THE JAMAICAN HYPERTENSION

PREVALENCE STUDY
Dalip Ragoobirsingh, PhD, Donovan McGrowder, PhD,
Errol Y. Morrison, MD, PhD, FRCP, FACP, FRSM (UK), Pauline Johnson, MSc,
Eva Lewis-Fuller, MBBS, MPh, and John Fray, PhD
Kingston, Jamaica; Worcester, Massachusetts

This study was designed to investigate the prevalence of hypertension in Jamaica. Jamaica
has an area of 4,411 square miles and is divided into 14 parishes. The visited districts were
randomly selected. The sample population was selected based upon a two-stage stratified
random sampling design. Each dwelling in the "Sampling Universe" had an equal probability of
being selected.
The survey team spent a week in the districts in each parish selected. Employing the Statistical
Institute of Jamaica's (STATIN) two-stage stratified random sampling design, preselected house-
holds were visited. Non-response was documented and considered in the final analysis. Only
individuals 15 years and older were allowed to participate in the study.
The 2,064 subjects who participated were the basis for estimates of hypertension. Following
logistic regression analysis, the main risk factors for hypertension are being female, advancing
age, obesity, having diabetes and having a family history of hypertension.
Jamaica has a point prevalence of hypertension of 30.8% in the 15-and-over age group.
These findings would greatly assist in formulating policies to deal with this scourge of society.
. Natl Med Assoc. 2002;94:561-565.)

Key words: epidem.,iological study *
hypertension * Jamaica
point prevalence *
risk markers for hypertension *
systematic island-wide survey
© 2002. Thdnks to the Caribbean Food and Nutrition Institute, Uni-
versity of the West Indies, Ministry of Health, Kingston, Jamaica, and
the Department of Physiology, University of Massachusetts Medical
School, Worcester, MA.
Send correspondence to Dr. D. Ragoobirsingh, Biochemistry Sec-
tion, Faculty of Medical Sciences, UWI, Mona, Kingston 7, Jamaica,
WI; Phone: (876) 927-2290; Fax: (876) 977-3823; E-mail:
dragoo@uwimona.edu. jm. For reprints, contact Professor E. Morrison,
Biochemistry Section, Faculty of Medical Sciences, UWI, Mona, King-
ston 7, Jamaica, WI; Phone: (876) 977-1749; Fax: (876) 977-5233;
Email: emorrisn@uwimona.edu.jm
In Jamaica, the loss of man hours in produc-
tive employment due to the effects of hyperten-
sion is becoming more and more recognized.
No previous systematic island-wide study of this
disorder had been undertaken in this country.
Hence, this was a timely exercise, which could
greatly assist the government in formulating
plans for the health sector of the country, and
eventually in the advancement of the economy.
The present survey was a cross-sectional study
designed to estimate the prevalence of hyperten-
sion and risk markers for this condition in the
adult population. From the most recent census,'
68.1% of the total population was over 15 years of
age. From this, a suitable sample size was chosen
to give precise prevalence estimates and allow the

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 94, NO. 7, JULY 2002 561
JAMAICAN HYPERTENSION
exploration of relationships between the disease
states and risk markers.
METHODS
Jamaica has an area of 4,411 square miles
and is divided into 14 parishes, each of which
was visited by the survey team. The districts in
each parish were randomly selected. The sam-
ple population was selected based on a two-
stage stratified random sampling design, with
the first stage being a selection of areas of
Enumeration Districts (ED) of the population
census and the second stage being a selection
of dwellings. Each dwelling in the "sampling
universe" had an equal probability proportion-
ate to size. At the second stage, 18 dwellings
from each ED were included in the sample.
The sampling number was derived by finding
the product of the number of EDs, number of
households in the Eds, and persons in each
household; the latter being taken as two. This
was a method specially developed and tested by
STATIN.1 Informed consent was obtained after
the nature of the procedures had been fully
explained to participants.
At the homes visited, only those individuals 15
years of age and older were interviewed. Mem-
bers of the health team administered a question-
naire to each participant; this included personal,
medical and family histories. In addition, anthro-
pometric measurements were done in accor-
dance with the Monica Manual.2
Height and Weight
Height was measured to the nearest half cen-
timeter. Each subject was asked to remove his
or her shoes and stand with his/her back to the
rule. The back of head, back, buttocks, calves,
and heels touched the upright. The head was
positioned so that the top of the external audi-
tory meatus was level with the inferior margin
of the bony orbit.
Weight was to the nearest tenth of a kilo-
gram. Each subject was weighed without shoes
and was lightly dressed. Body Mass Index
(BMI) was calculated using the formula: weight
.height2 kg/in2.
