Care models evolving to meet women’s heart health needs

Long seen as more of a man’s condition, hypertension is often missed and poorly managed in women—especially in low- and middle-income countries. New efforts call for targeted, gender-sensitive approaches to promote lasting health benefits.

After menopause, and especially after the age of 60, women face a higher risk of hypertension due to declining oestrogen levels. Photo: Lagos Food Bank

It is known as a silent killer because uncontrolled hypertension, or high blood pressure, is a key risk factor for cardiovascular disease, which is the world’s leading cause of death. Yet, although hypertension can be easily treated, the burden of the condition is not spread equally.

“It is estimated that of the 1.4 bn people with hypertension, over 1 bn reside in low- and middle-income countries (LMICs),” says Alta Schutte, professor of cardiovascular medicine at the University of New South Wales and co-director of the global cardiovascular programme at The George Institute for Global Health.

While the condition affects both sexes, women in LMICs face particular risks. Hypertension, long considered a “man’s problem”, is frequently under-recognised and undertreated in women.

Till the age of 50, men are more likely to have hypertension than women, but after 60 and preceded by menopause, rates increase in women as their oestrogen levels decline. Historically, most research studies were conducted on men, and high-risk moments for women during pregnancy and post-menopause are often poorly understood, as is the fact that symptoms can present differently in women.

A recent study from Toronto’s Sunnybrook Health Sciences Centre found that common risk factors for cardiovascular disease, including blood pressure, have a greater impact on cardiovascular risk in women than men.

Schutte also points to new research demonstrating that lower blood pressure thresholds may even be required for women pre-menopause, as data suggests that even at the same blood pressure level as men, women have a higher risk of cardiovascular disease.

Increasingly, it is becoming clear that hypertension, and cardiovascular disease, need to be seen through more of a gendered lens.

Hypertension and women in LMICs

In its recent Global Report on Hypertension, the World Health Organization (WHO) highlighted vast geographic disparity in treatment coverage, with the highest levels (60%) reported in the Americas, and the lowest in the African regions (27%).

The WHO report notes that globally, more men have hypertension (34%) than women (32%); however, for people aged between 50 and 79 years, both sexes are estimated to have equivalent hypertension prevalence of 49%.

In LMICs, however, the picture is more nuanced. A study examining hypertension rates in sub-Saharan Africa between 2017 and 2023 showed that the prevalence was around 48% in women versus 34% in men. The report also noted a trend in some LMICs for increased rates of obesity and salt consumption in women.

“While heart disease and stroke are the leading causes of death and morbidity in both men and women, community surveys have found women perceive they are at lower risk.”

There are also major geographical differences in control rates where people are managing hypertension after being diagnosed. In South Korea and Canada, for example, control rates are 57%, but in sub-Saharan Africa they are less than 10%, and for some islands in Oceania, as low as 5%, according to a 2021 Lancet report. It also noted that 50–60% of women and nearly 70% of men with hypertension were unaware of their condition.

Dr Clara Chow, a cardiologist, professor of medicine at The University of Sydney, and co-author of the 2021 Lancet report, says it can be difficult to quantify hypertension rates in women in LMICs, as it is often underdiagnosed and screening is patchy.

“While heart disease and stroke are the leading causes of death and morbidity in both men and women, community surveys have found women perceive they are at lower risk,” she says.

“High blood pressure generally does not cause symptoms, so blood pressure needs to be measured to diagnose hypertension. In LMICs, there are fewer systematic health checking systems in place and limited access to primary care, and so women are less likely to have their blood pressure checked and treated.”

Towards better treatment in Nigeria

In Nigeria, where rates have risen sharply, especially for women, there is increasing awareness of the need to provide better detection and treatment. A 2017 survey revealed the prevalence of hypertension was 41.8% for women and 31.8% for men. The WHO Hypertension Country Profile 2023 reveals that only around 11% of men and women have their blood pressure under control; and obesity, inactivity, and salt consumption are all higher in women than men.

“We not only see heart failure that is due to uncontrolled hypertension, but also chronic kidney diseases and diabetes,” says Professor Dike Ojjie, a practising cardiologist and head of the Cardiovascular Research Unit at the University of Abuja.

As part of a local initiative in 2024 to train health workers to test for hypertension in primary healthcare settings, one community health worker recalls visiting a woman who was eight months pregnant but had had hardly any antenatal healthcare, highlighting patchy screening services at a time when hypertension carries additional health risks. “She was excited, [because] she said in her previous pregnancy, she went for antenatal care (in the hospital) and throughout her visits, her blood pressure wasn’t checked,” the worker reported.

In another case, where a pregnant woman tested by a health worker was found to have very high blood pressure, the part played by gender roles was highlighted. “I told her to go to the hospital immediately. She was reluctant because she was not sure if the husband would give her permission. I insisted… and told her I’ll accompany her... [Her husband] asked to speak with me. I explained everything to him. He immediately gave his wife the permission to go to the hospital. I’m glad I insisted,” recalls the health worker, demonstrating the importance of culturally sensitive interventions.

