An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective
Tóm tắt
Sub-Saharan African (SSA) countries are currently experiencing one of the most rapid epidemiological transitions characterized by increasing urbanization and changing lifestyle factors. This has resulted in an increase in the incidence of non-communicable diseases, especially cardiovascular disease (CVD). This double burden of communicable and chronic non-communicable diseases has long-term public health impact as it undermines healthcare systems.
The purpose of this paper is to explore the socio-cultural context of CVD risk prevention and treatment in sub-Saharan Africa. We discuss risk factors specific to the SSA context, including poverty, urbanization, developing healthcare systems, traditional healing, lifestyle and socio-cultural factors.
We conducted a search on African Journals On-Line, Medline, PubMed, and PsycINFO databases using combinations of the key country/geographic terms, disease and risk factor specific terms such as "diabetes and Congo" and "hypertension and Nigeria". Research articles on clinical trials were excluded from this overview. Contrarily, articles that reported prevalence and incidence data on CVD risk and/or articles that report on CVD risk-related beliefs and behaviors were included. Both qualitative and quantitative articles were included.
The epidemic of CVD in SSA is driven by multiple factors working collectively. Lifestyle factors such as diet, exercise and smoking contribute to the increasing rates of CVD in SSA. Some lifestyle factors are considered gendered in that some are salient for women and others for men. For instance, obesity is a predominant risk factor for women compared to men, but smoking still remains mostly a risk factor for men. Additionally, structural and system level issues such as lack of infrastructure for healthcare, urbanization, poverty and lack of government programs also drive this epidemic and hampers proper prevention, surveillance and treatment efforts.
Using an African-centered cultural framework, the PEN3 model, we explore future directions and efforts to address the epidemic of CVD risk in SSA.
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Olshanky S, Ault A: The fourth stage of the epidemiologic transisiton: the age of delayed degenerative diseases. Milbank Quarterly. 1986, 64 (3): 335-391.
Reddy K, Yusuf S: Emerging epidemic of cardiovascular disease in developing countries. Ciruclation. 1998, 97 (6): 596-601.
Omran A: The epidemiologic transtion. A theory of the Epidemiology of population change. Bull World Health Organ. 2001, 79 (2): 161-170.
Popkin B: Dynamics of the nutrition transition and its implications for the developing world. Forum Nutr. 2003, 56: 262-264.
Yach D, Hawkes C, Gould C, Hofman K: The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA. 2004, 291 (21): 2616-2622.
Fezeu L, Minkoulou E, Balkau B, Kengne AP, Awah P, Unwin N, Alberti GK, Mbanya JC: Association between socioeconomic status and adiposity in urban Cameroon. Int J Epidemiol. 2006, 35 (1): 105-111.
Kadiri S, Salako B: Cardiovascular risk factors in middle aged Nigerians. East African Medical Journal. 1997, 74 (5): 303-306.
Asfaw A: The effects of obesity on doctor-diagnosed chronic diseases in Africa: empirical results from Senegal and South Africa. Journal of public health policy. 2005, 27 (3): 250-264. 10.1057/palgrave.jphp.3200089.
Bonita R, Beaglehole R: Stroke prevention in poor countries: time for action. Stroke. 2007, 38 (11): 2871-2.
Kengne AP, Awah PK: Classical Cardiovascular risk factors and all-cause mortality in rural Camroon. QJM. 2009, 102 (3): 209-215.
Peer N, Steyn K, Bradshaw D, Norman R, Laubscher R, Dennison CR, Levitt NS, Nyo MT, Nel JH, Commerford P: determinants of target organ damage in black hypertensive patients attending primary health care services in Cape Town: the Hi-Hi study. Am J Hypertension. 2008, 21 (8): 896-902. 10.1038/ajh.2008.210.
Unwin N, Setel P, Rashid S, Mugusi F, Mbanya J, Kitange H, Hayes L, Edwards R, Aspray T, Alberti K: Noncommunicable diseases in sub-Saharan Africa: where do they feature in the health research agenda?. Bull World Health Organ. 2001, 79 (10): 947-953.
Bonow R, Smaha L, Smith SCJr, Mensah GA, Lenfant C: World Heart Day 2002: the international burden of cardiovascular disease: responding to the emerging blobal epidemic. Circulation. 2002, 106 (13): 1602-1605.
Kengne AP, Amoah AGB, Mbanya JC: Cardiovascular Complications of Diabetes Mellitus in Sub-Saharan Africa. Circulation. 2005, 112 (23): 3592-3601.
Duda R, Kim M, Darko R, Adanu R, Seffah J, Anarfui J, Hill A: Results of the Women's Health Study of Accra: assessment of blood pressure in urba women. Int J Cardiol. 2007, 117 (1): 115-122.
