in four studies (14.8%). Studies among informal sector
151.7913.6
Mean SBP
workers were more likely to report a prevalence ]30%

than formal sector studies (5/11 vs. 5/15). The prevalence
in male workers ranged from 16.0 to 68.9% while that
in female workers ranged from 9.9 to 43.5%. As before,
the prevalence of hypertension was most frequently
higher in male workers than in female workers. The sex

differences in the prevalence in these studies ranged from
Total sample
2.0 to 21.5 percentage points. Only two of the 12 studies

Prevalence BP 160/95 mmHg %
11.9
reported a higher prevalence in females (38, 55).

There was a 3.4-fold difference in the prevalence of
hypertension among representative samples of civil ser-
vants (51, 84), a 1.8-fold difference among health workers
Females
7.4
(62, 65), and a 1.6-fold difference among university workers

(58, 60). The differences remained when the age-specific
prevalence was analysed among civil servants (Table 3).
Males
14.3
Among civil servants aged 2534 years, the prevalence in

Benin City was 3.9% (51) compared with 9.8% in Accra
Total sample
(30). The earlier reported heterogeneity in the charac-

Prevalence BP 140/90 mmHg %
teristics of subjects, study populations, and measure-

19.2
24.1
43.7
ment techniques of BP remained in the restricted subset

of higher quality studies. The results of the entire set of
retrieved studies are therefore reported.
Females
18.2
20.6
Trends
It was not possible to directly estimate trends in the
Males
20.0
26.3
prevalence of hypertension in workers. The Benin City

Civil Servants Studies conducted in 19871988 and in
1992 by the same group of investigators did not have
Mean age9sd
comparable study populations (48, 51). The subjects in

the earlier study were from a greater number of ministries,
and were more likely to be female, younger, and heavier.
46.297.6
41.899.1
As expected, the prevalence of hypertension was twice as

41
much in the earlier study (30.4%) as in the latter study

(15.8%) after only a 5-year interval.
tuber mill operators (72)
In 1977, Oviasu and Okupa screened civil servants

Information technology
Vegetable, cereal and
Study population
aged 1560 years in Benin City and found 13.3% of them

Telecommunication
had hypertension based on the 160/95 mmHg threshold

workers (31)
workers (69)
(54). Ten years later, the Benin Civil Servants Study

reported a prevalence of 16.3% in workers aged 2564

hypertension.
years (47).
In the late 1990s, Kadiri et al. observed that the age-
specific BP levels on their study among bank workers in
No.
43
44
45
Ibadan were lower than those of other urban workers

a
14
Table 4. Age-specific prevalence of hypertension among workers in West Africa
1524 2534 3544 4554 5564
Study population Location M F T M F T M F T M F T M F T
Civil servants (30) Accra 9.8 20.1 43.9 49.4

Civil servants (48) Bendel State 20.3 12.9 18.2 36.5 16.0 32.0 52.0 44.4 51.4
Civil servants (79) Sokoto 8.9 3.8 12.1 17.6 23.0 23.1 54.5
Civil servants (50) Calabar 1.4 5.9 12.6 22.3 27.8
Civil servants (51) Benin City, Edo 3.9 11.0 27.1 42.5
State
Male civil servants (52) Benin City, Bendel 29.3 27.7 38.5 68.9
State
Policemen (52) Benin City, Bendel 15.7 21.6 31.8 58.8
State
University staff (58) Ibadan
Bank workers (73) Ibadan 17.9 2.8 10.7 15.1 7.9 12.6 21.9 26.5 23.3 50.7 28.0 44.8 83.3 100.0 85.7
Health workers (80) Umuahia, Abia 31.1 36.3 57.9

