18 / 84
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 2, March/April 2018
80
AFRICA
one-third of participants with any of these conditions had access
to treatment, which demonstrates the inadequacy of the region’s
health system to help patients manage risk factors. Economic
difficulties and the lack of drugs to address CVD may also help
explain the low levels of treatment and control found.
Nevertheless, a positive note should be made as to the
number of patients who had controlled levels of blood pressure,
blood sugar and cholesterolaemia in this specific population.
Considering that they were younger and better educated, they
could have had easier access to drugs and health facilities. Also
noteworthy, in the absence of access to drugs, physicians’ advice
in most cases is to adopt non-pharmacological approaches to
reducing modifiable risk factors, mainly associated with diet.
Strengths and limitations of the study
Our study findings should be interpreted cautiously because
the Dande-HDSS was developed as a district-level surveillance
system in an urban and rural setting and is therefore not
representative of the demographic structure of the country. In
addition, age groups over 65 years old (known for higher rates
of the conditions studied) were not considered owing to their low
representation in the general structure of the population (3.6%
of the Dande-HDSS population),
18
which is a common practice
for surveys conducted in sub-Saharan Africa.
Internal migration and the geographical isolation of some
hamlets within the Dande-HDSS, together with the fact that
working individuals were unavailable during the daytime,
17
were
reflected in the sampling definition, with a 30% non-participation
rate. The distribution of non-respondents was uneven, with a
higher proportion of younger people and men (data not shown).
This may have caused instability in the estimates in some strata.
Participants were requested not to eat anything eight hours
before participating in the study; however, it was difficult to
measure adherence to this request, which adds uncertainty to
the measures of blood glucose and cholesterol. We used dry
chemistry devices to measure glycaemia and cholesterolaemia,
but owing to high temperatures and humidity during field
surveys, data collection was not possible in some cases, causing a
higher number of missing data than expected.
Due to the many variables covered in the survey and to
avoid drop-out of participants in future rounds, additional
questions relating to awareness, pharmacological treatments
and non-pharmacological approaches were conducted in a more
detailed form in individual follow-up visitations. These are not
dealt with extensively in this article. Also the low number of
aware individuals and consequently under-treatment limited the
statistical analysis of data regarding these aspects.
It is therefore not possible to extrapolate our findings to a
larger population at country level. However, this study reveals
new data about the prevalence, awareness, treatment and control
of diabetes and hypercholesterolaemia, and it is the most
comprehensive community-based study conducted to date in
Angola.
Future direction
The inclusion of younger participants (15 to 24 years) allows
a better representation of the demographic structure of the
country and creates a baseline for future surveys. The emphasis
for future interventions should be aimed at younger populations
in which the prevalence of major risk factors is still low, so as to
make a difference in the long term.
In all LMIC, NCDs are the leading cause of death and
disability, killing nearly eight million people under 60 years
old in 2013.
25
Over the past decade, the focus of assistance in
these countries has primarily addressed maternal and child
health and infectious diseases. Without setting these aside, there
is an opportunity to use structures that are already in place,
to maximise resources. The international community should
consider expanding the mandate of current programmes to
include outcome-orientated measures for improving general
health and lifestyles.
Many of the methods of NCD prevention, management and
treatment, which are responsible for the decline in some of these
diseases in high-income countries, are inexpensive but are not
widely used in LMIC. These methods could be implemented
through established global health strategies, such as increased
use of low-cost drugs,
35
and improved access to NCD services
for young adults and people with low educational attainment.
36
Conclusions
This report reinforces the available data for the main CVD
risk factors in Angola and helps to build the basis for further
prospective studies, especially among the younger group in
this region. We provide the first evidence that hypertension
prevalence is rising, together with diabetes, when compared with
previous studies in the region.
Despite being a growing economy, Angola’s primary health
system may not be currently able to provide an adequate answer
to the changing health needs of this population. A gradual
shift from infectious diseases to NCDs is underway and this
puts additional stress on the reinforcement of primary care
intervention in the region.
The authors thank the clinical staff of Bengo General Hospital for establishing
and supporting the follow-up consultation. We thank all Dande-HDSS staff for
their continuing support during fieldwork, namely Joana Paz and Ana Oliveira
for their field supervision roles, Eduardo Saraiva for data entry supervision
and database management, Edite Rosário for the training of field workers and
assistance in data-collection procedures. Most importantly, we thank the local
administration and all of the individuals who agreed to take part in the study.
This study was funded by the promoters of the CISA as follows: Camões,
Institute of Cooperation and Language, Portugal; Calouste Gulbenkian
Foundation, Portugal; Government of Bengo Province, Angola; and the
Angolan Ministry of Health. Also, the Eduardo dos Santos Foundation,
Angola and the Institute of Public Health of the University of Porto,
Portugal (ref UID/DTP/04750/2013) funded this study. The funders had no
role in the study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
References
1.
World Health Organization.
Global status report on Noncommunicable
diseases
. Geneva: World Health Organization, 2014.
2.
World Health Organization.
Global atlas on cardiovascular disease
prevention and control
. Geneva: World Health Organization, 2011.
3.
Tunstall-Pedoe H.
World largest study of heart disease, stroke, risk
factors and population trends, 1979–2002.
MONICA Monograph and