Steyn K, Sliwa K, Hawken S, Commerford P, Onen C, Damasceno A, Ounpuu S, Yusuf S, INTERHEART Investigators in Afric: Risk factors associated with myocardial infarction in Africa: the INTERHEART Africa study. Circulation. 2005, 112 (23): 3536-3540.
Sande van der MA, Milligan PJ, Walraven GE, Dolmans WM, Newport M, Nyan OA, Banya WA, Thien T, Ward R, McAdam KP: Geographical variation in prevalence of hypertension within The Gambia. Journal of human hypertension. 2001, 15 (10): 733-739.
Sande van der MA: Cardiovascular disease in sub-Saharan Africa: a disaster waiting to happen. Neth J Med. 2003, 61 (2): 32-36.
Sande van der MA, Milligan PJ, Nyan OA, Rowley JT, Banya WA, Ceesay SM, Dolmans WM, Thien T, McAdam KP, Walraven GE: Blood pressure patterns and cardiovascular risk factors in rural and urban Gambian communities. J Hum Hypertens. 2000, 14: 489-496.
Addo J, Amoah AG, Koram KA: The changing patterns of hypertension in Ghana: a study of four rural communities in the Ga District. Disease Ethnology. 2006, 16 (4): 894-899.
Addo J, Smeeth L, Leon DA: Hypertension In Sub-Saharan Africa: A Systematic Review. Hypertension. 2007, 50 (6): 1012-1018.
Agyemang CO: Rural and urban differences in blood pressure and hypertension in Ghana, West Africa. Public Health. 2006, 120 (6): 525-533.
Agyemang C, Bruijnzeels MA, Owusu-Dabo E: Factors associated with hypertension awareness, treatment, and control in Ghana, West Africa. J Hum Hypertens. 2006, 20: 67-71.
Agyemang C, Owusu-Dabo E: Prehypertension in the Ashanti region of Ghana, West Africa: An opportunity for early prevention of clinical hypertension. Public Health. 2008, 122 (1): 19-24.
Mufunda J, Mebrahtu G, Usman A, Nyarango P, Kosia A, Ghebbrat Y: The prevalence of hypertension and its relationship with obesity: Results from a national blood pressure survey in Eritrea. J Hum Hypertens. 2006, 20: 59-65.
Adedoyin RA, Mbada CE, Balogun MO, Martins T, Adebayo RA, Akintomide A, Akinwusi PO: Prevalence and pattern of hypertension in a semiurban community in Nigeria. Eur J Cardiovasc Prev Rehabil. 2008, 15 (6): 683-687.
Ofuya Z: The incidence of hypertension among a select population of adults in the Niger Delta region of Nigeria. Southeast Asian J Trop Med Public Health. 2007, 38 (5): 947-949.
Lawoyin TO: Prevalence of cardiovascular risk factors in an African, urban inner city community. West African journal of medicine. 2002, 21 (3): 208-211.
Kaufman JS, Owoaje EE, Rotimi CN, Cooper RS: Blood pressure change in Africa: case study from Nigeria. Hum Biol. 1999, 71 (4): 641-657.
Poulter NR, Khaw K, Hopwood BEC, Mugambi M, Peart WS, Sever PS: Determinants of blood pressure changes due to urbanisation: a longitudinal study. J Hypertens. 1985, 3: 5375-5377.
Steyn KBD, Norman R, Laubscher R: Determinants and treatment of hypertension in South Africans: the first Demographic and Health Survey. S Afr Med J. 2008, 98 (5): 376-380.
Mbanya JC, Ramiaya K: Diabetes. Disease and Mortality in Sub-Saharan Africa. Edited by: Jamison DT, Feachem RG, Makgoba MW, Bos ER, Baingana FK, Hofman KJ, Rogo KO. 2006, Washington, DC: The World Bank, 2
International Diabetes Federation: The Diabetes Declaration and Strategy for Africa. 2006, http://www.idf.org/webdata/docs/Diabetes%20Declaration%20&%20Strategy%20for%20Africa_full.pdf
World Health Organization: Diagnosis and Classification of Diabetes Mellitus. Definition, Diagnosis and Classification of Diabetes Mellitus and Its Complications. Edited by: O WH. 1999, Geneva: World Health Organization
Gill G, Mbanya JC, Ramaiya K, Tesfaye S: A sub-Saharan African perspective of diabetes. Diabetologia. 2009, 52 (1): 8-16.
Levitt NS, Katzenellenbogen JM, Bradshaw D, Hoffman MN, Bonnici F: The prevalence and identification of risk factors for NIDDM in urban Africans in Cape Town, South Africa. Diabetes Care. 1993, 16 (4): 601-607.
