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Epidemiology of cardiovascular disease risk factors in Ethiopia: the rural-ruban gradient
Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]


Changes in the population structure and the main causes of death result in the growing burden of chronic diseases, which characterize the epidemiological transition. The transition takes place at different paces in different parts of the world. The developed world has taken over a century to complete the transition, and the rapidly developing countries of Asia and Latin America are undergoing a swift transition. In contrast, many sub-Saharan African countries are said to be experiencing a delayed transition. In Ethiopia, routine health care reports are incomplete and erratic. Lack of nationwide data on causes of death clouds understanding of the burden of disease or its composition. Consequently, there is limited knowledge on the course of the epidemiological transition, which has left room for widespread scepticism concerning the importance of chronic diseases in the country. Hence, the health system continues to be heavily reliant on the conventional “infectious disease paradigm”, and fails to be responsive to emerging health problems. Assessing the pattern and causes of disease burden enables meeting the health care needs of vulnerable population segments and devising cost-effective interventions that avert the impact of emerging diseases on the health and well-being of the nation. However, in countries without a functional system for registration of vital events, such as births and deaths, complete and reliable data on the burden of chronic diseases will not be available. Data on their risk factors, which are valuable for prevention and control programmes, can be generated through population-based surveillance, and serve as a practical alternative.


This research project was implemented in order to illustrate the distribution of risk factors for cardiovascular diseases (CVD), and examine the gradient across urban and rural populations in Ethiopia, thereby contributing to national and global efforts of tracking the course of the epidemiological transition.


The WHO STEPS instrument was employed in two populations of central Ethiopia, representing a predominantly rural district (Butajira) and the national capital – Addis Ababa. Over 8000 adults in the age group 25-64 years, from the two populations, participated in interview and physical measurements, which were conducted in a standard manner. Ethical clearance for the project was obtained from appropriate national bodies and ethical conduct was maintained throughout the research process.


The findings revealed wide disparities, between urban and rural populations, in the distribution of the main risk factors of CVD. Elevated blood pressure, obesity, and physical inactivity were more concentrated in urban populations, while the rural-urban gap was narrower with the distribution of cigarette smoking and binge drinking of alcohol. The use of substances like khat (Catha edulis Forsk), which may increase the risk of acute myocardial infarction, is expanding from rural areas that grow the plant to urban populations, partly due to improved transportation and market forces. The gap in the distribution of risk factors between the sexes is wider in rural populations and narrows down in urban areas. Thus, men in rural areas have a markedly higher prevalence of hypertension than women, while the level is similar between men and women in urban areas. Urban women carry more risk of CVD due to higher prevalence of physical inactivity, overweigh and obesity. Intake of fruits and vegetables is not consistent with optimal cardiovascular health in both rural and urban populations, but comparatively better in rural areas.

Conclusion and recommendations

The prevalence of high blood pressure in urban Ethiopia is similar to other sub-Saharan African countries, and closely comparable to the situation in the developed world. Owing to the established contribution of high blood pressure to CVD morbidity and mortality, it (elevated blood pressure) may represent the principal risk factor for CVD in the Ethiopian population, particularly in urban areas. Programmes for the prevention and control of CVD in Ethiopia should give due priority to the prevention of high blood pressure and its precursors, such as physical inactivity, overweight and obesity. Population wide strategies should be implemented to promote healthy dietary behaviour and physical activity, and to prevent smoking and substance use behaviours. Programmes should also aim to improve awareness, detection and appropriate clinical management of high blood pressure among health care providers and the public at large. The stepwise surveillance of chronic disease risk factors (STEPS) should be implemented on a sentinel nationwide basis in Ethiopia, in order to inform policy and guide strategies and programmes for the prevention and control of CVD and other chronic diseases. The national health extension program offers an opportunity to establish a system for registration of birth, death, and similar vital events at a population level, which provides a more reliable foundation for estimating vital indicators and disease burdens.