State
Industrial and hotel Dakar 2.9 3.3 3.1 11.7 7.9 10.4 17.9 21.8 19.2 36.1 47.7 39.6
workers (45)
University staff (61) Lome 0 0 2.3 0 8.93 12.3 16.7 25.2 43.8 40
Mmales; F females; T total sample.
(factory and sales workers) from their studies three as in those with BP B140/90 mmHg and increased with
to four decades earlier (1, 73). They concluded that the increasing BP.
prevalence of hypertension appeared ‘not to have chan- The prevalence of hypertension among 534 apparently
ged dramatically in the same urban workforce over the healthy traders who did not have diabetes in a market
last three to four decades’ (73). in Ibadan was 36.3% (38). Among those with hyperten-
As a proxy for overall trend, the crude prevalence of sion, 41.2% had Stage 2 hypertension with BP ]160/100
hypertension based on the BP 140/90 mmHg threshold mmHg and 63.4% had metabolic syndrome.
for the studies published was obtained for each decade as The prevalence of left ventricular hypertrophy (LVH)
the quotient of the sum of hypertensive workers and the ranged from 3.1 to 29.1% among 766 civil servants with a
total number in the study sample in that decade (89, 90). mean age of 41 years working in Benin City, Edo State,
It increased steadily from 12.9% in the 1980s, through depending on the criteria used (51). It occurred 2.34.4
18.5% in the 1990s to 31.9% in the 2000s. The prevalence times as frequently in those with hypertension as in those
for studies published from 2010 to 2014 was 34.4%. with normal BPs, with prevalence of up to 48.8% among
hypertensives, depending on the criteria used. The pre-
Severity of hypertension valence of LVH increased with increasing stage of hyper-
Evidence of the severity of hypertension is derived from the tension, being 6.529.6 times as frequent in those with
prevalence of grade 2 (moderate) hypertension, presence Stage 3 hypertension as in those with Stage 1 hypertension.
of target organ damage, and history of hospitalisation. After adjusting for age and systolic BP, body mass index
Twelve to fifteen percent of health workers (62), market and chest depth were independently associated with LVH
workers (40), traders (38), and information technology in the male civil servants.
workers (31) had moderate hypertension (BP ]160/100 Among 73 traditional chiefs in oil-rich communities,
mmHg). Six percent of civil servants in Accra (30) and 28.8% reported having ever been hospitalised as a result
8.0% of market women in Enugu, Nigeria, had severe of the hypertension (77).
hypertension (40). Among civil servants in Accra diag-
nosed with hypertension, 25.4% had moderate hyperten- Co-morbidity and clustering of risk factors
sion and 19.2% had severe (Grade 3) hypertension (30). Workers with hypertension frequently had other cardio-
Nearly half (47.5%) of the hypertensive subjects examined vascular risk factors as well as other NCDs. Among 402
had evidence of target organ damage (14). The odds of Senegalese workers of information technology compa-
having hypertensive target organ damage was 56 times nies, 44.8% were diagnosed with at least one NCD (31).
as much in severe hypertensives (BP ]180/110 mmHg) Of those diagnosed with NCDs, 38.9% had two NCDs

William K. Bosu
and 12.2% had three NCDs. Only 15.5% had isolated Overall, 21.5% of the university workers reported hav-
hypertension while 38.3% had hypertension in combina- ing been diagnosed with hypertension and 11.1% with
tion with at least one of three diseases chronic kidney diabetes.
disease, obesity, or diabetes. Among 52 oil workers in the Niger Delta region
Nearly one-fifth (18%) of telecommunications workers of Nigeria diagnosed with diabetes, 38.5% were obese,
in Senegal diagnosed with hypertension were estimated 46% were hypertensive, 67.3% had metabolic syndrome,
to be at high risk of a cardiovascular event, based on and 88.5% had dyslipidaemia (91). In Lagos, 22.3% of
the Framingham risk score (69). The major cardiovas- hypertensive bank workers had diabetes compared with
cular risks were hypertension (43.7%), physical inactivity 1.9% of non-hypertensives (74). Of the bank workers with
(68.0%), hypercholesterolaemia (37.9%), LVH (17.0%), diabetes, 75.8% had hypertension compared with 17.5%
obesity (11.3%), and tobacco use (12.3%). Twenty-eight of non-diabetics.
percent of the workers had one risk factor, 51% had two
risk factors, and 21% had three or more risk factors. Awareness, treatment, and control
Ige et al. observed that NCDs and high-risk behaviour Among the various workers with hypertension, 2084%
were common among university staff in Ibadan (58). were aware of their hypertensive status (Table 5). As
Ninety-six percent of the staff reported unhealthy diets, expected, health workers and the most highly edu-
27% low physical activity, 5% excessive alcohol intake, cated group of workers were most likely to be aware of
and tobacco smoking 2%. While 67.4% reported only one their hypertensive status. Specifically, 6584% of hospital
risk behaviour, 29.9% reported multiple risk behaviour. workers (62, 64) and 75% of medical school lecturers (59)
Table 5. Awareness, treatment, and control of hypertension among workers
Among all hypertensives %