562 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Waist and Hip Circumference
These parameters were measured over rela-
tively light clothing. Subjects were asked to
stand with their feet 12 to 15 cm apart, weight
equally distributed on each leg and breathing
normally. The observer either sat or knelt in
front of the subject to place the tape and take
the reading. The waist girth was measured at
the mid-point between the iliac crest and the
lower margin of the ribs. The hip girth was
recorded as the maximum circumference
around the buttocks posteriorly and anteriorly
by the symphysis pubis. Readings were taken to
the nearest 0.5 centimeter.
Blood Pressure Measurements
Blood pressures were done on the left arm of
subjects who had been sitting for approxi-
mately 10 minutes. All clothing was removed
from the arm. In the case where a blouse, or
shirt was not to be removed, it was enclosed
under the cuff rather than rolling the sleeve
into a constricting band. The cuff was wrapped
around the arm ensuring that the bladder di-
mensions were accurate. If the bladder did not
completely encircle the arm, the center of the
bladder was placed over the brachial artery.
The brachial artery was palpated with one
hand, and the cuff rapidly inflated to about
30mm Hg above the disappearance of the
pulse, and then slowly deflated, 2mm Hg per
second. The stethoscope was placed over the
brachial artery.
The appearance of Korotkoff sounds was re-
corded as the systolic pressure, which corre-
lates well with the intra-arterial pressure and
the disappearance of Korotkoff sounds as the
diastolic.
Blood pressure measurements were re-
peated and recorded to the nearest 2mm Hg.
High blood pressure was indicated by a dia-
stolic of ' 90mm Hg and/or systolic of ' 140
mm Hg.
QUALITY CONTROL
All members of the survey team were trained
in all the measurements. Visual quality control
VOL. 94, NO. 7, JULY 2002

was a continuous part of the fieldwork. Retrain-
ing and examining of survey team members in
the measurements were done on a weekly basis.
In addition, completed questionnaires were
checked for illegible answers and unanswered
questions before leaving an area or parish.
Data Analysis
Data were analyzed by a statistician, using
the SPSS statistical software version 8. Follow-
ing computations of some variables and using
diagnosis of hypertension and measured blood
pressure as outcome variables, frequencies and
cross-tabulations were performed with a num-
ber of exposure variables. Mean and chi
squared analyses were performed. Multivariate
analyses were carried out using the logistic re-
gression procedure.
Using the measured blood pressure, high
blood pressure was defined as a systolic of 140
or greater and/or a diastolic of 90 or greater.
The totals may be inconsistent at times, due to
non-response for some of the variables. Over-
all, non-response, approximately 40% of the
sample population, was noted only after visiting
a home on three separate occasions and not
finding participants, or in cases where, for un-
known reasons, subjects refused to participate.
RESULTS
A total of 2064 individuals responded to the
all-island survey, with 64.6% being females. For
the sample population, the highest proportion
was among the respondents in the 15-to-24-year
age group, while the lowest was in the 75+ year
age group. Jamaica has a point prevalence of
hypertension of 30.8% in the 15 and over age
group.
The analysis of the risk factors associated
with hypertension in the population showed
several striking differences.
Advancing age increases the risk for hyper-
tension. Respondents in the 25-to-34 age group
have twice the risk of becoming hypertensive,
while respondents in the 65-to-74 age group are
15 times more vulnerable than those in the
15-to-24 age group (P = 0.001).
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JAMAICAN HYPERTENSION
Females are three times at risk of becoming
hypertensive than their male counterparts (p =
0.001).
Overweight to obese subjects have an increas-
ing risk to hypertension. Respondents with a BMI
of 30+ have approximately four times the risk of
being hypertensive when compared to normal
weight individuals (P = 0.001).
Diabetic patients are approximately two
times more at risk for becoming hypertensive
compared with non-diabetics (p = 0.004).
This study also shows that respondents with
known family history of hypertension had twice
more risk than those individuals with no family
history of hypertension (P = 0.001).
Other factors that were investigated but
showed no statistically significant association
with the prevalence of hypertension included
residential area, education level attained,
smoking status and alcohol consumption.
The survey also revealed that only 52.2% of
the hypertensive population was on prescribed
medication; 9.0% were taking non-prescription
forms of therapy, while 38.8% were on no treat-
ment at all. Of those on prescribed medication,
52.6% were well controlled, with mean blood
pressure of 130/80, while 47.4% were either
not responding to, or non-compliant with their
medication.
