Advertisement

Emotional Stress as a Risk for Hypertension in Sub-Saharan Africans: Are We Ignoring the Odds?

  • Leoné Malan
  • Nico T. Malan
Part of the Advances in Experimental Medicine and Biology book series (AEMB, volume 956)

Abstract

Globally most interventions focus on improving lifestyle habits and treatment regimens to combat hypertension as a non-communicable disease (NCD). However, despite these interventions and improved medical treatments, blood pressure (BP) values are still on the rise and poorly controlled in sub-Saharan Africa (SSA). Other factors contributing to hypertension prevalence, such as chronic emotional stress, might provide some insight for future health policy approaches.

Currently, Hypertension Society guidelines do not mention emotional stress as a probable cause for hypertension. Recently the 2014 World Global Health reports, suggested that African governments should consider using World Health Organization hypertension data as a proxy indicator for social well-being. However, the possibility that a stressful life and taxing environmental factors might disturb central neural control of BP regulation has largely been ignored in SSA.

Linking emotional stress to vascular dysregulation is therefore one way to investigate increased cardiometabolic challenges, neurotransmitter depletion and disturbed hemodynamics. Disruption of stress response pathways and subsequent changes in lifestyle habits as ways of coping with a stressful life, and as probable cause for hypertension prevalence in SSA, may be included in future preventive measures. We will provide an overview on emotional stress and central neural control of BP and will include also implications thereof for clinical practice in SSA cohorts.

Keywords

Emotional Distress Emotional Stress Insular Cortex Hypertension Prevalence Sympathetic Hyperactivity 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

The SABPA study and findings on emotional stress and hypertension would not have been possible without the volunteering participant sample, the dedicated input of the Hypertension in Africa Research Team (HART), GJ Motlhasedi (Fieldworker), C Lessing (Research Nurse), S Péter (MD) and in-kind analyses of the national and international expert team.

Conflicts of Interest

No conflicts of interest declared.