No. of No. of Treatment Control among
hypertensives hypertensives Awareness Treatment Control among those those on
Study population Location BP ]140/90 BP ]160/95a % % % aware % treatment %
Bank workers (73) Ibadan 264 85 49.4

Civil servants (53) Ibadan 103 24.3
Civil servants (30) Accra 307 54.1 31.3 12.7 82.8 40.6
Civil servants (56) Lome 112 22.3 1.8 1.0 8.0 100
Civil servants (51) Benin City 121 8.3
Civil servants, factory Calabar 419 19.6
and plantation
workers (50)
Factory and hotel Dakar 152 64.9 24.5 12.6 37.8 51.4
workers (45)
Health workers (62) Jos City 124 66.1 43.5 65.9
Health workers (64) Abidjan 144 84.0 79.2 94.2
Information technology Dakar 97 68.0
workers (31)
Market workers (40) Enugu 290 29.3
Medical school Port 16 75.0 75.0 100.0
lecturers (59) Harcourt
Mill operators (72) Ibadan 23 73.9
Policemen and male Benin City 95 9.7
civil servants (52)
Rubber plantation Rural 448 0
workers (43)
Telecommunication Not stated 537 14.9
workers (69)
Traditional chiefs (77) Rivers 73 54.8 50.7 80.4
State
University staff (60) Accra 48 43.8 43.8 0.0 100.0 0
a
% hypertensives aware of their status or on treatment is based on BP 160/95 mmHg cut-off.
16
previously knew they were hypertensives. In contrast, only factors for ischaemic heart disease. Forty percent consid-
29% of market workers comprising traders and artisans ered hypertension as a leading NCD cause of death; even
knew they had hypertension (40). Beyond these groups less knew about heart attack, diabetes, or cancer as leading
of workers, the patterns of awareness were variable. For causes of deaths.
example, 73.9% of mill operators in an Ibadan market (72) There was sometimes a disconnection between the
compared with 2224% of civil servants in Lome (56) and perception and the reality of being overweight or obese.
Ibadan (53) were aware of their previous diagnosis of Whereas 72% of health workers in a university teaching
hypertension. hospital were found to be overweight or obese, only 27%
On the whole, awareness of hypertension status was high perceived themselves to be overweight (62).
except in four studies in which only about one-fifth to half
of civil servants, plantation and factory workers (50), civil Compliance
servants (53), university workers in the health sciences There were scant reports of non-compliance with treat-
departments (60), and bank workers (73) knew about their ment among workers in West Africa. Poor compliance
hypertension. There were still important awareness gaps was observed even among health workers. In Abidjan,
among workers. Even in the study reporting the highest 71% of health workers, particularly assistant nurses and
rate of awareness in Abidjan, 15% of the doctors with nurses, had difficulties complying with their antihyper-
hypertension were newly diagnosed (64). tensive treatment (64). Contrary to expectation, persons
The proportion of workers with hypertension who on multiple therapy were more compliant than those on
were on treatment ranged from 0% among rubber planta- monotherapy.
tion workers to 79% among health workers. Again, health In Lome, 92% of all hypertensive civil servants who
workers and medical school lecturers were most likely to be
were aware of their diagnoses had stopped taking their
on treatment. In nearly all of the studies with available
medication or would only take them when they had
data, less than half of workers with hypertension were on
symptoms (56). Sixty percent of the hypertensives had
treatment. Among the traditional chiefs from oil-rich
been first diagnosed during the course of an illness.
communities in Nigeria in whom the highest prevalence
of hypertension was observed, 55% were previously aware
they had hypertension and about half were on medication. Uptake of medical check-up
Treatment rates improved dramatically to 38100% Consistent with their low awareness and knowledge
when assessed among those hypertensives who were pre- about CVDs, West African workers infrequently under-
viously aware of their diagnosis. Most workers including went a medical check-up. Hypertensive senior executives
medical staff on treatment were on monotherapy (62, 64). in Nigeria had not had a check-up for a varying period of
In the five studies in this review in which it was reported, 022 years with a mean of 2.891.7 years (68). Among
the controlled rates ranged from 0 to 13% among all hyper- university workers in Calabar, only 25% had visited the
tensives and from 0 to 100% among those on treatment. hospital for a routine medical check-up (94). Most only
went to the hospital when they were ill.
Similarly, Funke and Ibrahim found that most (58.5%)
Knowledge and perceptions
health workers in the Jos University Teaching Hospital of
Knowledge about the aetiology and management of hy-
pertension among some workers is inadequate. Seventy- Nigeria rarely checked their BP except when they were ill
three percent of university workers in Nigeria thought (62). Thirty-five percent had not checked their BP in the
hypertension was caused by undue thinking, stress, or preceding 1 year. Medical staff, senior staff, and those
worries, and 65% did not know it required life-long with tertiary education were more likely to regularly
treatment (92). Among hospital workers in Abeokuta, monitor their BP. More than 60% rarely checked their
Nigeria, 89% correctly identified hypertension as a risk weight or had never done so.
factor for stroke while 15% attributed it to evil spirits or
the will of God (93). However, 29% of the workers Discussion
(of whom nearly a quarter were clinical workers) could This is the first review of the prevalence of hypertension
not identify the brain as the organ affected. While 61% as well as its awareness, detection, and control among
preferred hospital treatment, 13% preferred spiritual workers in West Africa. A particular strength of this
treatment. Higher level of education and being a clinical review is the identification of a large number of studies
worker were significantly associated with adequate knowl- including those in which the prevalence of hypertension
edge of stroke. was a secondary or an incidental objective. The review
Similarly, senior and junior staff of the University of also identified some publications in French, which are
Calabar, Nigeria, had poor knowledge of the risk factors usually not included in English-language-based reviews.
for ischaemic heart disease (94). Only 642% knew obesity, It covered a wide range of formal and informal sector
sedentary lifestyle, and oral contraceptives were risk workers. Of particular interest is the behaviour of health