Place, publisher, year, edition, pages
Umeå: Epidemiologi och folkhälsovetenskap , 2008.
Umeå University medical dissertations, ISSN 0346-6612 ; 1151
Research subject
URN: urn:nbn:se:umu:diva-1543ISBN: 978-91-7264-492-2OAI: diva2:141340
Public defence
2008-02-29, sal 135, 9A, NUS, Umeå, 09:00 (English)
Available from: 2008-02-14 Created: 2008-02-14 Last updated: 2009-05-07Bibliographically approved
List of papers
1. Association between body mass index and blood pressure across three populations in Africa and Asia.
Open this publication in new window or tab >>Association between body mass index and blood pressure across three populations in Africa and Asia.
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2007 (English)In: Journal of Human Hypertension, ISSN 0950-9240, Vol. 21, no 1, 28-37 p.Article in journal (Refereed) Published
Adult, Blood Pressure, Body Mass Index, Ethiopia/epidemiology, Female, Humans, Hypertension/*epidemiology, Indonesia/epidemiology, Male, Middle Aged, Risk Factors, Vietnam/epidemiology
urn:nbn:se:umu:diva-16205 (URN)10.1038/sj.jhh.1002104 (DOI)17066088 (PubMedID)
Available from: 2007-08-28 Created: 2007-08-28 Last updated: 2015-04-29Bibliographically approved
2. Concurrent comparison of energy intake and expenditure among adults in Butajira District, Ethiopia
Open this publication in new window or tab >>Concurrent comparison of energy intake and expenditure among adults in Butajira District, Ethiopia
2008 (English)In: Public Health Nutrition, ISSN 1368-9800, E-ISSN 1475-2727, Vol. 11, no 7, 675-683 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To estimate and compare dietary energy intake (DEI) and total energy expenditure (TEE) among adults, using questionnaires. DESIGN: Comparative, cross-sectional study. SETTING: Community-based, at the demographic surveillance site (DSS) in Butajira District of Ethiopia. SUBJECTS: A total of 619 adults, 18-64 years of age, were randomly selected from among the urban and rural population of Butajira using the DSS sampling frame. Habitual dietary intake and physical activity were assessed using questionnaires. BMR was estimated using a regression equation, and TEE was calculated from BMR and the metabolic energy equivalent task (MET) and duration of reported activities. Physical activity level (PAL) was calculated as TEE/BMR, while food intake level (FIL) was calculated as DEI/BMR. The mean DEI:TEE ratio was used to evaluate reported DEI at the population level, while individual misreporters were identified by applying the Goldberg cut-off points at three levels of PAL. RESULTS: Based on the Goldberg method, 57% of the study participants were identified as acceptable reporters of DEI, among whom mean TEE was 8.21 (95% CI 8.01, 8.42) MJ (1963 (95% CI 1914, 2012) kcal), mean DEI was 8.13 (95% CI 7.93, 8.34) MJ (1944 (95% CI 1895, 1993) kcal) and mean DEI:TEE was 1.01 (95% CI 0.99, 1.04). CONCLUSION: The dietary history and physical activity questionnaires provide comparable estimates of mean energy intake and expenditure at a population level. Acceptable reporters have to be identified in order to obtain better estimates. Questionnaire-based estimates of energy intake should not be interpreted without an inherent system of comparison or validation.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
urn:nbn:se:umu:diva-22385 (URN)10.1017/S1368980008001705 (DOI)18279561 (PubMedID)
Available from: 2009-05-07 Created: 2009-05-07 Last updated: 2015-04-29Bibliographically approved
3. Association of Smoking and Khat (Catha edulis Forsk) Use With High Blood Pressure Among Adults in Addis Ababa, Ethiopia, 2006
Open this publication in new window or tab >>Association of Smoking and Khat (Catha edulis Forsk) Use With High Blood Pressure Among Adults in Addis Ababa, Ethiopia, 2006
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2008 (English)In: Preventing chronic diseases, ISSN 1545-1151, Vol. 5, no 3Article in journal (Refereed) Published
Abstract [en]

Introduction We assessed the prevalence of substance use and its association with high blood pressure among adults in Addis Ababa, Ethiopia.

Methods We employed a cross-sectional descriptive study design. The World Health Organization instrument for stepwise surveillance of risk factors for chronic diseases was applied on a probabilistic sample of 4001 men and women aged 25 to 64 years in Addis Ababa. We determined the prevalence of cigarette smoking, alcohol drinking, and khat (Catha edulis Forsk) chewing. We measured blood pressure by using a digital device and determined mean levels of systolic and diastolic blood pressure.

Results Smoking cigarettes, drinking alcohol, and chewing khat were widely prevalent among men. Among men, the prevalence of current daily smoking was 11.0% (95% confidence interval [CI], 9.5%–12.5%). Binge drinking of alcohol was reported by 10.4% (95% CI, 9.0%–11.9%) of men. Similarly, 15.9% (95% CI, 14.1%–17.6%) of men regularly chewed khat. Consequently, 26.6% of men and 2.4% of women reported practicing one or more of the behaviors. Current daily smoking and regular khat chewing were significantly associated with elevated mean diastolic blood pressure (β = 2.1, P = .03 and β = 1.9, P = .02, respectively).

Conclusion Cigarette smoking and khat chewing among men in Addis Ababa were associated with high blood pressure, an established risk factor for cardiovascular disease. Health promotion interventions should aim to prevent proliferation of such behaviors among young people and adoption by women. Surveillance for risk factors for cardiovascular disease should be implemented nationwide to provide information for policy decisions and to guide prevention and control programs.

Place, publisher, year, edition, pages
National Center for Chronic Disease Prevention and Health Promotion, 2008
National Category
Public Health, Global Health, Social Medicine and Epidemiology
urn:nbn:se:umu:diva-2953 (URN)
Working title Cigarette smoking and Khat (Cata Edulis Forsk) use are associated with elevated blood pressure among adults in Addis Ababa - EthiopiaAvailable from: 2008-02-14 Created: 2008-02-14 Last updated: 2015-04-29Bibliographically approved
4. High blood pressure among adults in Addis Ababa: a silent epidemic
Open this publication in new window or tab >>High blood pressure among adults in Addis Ababa: a silent epidemic
(English)In: Journal of human hypertensionArticle in journal (Refereed) Submitted
urn:nbn:se:umu:diva-2954 (URN)
Available from: 2008-02-14 Created: 2008-02-14 Last updated: 2015-04-29Bibliographically approved

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