Mbanya JC, Ngogang J, Salah JN, Minkoulou E, Balkau B: Prevalence of NIDDM and impaired glucose tolerance in a rural and an urban population in Cameroon. Diabetologia. 1997, 40 (7): 824-829.
Elbagir M, Eltom MA, Elmahadi EMA, Kadam IMS, Berne C: A high prevalence of diabetes mellitus and impaired glucose tolerance in the Danagla community in northern Sudan. Diab Med. 1998, 15: 164-169. 10.1002/(SICI)1096-9136(199802)15:2<164::AID-DIA536>3.0.CO;2-A.
Motala AA, Omar MA, Pirie FJ: Epidemiology of type 1 and type 2 diabetes in Africa. J Cardiovasc Risk. 2003, 10 (2): 77-83.
Balde MN: Associated tuberculosis and diabetes in Conkary, Guinea; prevalence and clinical chracateristics. The international journal of tuberculosis and lung disease. 2006, 10 (9): 1036-1040.
Mollentze WF, Moore AJ, Steyn AF, Joubert G, Steyn K, Oosthuizen GM, Weich DJ: Coronary heart disease risk factors in a rural and urban Orange Free State black population. S Afr Med J. 1995, 85 (2): 90-96.
Baldé NMDI, Baldé MD, Barry IS, Kaba L, Diallo MM, Kaké A, Camara A, Bah D, Barry MM, Sangaré-Bah M, Maugendre D: Diabetes and impaired fasting glucose in rural and urban populations in Futa Jallon (Guinea): prevalence and associated risk factors. Diabetes Metab. 2007, 33 (2): 114-120.
Njelekela MA, Mpembeni R, Muhihi A, Mligiliche NL, Spiegelman D, Hertzmark E, Liu E, Finkelstein JL, Fawzi WW, Willett WC: Gender-related differences in the prevalence of cardiovascular disease risk factors and their correlates in urban Tanzania. BMC Cardiovasc Disord. 2009, 17 (9): 30-10.1186/1471-2261-9-30.
Okafor CI, Fasanmade OA, Oke DA: Pattern of dyslipidaemia among Nigerians with type 2 diabetes mellitus. Niger J Clin Pract. 2008, 11 (1): 25-31.
Elnasri HA, Ahmed AM: Patterns of lipid changes among type 2 diabetes patients in Sudan. East Mediterr Health J. 2008, 14 (2): 314-324.
Otieno CF, Mwendwa FW, Vaghela V, Ogola EN, Amayo EO: Lipid profile of ambulatory patients with type 2 diabetes mellitus at Kenyatta National Hospital, Nairobi. East Afr Med J. 2005, 82 (12 Suppl): S173-179.
Fezeu L, Balkau B, Kengne A, Sobngwi E, Mbanya J: Metabolic syndrome in a sub-Saharan African setting: central obesity may be the key determinant. Atherosclerosis. 2007, 193 (1): 70-76.
Eghan BA, Acheampong JW: Dyslipidemia in outpatients at General Hospital in Kumasi, Ghana: cross-sectional study. Croat Med J. 2003, 44 (5): 576-578.
Akpa MR, Agomouh DI, Alasia DD: Lipid profile of healthy adult Nigerians in Port Harcourt, Nigeria. Niger J Med. 2006, 15 (2): 137-140.
Chapman AR: Globalization, human rights, and the social determinants of health. Bioethics. 2009, 23 (2): 97-111.
BeLue R, Schreiner A, Taylor-Richardson K, Murray-Kolb L, Beard J: What matters most: an investigation of predictors of perceived stress among young mothers in Khayelitsha. Health Care for Women International. 2008, 29: 638-648.
Olufemi O, Oluseyi M: The urban poor and mobility stress in Nigerian cities. Environmental Research Journal. 2007, 1: 1-8.
Pike I, Williams S: Incorporating psychosocial health into biocultural models: preliminary findings from Turkana women of Kenya. Am J Hum Biol. 2006, 18 (6): 729-740.
Siervo M, Grey P, Nyan OA, Prentice AM: Urbanization and obesity in the Gambia: a country in the early stages of the demographic transition. European journal of clinical nutrition. 2006, 60 (11): 455-463.
Baum A, Garofalo JP, Yali AM: Socioeconomic status and chronic stress: does stress account for SES effects on health?. Annals of the New York Academy of Sciences. 2006, 896: 131-144. 10.1111/j.1749-6632.1999.tb08111.x.
Levenstein S, Smith MW, Kaplan G: Psychosocial predictors of hypertension in men and women. Arch Intern Med. 2001, 161: 1341-1346.
Yen I, Kaplan G: Poverty area residence and changes in depression and perceived health status: evidence from the Alameda County Study. International Journal of Epidemiology. 1996, 28: 90-94. 10.1093/ije/28.1.90.