William K. Bosu
workers who are expected to be models of healthy living The review showed high prevalence of hypertension
in their societies. particularly among the men, older group, and senior staff.
However, it is possible that the review under-repre- The prevalence of hypertension in male civil servants
sented studies among workers in French- and Portuguese- in Nigeria was reported to be similar to that of US
speaking West African countries. The search in French black males (48). High prevalence of hypertension of up
was only limited to Google Scholar and fewer French or to 50.2% among men and 68.8% among women was
Portuguese journals are included in the databases that similarly reported in a 60-year review of hypertension in
were searched. There were two publications from French- Nigeria (89). In Ghana, a systematic review reported a
speaking Senegal that were published in English (31, 45). prevalence of 19.248.0% (95). Addo et al. observed lower
The findings among the different workers may not be prevalence of 12.529.4% in their systematic review of
generalised to the general population in West Africa. studies in Africa (15). Studies which excluded persons with
However, many of the findings, such as the high pre- diabetes or known hypertension from their sample (65, 71)
valence of hypertension, low awareness, and control, or only measured systolic hypertension may have under-
reflect patterns in the general population (15, 89, 95). estimated the true prevalence in the workers.
Hypertension is now a pandemic in West Africa with In contrast with the findings of national (95) and
significant levels, not only in the urban populations, regional reviews (15, 101) which reported minimal sex
but also rural populations (96) and marginalised groups differences, this review found higher prevalence among
(97). Locating articles was particularly difficult as several male workers in most studies. It is not clear if sex dif-
publications, particularly older journals, and the most ference reflects the differences in the study populations
recent publications of African journals were not avail- or methods. Consistent with this review, most STEPS
able online. Comparisons of the prevalence of hyper- surveys in Africa and other studies have found a higher
tension between workers from different studies were prevalence of hypertension among men (16, 101). It
difficult due to the wide diversity of the groups and the has been proposed that the molecular mechanisms under-
lack of standardised rates. However, age-specific preva- lying vasculature, nervous system, and kidney functions
lence rates were obtained where available. There were that lead to hypertension and the pathways for the
differences in the methods of measurements of BP in control of BP may explain the differences between the
terms of type of equipment, number of measurements, sexes (102).
number of visits, and in the values analysed to compute The review also highlighted high levels of hypertension
the final BP. among sedentary groups such as traders, and traditional
Assessing the quality of studies was complicated by the chiefs or the informal sector who are rarely targeted by
methodological challenges in data collection and reporting national cardiovascular health programmes or policies.
deficiencies. Most of the studies enrolled a representative Models for workplace or employee well-being pro-
sample of workers. Staff lists were available for most grammes are almost exclusively based on structured
formal sector workers as well as for some informal sector formal sector workplaces (103). In low-income settings,
workers. Studies without staff lists strived to achieve high it is important for national programmes on occupa-
participation through active door-to-door mobilisation of tional health and NCDs to target these informal sector
available staff or the cooperation of the workers’ leader- workers through their unions and associations and
ship. Non-participation may have the effect of biasing integrate these programmes into their work-related
the prevalence in either direction. However, as has been activities (39).
rightly argued, any effect is likely to be minimal owing to Severe hypertension and target organ damage were
the prevailing low awareness of hypertension, even among relatively common among those with hypertension. This
these formal sector workers (79). was probably caused or worsened by the prevailing
Several important findings emerged from the review. low awareness, treatment, and poor control rates, infre-
Only a few of the ECOWAS Member States have published quent medical check-up, co-morbidity, low compliance