“Women are better in terms of health-seeking behaviour. At my clinics, I see that between 60–70% of patients are women.”

Ojjie is optimistic about the situation because as awareness grows, women are more likely than men to attend clinics.

“Women are better in terms of health-seeking behaviour. At my clinics, I see that between 60–70% of patients are women. In rural communities, healthcare used to be more focused on infectious diseases and HIV; but now the policy is that everyone over 18 should have their blood pressure checked,” he says.

Outside of Nigeria, Schutte explains that it can be challenging to understand complex societal barriers to care, which can be very regional and specific to different cultures. “General inequalities in healthcare access and delivery, and the disregard of women’s self-reported symptoms may all contribute. Women often have lower literacy rates in some regions and limited autonomy to act on health information,” she says.

Excess salt increases rates of hypertension

One of the major drivers of hypertension in women, in particular, is higher salt consumption and rates of obesity, as well as urbanisation and sedentary jobs.

“With the landscape changing so rapidly in LMICs, particularly [with increased] access to energy-dense foods, increase in salt intake, less fruit and vegetable intake, and with access to technology [increasing sedentary behaviour], there is a strong, increasing trend in obesity, hypertension, and related cardiovascular outcomes in women,” Schutte says.

Says Ojjie, “We recently did a study that revealed … people are on average consuming twice the [4g] salt recommended by the WHO. They’re adding salt to their food: using salty bouillon stock, and preserving meat and fish with salt,” he says, citing further research that shows women consume more salt than men in West Africa.

Research shows that women consume more salt in West Africa than men. Photo: Tope Asokere

He and others are now working to disseminate the dangers of high salt consumption and to urge women to replace it with low-sodium varieties of foods and increase their potassium levels to cut the risk of hypertension.

Another major issue is the cost of medications and the lack of universal access to healthcare in LMICs. In Nigeria, for example, Ojjie says, only 10% of the population has health insurance, a major barrier to effective hypertension detection and treatment. “People don’t necessarily trust the government to deliver if they pay their premium. Healthcare is supposed to be open to everybody; but in reality, the only people who enjoy it are those employed by the government and maybe some other private organisations.”

This lack disproportionately affects women, who are less likely to be employed or have health insurance, and often depend on male permission to pay for care, and therefore face greater financial barriers to ongoing treatment.

Solutions with women’s needs in mind

Despite the challenges, many initiatives are looking at ways to improve hypertension rates among women in LMICs. Empowering community health workers—who live in the communities they serve and act as an important link to formal healthcare facilities—to provide consistent, home-based hypertension support to women can be an effective strategy to fill care gaps in places with limited resources.

These workers understand the local culture, socioeconomic challenges, and gender roles, and can also deliver messages on the importance of maintaining a healthy weight, exercising regularly, and avoiding alcohol and smoking. “Community health workers are well respected; they are like doctors in these places, so people appreciate them visiting them at home,” Ojjie says.

“Blood pressure control prevention is not difficult. You need blood pressure machines. You need a good chair and a table, and you need good, generic medications; that's what we've been crying for.”

In Nigeria’s Gombe state, a community-led hypertension intervention equipped village health workers with blood pressure monitors to screen pregnant women at home. Over six months, more than 9,000 expectant mothers were visited, and hypertension prevalence fell from 1.5% to 0.8%.

Yet despite these initiatives around pregnancy, there seems to be a lack of awareness and projects in place to reach post-menopausal women with high blood pressure. “If these health services could be extended to also support women through the life course, they could present an opportunity for care of older women as well,” Chow says.

There is a lack of awareness and projects to reach post-menopausal women with high blood pressure. Photo: Mufid Majnun

Schemes to reduce medication costs are also vital. In 2020, Nigeria launched a pilot with Resolve to Save Lives and the WHO to improve access to blood pressure drugs by addressing cost and availability. A revolving drug fund—trialled in clinics in Kano and Ogun states—sold medication at a small markup and reinvested the income to restock. Prices dropped by up to 49%, and by mid-2021, the scheme had expanded to nearly 300 clinics, reaching over 38,000 people.

These initiatives demonstrate that while reducing hypertension rates among women is possible, crucially they need government funding and political will.

“Blood pressure control prevention is not difficult. You need blood pressure machines. You need a good chair and a table, and you need good, generic medications; that's what we've been crying for. We have the resources, but there is misappropriation, and we can do far better,” Ojjie says.

Schutte calls for a much stronger focus on female-led research and treatment. “All clinical trials in hypertension and cardiovascular disease should include equal numbers of men and women, and animal research should not only include male animals, as has been the case for many years. A better physiological understanding of disease development and treatment efficacy is important to ensure women get the best treatment possible,” she says.

With better data, targeted investment, and community-based solutions, the silent threat of hypertension can be tackled, especially for the women who all too often slip through the cracks.