References

  1. Agyemang C (2006) Rural and urban differences in blood pressure and hypertension in Ghana. West Afr Public Health 120(6):525–533CrossRefGoogle Scholar
  2. Akinroye K (2013) Nigerians wake up to high blood pressure. Bull World Health Organ 91:242–243CrossRefGoogle Scholar
  3. Alberts M, Urdal P, Steyn K, Stensvold I, Tverdal A, Nel JH et al (2005) Prevalence of cardiovascular diseases and associated risk factors in a rural black population of South Africa. Eur J Cardiovasc Prev Rehab 12(4):347–354CrossRefGoogle Scholar
  4. Amirkhan JH (1990) A factor analytically derived measure of coping: the coping strategy indicator. J Pers Soc Psych 59:1066–1074CrossRefGoogle Scholar
  5. Barton DA, Dawood T, Lambert EA, Esler MD, Haikerwal D, Brenchley C, Socratous F, Kaye DM, Schlaich MP, Hickie I, Lambert GW (2007) Sympathetic activity in major depressive disorder: identifying those at increased cardiac risk? J Hypertens 25(10):2117–2124CrossRefPubMedGoogle Scholar
  6. BeLue R, Okoror TA, Iwelunmor J, Taylor KD, Degboe AN, Agyemang C, Ogedegbe G (2009) An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective. Glob Health 5:1CrossRefGoogle Scholar
  7. Biccard BM (2008) Anaesthesia for vascular procedures: how do South African patients differ? SAJAA 14:109e115Google Scholar
  8. Björntorp P (2001) Do stress reactions cause abdominal obesity and comorbidities? Obes Rev 2:73–86CrossRefPubMedGoogle Scholar
  9. Bosu WK (2010) Epidemic of hypertension in Ghana: a systematic review. BMC Public Health 10:418CrossRefPubMedPubMedCentralGoogle Scholar
  10. Cabib SS (1996) Stress, depression and the mesolimbic dopamine system. Psycho-Pharmacol (Berl) 128(4):331–342CrossRefGoogle Scholar
  11. Carver CS, Scheier MF, Weintraub JK (1989) Assessing coping strategies: a theoretically base approach. J Pers Soc Psych 57(2):267–283CrossRefGoogle Scholar
  12. Chang EC (1996) Cultural differences in optimism, pessimism, and coping: predictors of subsequent adjustment in Asian American and Caucasian American college students. J Couns Psych 43(1):113–123CrossRefGoogle Scholar
  13. Cois A, Ehrlich R (2014) Analysing the socioeconomic determinants of hypertension in South Africa: a structural equation modelling approach. BMC Public Health 14(1):414CrossRefPubMedPubMedCentralGoogle Scholar
  14. Curtis BM, O’Keefe JH (2002) Autonomic tone as a cardiovascular risk factor: the dangers of chronic fight or flight. Mayo Clin Proc 77:45–54CrossRefPubMedGoogle Scholar
  15. Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ et al (2011) National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2 · 7 million participants. Lancet 378(9785):31–40CrossRefPubMedGoogle Scholar
  16. De Kock A, Malan L, Potgieter JC, Steenekamp W, Van der Merwe M-T (2012) Metabolic syndrome indicators and target organ damage in urban active coping African and Caucasian men: the SABPA Study. Exp Clin Endocrin Diab 120(5):282–287CrossRefGoogle Scholar
  17. De Kock A, Malan L, Hamer M, Cockeran M, Malan NT (2015) Defensive coping and renovascular disease risk – adrenal fatigue in a cohort of Africans and Caucasians: the SABPA study. Phys Behav 147(8):213–219CrossRefGoogle Scholar
  18. Deasy C, Coughlan B, Pironom J, Jourdan D, Mcnamara PM (2014) Psychological distress and lifestyle of students: implications for health promotion. Health Prom Int. doi: 10.1093/heapro/dau086Google Scholar
  19. Dobrunz LE, Stevens CF (1997) Heterogeneity of release probability, facilitation, and depletion at central synapses. Neuron 18:995–1008CrossRefPubMedGoogle Scholar
  20. Donnison CP (1929) Blood pressure in the African native: its bearing upon the aetiology of hyperpiesa and arteriosclerosis. Lancet 223:6–7CrossRefGoogle Scholar
  21. Folkow B (2000) Perspectives on the integrative functions of the ‘sympatho-adreno-medullary system’. Auton Neurosci 83:101–115CrossRefPubMedGoogle Scholar
  22. Groenewald P, Vos T, Norman R, Laubscher R, Van Walbeek C, Saloojee U et al (2007) Estimating the burden of disease attributable to smoking in South Africa in 2000. S Afr Med J 97(8):674–681PubMedGoogle Scholar