any studies on hypertension in workers. Nigeria alone with treatment, inappropriate therapy, and use of plant
produced the overwhelming majority of all the identi- medicine with unproven efficacy (104). In West Africa,
fied studies, likely a reflection of its large population and many hypertensives are diagnosed for the first time when
research capacity. The production rate of studies has they present with complications such as stroke or heart
dramatically increased over the past 5 years compared failure (105, 106). In one tertiary hospital in Nigeria,
to 20 or 30 years previously. The strikingly low production for instance, about half of the hypertensive-related admis-
of studies and systematic reviews on NCDs from low- sions were undiagnosed (107). Autopsy findings also
income settings has been described (98, 99). Low nutrition confirm sudden deaths from undiagnosed hyperten-
capacity has also been recently described in West Africa sion (108). Co-morbidity and clustering of risk factors,
where only nine countries offer any degree programmes which was relatively common among workers, have also
(100). been reported among the general adult population (86).
18
Contrary to the observation of Kadiri and his colleagues regional NCD strategic plan, it now has the opportunity to
15 years ago (73), there is evidence from a systematic review give more priority to the control of NCDs in workplace
of increasing prevalence of hypertension in Nigeria (109). settings.
Evidence of increasing trend is supported by another
systematic review in Nigeria which found that the crude Conclusions
decade prevalence increased from 8.6% in 19701979 to The prevalence of hypertension among workers in ECO-
22.5% in 20002009 (89). WAS Member States is quite high. A significant propor-
As they are better educated and are more likely to tion of the disease is undiagnosed, severe, and complicated.
undergo medical examination, workers were more likely to While better than that of the general population, the
be aware of their hypertension than the general popula- awareness, treatment, and control of the disease is low.
tion (110). Improving access to screening programmes Workers have little knowledge of the disease, and they
through community-based health insurance schemes infrequently undergo a medical check-up. Occupational
has been shown to reduce mean population arterial BP health programs should aim to improve the general
(111, 112). awareness of workers, promote healthy behaviour, screen
It is remarkable that high prevalence of hypertension for risk factors, and institute integrated control of NCDs.
and inadequate health behaviour were observed even
among health workers, lecturers, and senior officials. Author’s contribution
Health care workers, whether or not engaged in clinical WKB is responsible for all aspects of this study including
care, have the opportunity to undergo a periodic medical the study concept, data collection, interpretation of results,
check-up. There is some concern that health workers and drafting, revision, and finalisation of the paper.
with unhealthy behaviour may not be well disposed to
counselling patients or providing care relating to that
Author’s information
behaviour (113). There are some emerging initiatives.
WKB works as the Professional Officer in charge of
For example, the Ghana Health Service has established a
nutrition and non-communicable diseases at the West
gymnasium and encourages sub-national level health
African Health Organisation.
authorities to organise regular corporate physical activity
sessions (114, 115). Ghana also has a Regenerative Health
and Nutrition Programme that actively engages tra- Acknowledgements
ditional chiefs in physical activity. Cote d’Ivoire has I am deeply grateful to various libraries in West Africa and in the
a website (www.preventionci.net) dedicated to creating UK for providing some of the full-text articles reviewed. I would like
to thank the various authors who kindly sent me copies of their
public awareness about NCDs.
articles and provided clarifications for this review. Dr R Sodjinou
The poor control of hypertension has been confirmed in assisted with the map.
other reviews (17, 30, 95, 110). Uncontrolled systolic and
diastolic BPs are a risk factor for increased cardiovascular
and all-cause mortality (116). There is inadequate knowl-
Conflict of interest and funding
edge about treatment targets among practitioners (117). The author declares that he has no conflict of interest and
Patients are not adequately counselled about treatment funding.
and lifestyle modifications, leading many hypertensives
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Global Health Action

