Ali, Mohamed Ahmed

Background: Hypertension is a major risk factor for cardiovascular disease, yet nearly 46% of adults with hypertension remain undiagnosed. Without timely intervention, it can lead to severe complications, including stroke, heart failure, and kidney disease. In sub-Saharan Africa (SSA), hypertension prevalence varies widely from 19.3% in Eritrea to 39.6% in Seychelles. Urbanization has played a key role in increasing hypertension rates through its impact on diet, physical activity, and obesity. Still, urban-rural differences remain modest. Understanding demographic and lifestyle predictors is crucial for SSA's targeted prevention and control efforts. Methods: We conducted a cross-sectional analysis using nationally representative, de-identified data from the Demographic and Health Surveys (2016–2024) in five SSA countries: Lesotho, Tanzania, Gabon, Benin, and South Africa. Adults aged ≥18 years with valid blood pressure and covariate data were included (N=38,085). Blood pressure was measured three times, and the average of the second and third readings was used when available. Hypertension was defined per the 2017 ACC/AHA guidelines (SBP ≥130 mmHg or DBP ≥80 mmHg). Independent variables included age, sex, BMI, education, wealth index, smoking status, and recent caffeine intake. Results: Urban residents (n=20,773) had a higher hypertension prevalence than rural residents (n=17,312) (44.8% vs. 36.7%, p<0.001), along with higher median BMI (24.9 vs. 22.3 kg/m 2 ) and obesity rates (23.5% vs. 11.3%). South Africa exhibited the highest rates (urban 68%, rural 61%), while Tanzania and Lesotho had the lowest (~39–40%). In pooled multivariable analysis, hypertension odds increased steadily with age (OR 4.57 for ≥60 vs 18–24, p<0.001). Obesity demonstrated a dose–response relationship: Class III obesity was associated with a fivefold increase in risk (OR 5.38, p<0.001). Men had higher odds than women (OR 1.65, p<0.001). Secondary education and middle wealth status conferred modest increases in risk. Caffeine use was marginally significant; smoking was not. Predictor importance ranked: age > BMI > sex > wealth > education > smoking > caffeine. Conclusion: Hypertension is highly prevalent in both urban and rural SSA, with age and obesity emerging as the most powerful predictors. South Africa stands out with younger adults most affected. Early detection, awareness campaigns, and obesity-focused interventions are needed to mitigate the growing burden of hypertension in SSA.