Discussion
The survey shows that 30.8% of Jamaican
adult population is hypertensive. This relatively
high figure may be due in part to the fact that
more than 95.0% of theJamaican population is
of African origin. The higher rates of hyperten-
sion among persons of African descent in the
United States compared with whites has been
recognized for most of this century.3 However,
the underlying cause of this differential in risk
remains one of the most perplexing biological
questions. Two theories have emerged which
link the increased prediction of blacks that
crossed the Atlantic, to hypertension. Grim and
Wilson 4 have postulated that evolutionary pres-
sure, which forced Africans living in a salt de-
prived environment to adapt to the many ram-
VOL. 94, NO. 7, JULY 2002 563
JAMAICAN HYPERTENSION
ifications of slavery, subsequently manifested
itself physiologically as an enhanced genetic
expression of a salt-transporting system.
Falkner, on the other hand, has suggested that
the primary genetic defect is in the insulin-stim-
ulated glucose uptake system, giving rise to insu-
lin resistance. The ensuing hyperinsulinemia in-
teracts with the svmpathetic nervous system and
sodium-transporting processes in the kidney and
vasculature. Insulin excess also triggers structtural
changes that, collectively, lead to an increased
total peripheral resistance, a parameter higher in
black children than in whites.5 It is, therefore, not
surprising that the finding of this survey com-
pares favorably with those reported in the U.S.,3
where of the estimated 60 million hypertension
cases reported, blacks represents 25% (almost
two-fold higher than represented in the general
population). Not only are blacks more likely to
develop hypertension, but the disorder develops
earlier, is often more severe, and is more likely to
be fatal at an earlier age, compared with white
counterparts.6 Ethnicity coupled with the high
prevalence of diabetes mellitus may be the main
reasons for the high prevalence of hypertension
in Jamaica.
The prevalence of hypertension is much
higher in the diabetic population than in their
non-diabetic peers. The point prevalence of'
diabetes mellitus is a record high of 17.9% in
the adult Jamaican population.7 The preva-
lence of hypertension among people, with dia-
betes mellitus in the developing world is as
high as or higher than in the United States.8
In this study, as in the Framingham Study,9
obesity has a positive correlation with the inci-
dence of hypertension. It is apparent that insu-
lin resistance and the accompanying hyper-
insulinaemia associated with obesity are
important factors in the genesis of hyperten-
sion.10 Hyper-insulinaemia may contribute to
hypertension via activation of the sympathetic
nervous system and renal salt retention,"l while
insulin resistance appears to contribute to hy-
pertension through increasing peripheral vas-
cular resistance in association with altered cel-
lular cation transport.l'2
564 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
The greater prevalence of hypertension in
Jamaican females is not a unique finding. It has
been reported that central obesity is positively
associated with elevated blood pressures in
black women.'"
In addition, advanced age was a major risk
marker for hypertension. With increasing age,
physiological stress response molecules are trig-
gered, which eventually elevates blood pressure. 1 4
It also has been reported that chronic social role
stressors have a greater effect on systolic blood
pressure among older persons. These exacerbate
the already existing physiological changes. The
social stressors were not measured in this survey,
but psychological factors, which are thought to
play a key role, are particularly diffictult to mea-
sure in a generalizable manner.l'5
A remarkable finding of this survey is the
possible role of family history of hypertension.
It is particularly interesting because although
blacks with a parental history of hypertension
are at increased risk for developing the disor-
der compared with the off:spring of normoten-
sive, epidemiological evidence indicates that
the association of pareintal history and risk for
hypertension is not as strong among blacks as it
is among whites." However, an explicit as-
sutmption in the literature on parental history,
is that offspring of hypertensives inherit the
genetic risk for the disorder and its pathophys-
iological concomitants. Yet, given the strong
influence of psychosocial stressors in the patho-
genesis of hypertension, especially among
blacks,'7 the former may well overshadow, or
else augment the influence of parental history.
This study showed no significant correlation
between area of residence and incidence of hy-
pertension. One would have thought that folks
dwelling in tranquil, rtural districts would be less
predisposed to hypertension than their city-dwell-
ing counterparts.Jamaica is perhaps too small for
the residential area to impact significantly on the
incidence of the chronic diseases. Educational
standard attained did not have any effect on the
prevalence of hypertension.Jamaica has a literacy
problem and as such a much larger sample size
and more sophisticated instrument(s) may be re-
VOL. 94, NO. 7, JULY 2002

quired to probe the possible effect of this factor
on elevated blood.