ISSN: 1654-9716 (Print) 1654-9880 (Online) Journal homepage: http://www.tandfonline.com/loi/zgha20

The prevalence, awareness, and control of

To link to this article: http://dx.doi.org/10.3402/gha.v8.26227

© 2015 William K. Bosu

Published online: 22 Jan 2015.

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Download by: [University of Florida] Date: 05 August 2017, At: 16:53

The prevalence, awareness, and control of hypertension

Background: Interventions in workplace settings are considered to be cost-effective in preventing

T cardiovascular health of workers in West Africa

Citation: Glob Health Action 2015, 8: 26227 - http://dx.doi.org/10.3402/gha.v8.26227 3

Fig. 1. The process of selecting articles.

Sample Participation Sampling % Age group Mean

Prevalence, awareness, and control of hypertension

Oyemade (42) industrial workers Ewereko workers and

Sample Participation Sampling % Age group Mean

(urban) November 1977

Sample Participation Sampling % Age group Mean

Prevalence, awareness, and control of hypertension

Fig. 2. Map of West Africa showing distribution of selected studies.

Frequency of Initial Interval between

1 Konin et al. (64) 13. Those with 1015 Manual

Prevalence, awareness, and control of hypertension

13 Olatunbosun et al. (53) 1 1 Single reading Left arm Manual

Frequency of Initial Interval between

18 Balogun & Owoaje 1 2 5 5 Appropriate Seated Right arm Electronic OMRON

Among the informal sector workers, the prevalence

Both arms in the

was generally higher among largely sedentary workers

the prevalence of hypertension ranged from 2.8% in

2nd measurement used

3.5% among civil servants and factory workers in Calabar

in the analysis, if 1st

(50) to 12.8% among senior executives in Benin City (68).

In 26 studies with available data, the prevalence

in male workers ranged from 11.2 to 68.9% while in the

among female workers (Table 3). It was consistently

ferences were not insignificant in 12 cases, the pre-

observed in three studies among university workers at

Port of Abidjan, Cote d’Ivoire (76). In these three studies,

the prevalence of hypertension among males was about

studies in which there was a reversal, the prevalence of

hypertension in females was 1.22.0 times that in male

were less pronounced but also mostly higher in male

workers than female workers when the BP cut-off point

prevalence among females (45, 68).

Almost all the studies with available data consistently

Yayehd et al. (56)

Atatsi et al. (61)

In the few studies conducted in mixed settings, the mean

SBP, mean DBP, and the prevalence of hypertension

adjusting for age (48, 79). For example, the age-adjusted

Citation: Glob Health Action 2015, 8: 26227 - http://dx.doi.org/10.3402/gha.v8.26227 11

Prevalence BP 140/90 mmHg % Prevalence BP 160/95 mmHg %

1 Airport authority workers SHT 21.7; Severe

1 Airport authority workers SHT 21.7; Severe

Mmales; F females; T total sample.