  23. Gross CG (1998) Claude Bernard and the constancy of the internal environment. Neuroscientist 4(5):380–385CrossRefGoogle Scholar
  24. Hallgren M, Herring MP, Owen N, Dunstan D, Ekblom Ö, Helgadottir B, Nakitanda OA, Forsell Y (2016) Exercise, physical activity, and sedentary behavior in the treatment of depression: broadening the scientific perspectives and clinical opportunities. Front Psychiatr 7:36. doi: 10.3389/fpsyt.2016.00036CrossRefGoogle Scholar
  25. Hamer M, Von Känel R, Reimann MNT, Schutte AE, Huisman HW, Malan L (2015) Progression of cardiovascular risk factors in Black Africans: 3 year follow up of the SABPA cohort study. Atherosclerosis 238:52e54CrossRefGoogle Scholar
  26. Hamer M, Malan L, Malan NT, Schutte AE, Huisman HW, van Rooyen JM, Schutte R, Fourie CMT, Seedat YK (2011) Objectively assessed health behaviors and sub-clinical atherosclerosis in black and white Africans: the SABPA study. Atherosclerosis 215:237–242CrossRefPubMedGoogle Scholar
  27. Hastedt M, Büchner M, Rothe M, Gapert R, Herre S, Krumbiegel F et al (2013) Detecting alcohol abuse: traditional blood alcohol markers compared to ethyl glucuronide (EtG) and fatty acid ethyl esters (FAEEs) measurement in hair. Foren Sci Med Pathol 9(4):471–477CrossRefGoogle Scholar
  28. Huang HP, Zhu FP, Chen XW, Xu ZQ, Zhang CX, Zhou Z (2012) Physiology of quantal norepinephrine release from somatodendritic sites of neurons in locus coeruleus. Front Mol Neurosci 5(29):1–5Google Scholar
  29. Jennings JR, Muldoon MF, Ryan C, Price JC, Greer P, Sutton-Tyrrell K, van der Veen FM, Meltzer CC (2005) Reduced cerebral blood flow response and compensation among patients with untreated hypertension. Neurology 64(8):1358–1365CrossRefPubMedGoogle Scholar
  30. Kadirvelu A, Sadasivan S, Ng SH (2012) Social support in type II diabetes care: a case of too little, too late. Diabetes Metab Synd Obes Targets Ther 5:407–417CrossRefGoogle Scholar
  31. Kidd T, Livia A, Steptoe A (2014) The relationship between cortisol responses to laboratory stress and cortisol profiles in daily life. Biol Psych 99:34–40CrossRefGoogle Scholar
  32. Kobayashi S, Okada K, Koide H, Bokura H, Yamaguchi S (1997) Subcortical silent brain infarction as a risk factor for clinical stroke. Stroke 28:1932–1939CrossRefPubMedGoogle Scholar
  33. Könner AC (2011) Role for insulin signaling in catecholaminergic neurons in control of energy homeostasis. Cell Metab 13:720–728CrossRefPubMedGoogle Scholar
  34. Kotwani P, Kwarisiima D, Clark TD, Kabami J, Geng EH, Jain V et al (2013) Epidemiology and awareness of hypertension in a rural Ugandan community: a cross-sectional study. BMC Public Health 13:1151CrossRefPubMedPubMedCentralGoogle Scholar
  35. Kvetnansky R, Sabban EL, Palkovits M (2009) Catecholaminergic systems in stress: structural and molecular genetic approaches. Phys Rev 89(2):535–606Google Scholar
  36. Lambert GW, Ferrier C, Kaye D, Kalff V, Kelly MJ, Cox HS et al (1994) Monoaminergic neuronal activity in subcortical brain regions in essential hypertension. Blood Press 3:55–66CrossRefPubMedGoogle Scholar
  37. Lambert G, Johansson M, Agren H, Friberg P (2000) Evidence of reduced central nervous system norepinephrine and dopamine turnover in patients with depressive illness. Arch Gen Psychiatry 57:787–793CrossRefPubMedGoogle Scholar
  38. LeDoux J (2012) Rethinking the emotional brain. Neuron 73(4):653–676CrossRefPubMedPubMedCentralGoogle Scholar
  39. Lichtman J, Froelicher FS, Blumenthal JA, Carney RM, Doering LV, Frasure-Smith N et al (2014) Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations. A scientific statement from the American Heart Association. Circulation 129:1350–1369CrossRefPubMedGoogle Scholar
  40. Lloyd-Sherlock P, Beard J, Minicuci N, Ebrahim S, Chatterjii S (2014) Hypertension among older adults in low- and middle-income countries: prevalence, awareness and control. Int J Epidem 43(1):116–128CrossRefGoogle Scholar
  41. Lund C, De Silva M, Plagerson S, Cooper S, Crisholm D, Das J et al (2011) Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. Lancet 378:1502–1514CrossRefPubMedGoogle Scholar