Smoking status and alcoholic consumption
did not have any positive correlation with the
prevalence of hypertension in this study. This is
not, and should not be taken as a prescription
for engaging in these habits. There are ample
medical and social reasons for controlling, if
not curtailing, these practices.
The tremendous association between hyper-
tension and its associated risk factors seen in this
study was not a novel finding, nor are the treat-
ment modalities employed any different from
those practiced in more developed countries. Yet,
a major concern for us in Jamaica, and the wider
Caribbean region, is that a vast number of our
hypertensives go untreated. This may be either
due to non-compliance, the unaffordability or
unavailability of the drugs prescribed. In addi-
tion, there are questions about the efficacy of the
therapies employed and the success rate for those
being treated. There also are a large number of
traditional healers who recommend different
herbs as possible therapy.
Although the prevalence of hypertension is
equally high in the developed and the develop-
ing world, the devastating consequences of hy-
pertension are seen more severely in develop-
ing countries. The authors hope that the
findings of this study will help improve medical
care, and that this will result in a decrease in
the proportion of undiagnosed hypertensive
individuals, while the number of diagnosed,
treated and controlled hypertensive individuals
increase steadily.
REFERENCES
1. Demographic Statistics. The Statistical Institute of Ja-
imaica, 1993.
2. Monica Manuiial, par-t IIl, Sectioni I, population survey data
componenit. World Health Organization, Geneva, March 1992.
3. Coristock GW. An epidemiological study of blood pres-
suLre levels in a biracial community in the Southern United States.
Americai Journal of Hygiene. 1957;65:271-315.
4. Grim CE, Wilson TW. Salt, slavery and surNival: physio-
logical principles uinderlving the evolutionary hypothesis of salt
sensitivity hypertension in Western Hemisphere blacks. lkalho-
p/iysiologv of Hylertension in Blacks, Fray JCS, Douglas JG, eds.
Oxford University Press, NY, 1992.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JAMAICAN HYPERTENSION
5. Falkner B. Characteristics of hypertension in black chil-
dren. Pathophysiology of Hypertension in Blacks, Fray JCS, Douglas
JG, eds. Oxford University Press, NY, 1992.
6. FravJCS. Hypertension in Blacks: Physiological, Psycho-
social, Theoretical and Therapeutical Challenges. Pathophysiolog
oJ Hypertension in Blacks, FrayJCS, Douglas JG, eds. Oxford Uni-
versity Press, NY. 1993;p.3-22.
7. Ragoobirsingh D, Lewis-Fuller E, Morrison EY. St.A. The
Jamaican Diabetes Survey: A Protocol for the Caribbean. Diabetes
Care. 1995; 18: 1277-1279.
8. Barcelo A. Diabetes and Hypertension in the Americas.
West Indian MedicalJournal. 2000;49:262-265.
9. Kannel WB, Brand N, Skinner JJ Jr., Dawber TR, Mc-
Namar PM. The relation of adiposity to blood pressure and
development of hypertension: The Framingham Study. Ann. In-
tern. Med. 1967;67,48-59.
10. Ferrani E, Buzzigoli G, Bonadona R. Insulin resistance
in essential hypertension. > Engl. j Med. 1987;317:350-357.
11. Sowers JR, Khoury S, Standlev P, Zemel P, Zemel M.
Mechanisms of hypertension in diabetes. Am. J Hypertens. 1991;
4:177-182.
12. Sowers MF, Wallace RB and LemkeJH. The association
of intakes of vitamin D and calcium with blood pressure among
women. Am. J Clin. Nutr. 1985;42:135-142.
13. Hartz AJ, Rupley DC, Rimm AA. The association of girth
measurements with disease in 32, 856 women. Am. J. Epidemiol.
1984;19:71-80.
14. Fray JCS. Pathogenesis of Hypertension in Blacks: Fea-
tures of an Equilibrium Model. Pathophysiolo, of Hypertension in
Blacks, FrayJC'S and DouglasJG, eds. Oxford University Press, NY.
1993;239-270.
15. Anderson NB, McNeilly M, Myers H. Autonomic reac-
tivity and hypertension in Blacks: a review and proposed model.
Ethnicity Dis. 1991;1:154-170.
16. Stamler R, StamlerJ, Reidlinger W, Algera G, Roberts R.
Family (parental) history and prevalence of hypertension: results
of a nationwide screening program. JAMA. 1979;241:43-47.
17. Canessa M, Spalvins A, Adruga N, Falkner B. Red cell
sodium countertransport and cotransport in normotensive and
hypertensive blacks. Hypertension. 1984;6:344-351.
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VOL. 94, NO. 7, JULY 2002 565