  42. Lutfey K, Freese J (2005) Toward some fundamentals of fundamental causality: socioeconomic status and health in the routine clinic visit for diabetes. Am J Sociol 110:1326–1372CrossRefGoogle Scholar
  43. Malan NT, Van der Merwe JS, Eloff FC, Huisman HW, Kruger A, Eloff FC et al (1992) A comparison of cardiovascular reactivity of rural Blacks, Urban Blacks and Whites. Stress Med 8:214–246Google Scholar
  44. Malan NT, Brits JS, Eloff FC, Huisman HW, Kruger A, Laubscher PJ et al (1996) The influence of acculturation on endocrine reactivity during acute stress in urban black males. Stress Med 12:55–63CrossRefGoogle Scholar
  45. Malan L, Schutte AE, Malan NT, Wissing MP, Vorster HH, Steyn HS et al (2006) Specific coping strategies of Africans during urbanization: comparing cardiovascular responses and perception of health data. Biol Psych 72(3):305–310CrossRefGoogle Scholar
  46. Malan L, Malan NT, Wissing MP, Seedat YK (2008) Coping with urbanization: a cardiometabolic risk? Biol Psych 79:323–328CrossRefGoogle Scholar
  47. Malan L, Hamer M, Schlaich MP, Lambert GW, Harvey BH, Reimann M et al (2012) Facilitated defensive coping, silent ischaemia and ECG left-ventricular hypertrophy: the SABPA study. J Hypertens 30:543–550CrossRefPubMedGoogle Scholar
  48. Malan L, Hamer M, Schlaich MP, Lambert GW, Ziemssen T, Reimann M et al (2013) Defensive coping facilitates higher blood pressure and early sub-clinical structural vascular disease via alterations in heart rate variability: the SABPA study. Atherosclerosis 227:391–397CrossRefPubMedGoogle Scholar
  49. Malan L, Oosthuizen W, Scheepers JD, Möller-Wolmarans M, Malan NT (2014) Coping and autonomic dysfunction act in tandem with alcohol-related sub-clinical atherosclerosis: the SABPA Study. In: Raines J (ed) Substance abuse: prevalence, genetic and environmental risk factors and prevention. Nova Science Publishers, New York, pp 107–128Google Scholar
  50. Malan L, Hamer M, Frasure-Smith N, Steyn HS, Malan NT (2015) COHORT PROFILE: sympathetic activity and ambulatory blood pressure in Africans (SABPA) prospective cohort study. Int J Epidem 6:1814–1822CrossRefGoogle Scholar
  51. Malan L, Hamer M, von Känel R, Schlaich MP, Reimann M, Frasure-Smith N et al (2016) Chronic depression symptoms and salivary NOx associated with retinal vascular dysregulation: the SABPA study. Nitric Oxide 55–56:10–17Google Scholar
  52. Mancia G, Fagard R, Narkiewicz K, Redo J, Zanchetti A, Böhm M et al (2013) 2013 ESH/ESC guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology. J Hypertens 31:1281–1357CrossRefPubMedGoogle Scholar
  53. Maniam J, Morris MJ (2012) The link between stress and feeding behaviour. Neuropharmacology 63:97–110CrossRefPubMedGoogle Scholar
  54. Mashele N, Malan L, Van Rooyen JM, Harvey BH, Potgieter JC, Hamer M (2014) Blunted neuro-endocrine responses linking depressive symptoms and ECG left ventricular hypertrophy in black Africans: the SABPA study. Cardiovasc Endocrin 3:59–65CrossRefGoogle Scholar
  55. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D (2012) The burden of non-communicable diseases in South Africa. Lancet 374(9693):934–947CrossRefGoogle Scholar
  56. Mazzeo AT, Micalizzi A, Mascia L, Scicolone A, Siracusano L (2014) Brain–heart crosstalk: the many faces of stress-related cardiomyopathy syndromes in anaesthesia and intensive care. Br J Anaesth 112(5):803–815CrossRefPubMedGoogle Scholar
  57. McDougall SJ, Münzberg H, Derbenev AV, Zsombok A (2015) Central control of autonomic functions in health and disease. Front Neurosci 8:440. doi: 10.3389/fnins.2014.00440CrossRefPubMedPubMedCentralGoogle Scholar
  58. McEwen BS, Gianaros PJ (2010) Central role of the brain in stress and adaptation: links to socioeconomic status, health, and disease. Ann NY Acad Sci 1186:190–222CrossRefPubMedPubMedCentralGoogle Scholar
  59. McGuire KA, Janssen I, Ross R (2009) Ability of physical activity to predict cardiovascular disease beyond commonly evaluated cardiometabolic risk factors. Am J Cardiol 104:1522–1526CrossRefPubMedGoogle Scholar
  60. Moscarello JM, LeDoux JE (2013) Active avoidance learning requires prefrontal suppression of amygdala-mediated defensive reactions. J Neurosci 33(9):3815–3823CrossRefPubMedPubMedCentralGoogle Scholar
  61. Nagai M, Hoshide S, Kario K (2010) The insular cortex and cardiovascular system: a new insight into the brain-heart axis. J Am Soc Hypertens 4(4):174–182CrossRefPubMedGoogle Scholar
  62. National Development Plan(2016) South Africa, Vision 2030. The State of Urban Safety in South Africa ReportGoogle Scholar
  63. Ngcobo M, Pillay PJ (2008) Depression in African women presenting for psychological services at a general hospital. Afr J Psychiatr 11:133–137CrossRefGoogle Scholar
  64. Nishida Y, TandaI-Hiruma M, Kemuriyama T, Hagisawa K (2012) Long-term blood pressure control: is there a set-point in the brain? J Physiol Sci 62:147–161CrossRefPubMedGoogle Scholar
  65. Oosthuizen W, Malan L, Scheepers JD, Cockeran M, Malan NT (in press) The defence response and alcohol intake: a coronary artery disease risk? J Clin Exp HypertensGoogle Scholar
  66. Pal GK, Adithan C, Dutta TK, Pal P, Nanda N, Lalitha V et al (2014) Association of hypertension status and cardiovascular risks with sympathovagal imbalance in first degree relatives of type 2 diabetics. J Diab Invest 5(4):449–455CrossRefGoogle Scholar
  67. Parrott AC (1999) Does cigarette smoking cause stress? Am Psychol 54(10):817–820CrossRefPubMedGoogle Scholar
  68. Peck RN, Green E, Mtabaji J, Majinge C, Smart LR, Downs JA et al (2013) Hypertension-related diseases as a common cause of hospital mortality in Tanzania: a 3-year prospective study. J Hypertens 31(9):1806–1811CrossRefPubMedPubMedCentralGoogle Scholar
  69. Reed RV, Fazel M, Jones L, Panter-Brick C, Stein A (2012) Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors. Lancet 379:250–265CrossRefPubMedGoogle Scholar
  70. Rosmond R (2005) Role of stress in the pathogenesis of the metabolic syndrome. Psychoneuroendocrinology 30:1–10CrossRefPubMedGoogle Scholar
  71. Ryff CD, Singer B (2002) From social structure to biology. In: Snyder CR, Lopez SJ (eds) Handbook of positive psychology. Oxford University Press, Oxford, pp 541–555Google Scholar
  72. Saez I, Duran J, Sinadinos C, Beltran A, Yanes O, Tevy MF et al (2014) Neurons have an active glycogen metabolism that contributes to tolerance to hypoxia. J Cerebral Blood Flow Met 34:945–955CrossRefGoogle Scholar
  73. Scheepers JD, Malan L, De Kock A, Malan NT, Cockeran M, von Känel R (2015) Ethnic disparity in defensive coping endothelial responses: the SABPA study. Phys Behav 147(8):306–312CrossRefGoogle Scholar
  74. Scheepers JD, Malan L, von Ka´nel R, De Kock A, Cockeran M, Malan NT (2016) Hypercoagulation and hyperkinetic blood pressure indicative of physiological loss-of-control despite behavioural control in Africans: the SABPA study. Blood Pressure, 1–9 [Epub ahead of print]. PMID: 26806201Google Scholar
  75. Schutte AE, Schutte R, Huisman HW, van Rooyen JM, Fourie CM, Malan NT et al (2012) Are behavioural risk factors to be blamed for the conversion from optimal blood pressure to hypertensive status in Black South Africans? A 5-year prospective study. Int J Epidemiol 41(4):1114–1123CrossRefPubMedGoogle Scholar
  76. Seedat YK (2015) Why is control of hypertension in sub-Saharan Africa poor? Cardiovasc J Afr 26(4):193–195CrossRefPubMedPubMedCentralGoogle Scholar
  77. Sinha R, Jastreboff AM (2013) Stress as a common risk factor for obesity and addiction. Biol Psychiatry 73(9):827–835CrossRefPubMedPubMedCentralGoogle Scholar
  78. Skinner EA, Edge K, Altman J, Sherwood H (2003) Searching for the structure of coping: a review and critique of category systems for classifying ways of coping. Psych Bull 129(2):216–269CrossRefGoogle Scholar
  79. Sobngwi E, Mbanya J-C, Unwin N, Porcher R, Kengne A-P, Fezeu L et al (2004) Exposure over the life course to an urban environment and its relation with obesity, diabetes, and hypertension in rural and urban Cameroon. Int J Epidemiol 33:769–776CrossRefPubMedGoogle Scholar
  80. South African Cities Urban Safety Reference Group (USRG) (2016) The state of urban safety in South Africa report 2016. South African Cities Network: http://www.saferspaces.org.za/uploads/files/State-of-Urban-Safety-Brochure-web.pdf
  81. Stahrenberg R, Niehaus C-F, Edelmann F, Mende M, Wohlfahrt J, Wasser K et al (2013) High-sensitivity troponin assay improves prediction of cardiovascular risk in patients with cerebral ischaemia. J Neurol Neurosurg Pscyhiatr 84(5):479–487CrossRefGoogle Scholar
  82. Stroop JR (1935) Studies of interference in serial verbal reactions. J Exp Psych 18:643–662CrossRefGoogle Scholar
  83. Tagoe HA, Dake FAA (2011) Healthy lifestyle behaviour among Ghanaian adults in the phase of a health policy change. Glob Health 7:7CrossRefGoogle Scholar
  84. Taylor WD, Aizenstein HJ, Alexopoulos GS (2013) The vascular depression hypothesis: mechanisms linking vascular disease with depression. Mol Psych 18(9):963–974CrossRefGoogle Scholar
  85. Tomlinson M, Grimsrud AT, Stein DJ, Williams DR, Myer L (2009) The epidemiology of major depression in South Africa: results from the South African Stress and Health study. SA Med J 99(5, 2):367–373Google Scholar
  86. Triandis HC, McCusker C, Hui CH (1990) Multimethod probes of individualism and collectivism. J Pers Soc Psych 59:1006–1020CrossRefGoogle Scholar
  87. Tyrka AR, Walters OC, Price LH, Anderson GM, Carpenter LL (2012) Altered response to neuroendocrine challenge linked to indices of the metabolic syndrome in healthy adults. Horm Metab Res 44:543–549CrossRefPubMedPubMedCentralGoogle Scholar
  88. Van der Wateren E (1997) Dynamics of values, coping styles and psychological health in a young group. MA dissertation, Potchefstroom University for Christian Higher Education, Potchefstroom, 189 pGoogle Scholar
  89. Van Deventer CA, Lindeque JZ, Jansen van Rensburg PJ, Malan L, Van der Westhuizen FH, Louw R (2015) Use of metabolomics to elucidate the metabolic perturbation associated with hypertension in a black South African male cohort: the SABPA study. J Am Soc Hypertens 9(2):104–14CrossRefPubMedGoogle Scholar
  90. Van Lill AS, Malan L, van Rooyen JM, Ziemssen T, Reimann M (2011) Baroreceptor sensitivity and left ventricular hypertrophy in urban South African men: the SABPA Study. Blood Pressure 20:355–361Google Scholar
  91. Vedanthan R, Bansilal S, Soto AV, Kovacic JC, Latina J, Jaslow R et al (2016) Family-based approaches to cardiovascular health promotion. J Am Coll Cardiol 67(14):1725–1737CrossRefPubMedGoogle Scholar
  92. Venter PC, Malan L, Schutte AE (2014) Psychosocial stress but not hypertensive status associated with angiogenesis in Africans. Blood Press 23(5):307–314CrossRefPubMedGoogle Scholar
  93. von Känel R, Bruwer EJ, De Ridder JH, Swanepoel M, Hamer M, Cockeran M, Malan L (2016) Association between objectively measured physical activity, chronic stress and leukocyte telomere length. J Sport Med Phys Fitness [Epub ahead of print]. PMID: 27074439Google Scholar
  94. Vorster HH, Venter CS, Wissing MP, Margetts BM (2005) The nutrition and health transition in the North West Province of South Africa: a review of the THUSA (Transition and Health during Urbanisation of South Africans) study. Public Health Nutr 8(5):480–490CrossRefPubMedGoogle Scholar
  95. World Health Organisation (2008) Closing the gap in a generation: health equity through action on the social determinants of health. World Health Organization, Geneva. Accessed Mar 2016.Google Scholar
  96. World Health Organisation (2010) Mental health and development: targeting people with mental health conditions as a vulnerable group. World Health Organization, Geneva. Accessed Mar 2016.Google Scholar
  97. World Health Organisation. (2014)The World health report: Non-communicable diseases country profiles 2014. Report, 1-207. World Health Organisation, Geneva. Accessed Mar 2016Google Scholar
  98. Zatu MC, Van Rooyen JM, Kruger A, Schutte AE (2016) Alcohol intake, hypertension development and mortality in black South Africans. Eur J Prev Cardiol 23(3):308–315CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2016

Authors and Affiliations

  1. 1.Hypertension in Africa Research Team (HART)North-West UniversityPotchefstroomSouth Africa

Personalised recommendations