Mfenyana K, Griffin M, Yogeswaran P, Modell B, Modell M, Chandia J: Socio-economic inequalities as a predictor of health in South Africa - The Yenza cross-sectional. S Afr Med J. 2006, 96: 323-330.
Gulis G, Mulumba JA, Juma O, Kakosova BA: Health status of people of slums in Nairobi, Kenya. Environmental Research. 2003, 96 (2): 219-227. 10.1016/j.envres.2004.01.016.
Niakara A, Fournet F, Gary J, Harang M, Nebie L, Salem G: Hypertension, urbanization, social and spatial disparities: a cross-sectional population-based survey in West African urban environment (Ouagadougou, Burkina Faso). Transactions of the Royal Society of Tropical Medicine and Hygiene. 2007, 101: 1136-1142. 10.1016/j.trstmh.2007.07.002.
Sobngwi E, Mbanya J, Unwin N, Porcher R, Kengne A, Fezeu L: Exposure over the life course to an urban environment and its relation with obesity, diabetes, and hypertension in rural Cameroon. International Epidemiological Association. 2004, 33: 769-776.
Kaufman JS, Rotimi CN, Brieger WR, Oladokum MA, Kadiri S, Osotimehin BO, Cooper RS: Determinants of Hypertension in West Africa: Contribution of anthropometric and dietary risk factors to urban-rural and socioeconomic gradients. American Journal of Epidemiology. 1996, 143: 1203-1218.
Malan LMN, Wissing MP, Seedat YK: Coping with urbanization: a cardiometabolic risk? The THUSA study. Biol Psychol. 2008, 79 (3): 323-328.
Agyemang C, Owusu-Dabo E, de Jonge A, Martins D, Ogedegbe G, Stronk K: Overweight and obesity among Ghanaian residents in The Netherlands: how do they weigh against their urgan and rural counterparts in Ghana?. Public Health Nutr. 2008, 1-8. 2
Assah F, Ekelund U, Brage S, Corder K, Wright A, Mbanya J, Wareham N: Predicting physical activity energy expenditure using accelerometry in adults from sub-Sahara Africa. Obesity. 2009, 17 (8): 1588-95.
Kimokoti RW, Hamer DH: Nutrition, health, and aging in sub-Saharan Africa. Nutr Rev. 2008, 66 (11): 611-623.
Rotimi CN, Cooper RS, Ataman SL, Osotimehin B, Kadiri S, Muna W, Kingue S, Fraser H, McGee D: Distribution of anthropometic variables and the prevalence of obesity in populations of West African origin: The international collaborative study on hypertension in blacks (ICSHIB). Obesity research. 1995, 3 (Suppl 2): 95s-105s.
Kamadjeu RM, Edwards R, Atanga JS, Kiawi EC, Unwin N, Mbanya JC: Anthropometry measures and prevalence of obesity in the urgan adult population of Cameroon: an update from the Cameroon Burden of Diabetes Baseline Survey. BMC Public Health. 2006, 13 (6): 228-10.1186/1471-2458-6-228.
Abubakari AR, BHopal RS: Systematic review on the prevalence of diabetes, overweight/obesity and physical inactivity in Ghanaians and Nigerians. Public Health. 2008, 122 (2): 173-182.
Abubakari AR, Lauder W, Agyemang C, Jones M, Kirk A, Bhopal RS: Prevalence and time trends in obesity among adult West African populations: a meta-analysis. Obes Rev. 2008, 9 (4): 297-311.
Ntandou G, Delisle H, Agueh V, Fayomi B: Abdominal obesity explains the positive rural-urban gradient in the prevalence of the metabolic syndrome in Benin, West Africa. Nutr Res. 2009, 29 (3): 180-189.
Longo-Mbenza B, Mambune HF, Kasiamm JB, Vita EK, Fuele SM, Nsenga JN, Mabwa L, Nzuzi V: Relationship between waist circumference and cholesterol in Central Africans with congestive heart failure. West Afr J Med. 2007, 26 (3): 183-190.
Bourne LT, Lambert EV, Steyn K: Where does the black population of South Africa stand on the nutrition transition?. Public Health Nutr. 2002, 5 (1A): 157-162.
Joubert J, Norman R, Lambert EV, Groenewald P, Schneider M, Bull F, Bradshaw D: South African Comparative Risk Assessment Collaborating Group. Estimating the burden of disease attributable to physical inactivity in South Africa in 2000. S Afr Med J. 2007, 97 (8): 725-731.
Fezeu L, Assah F, Balkau B, Mbanya D, Kengne A, Awah P, Mbanya J: Ten-year changes in central obesity and BMI in rural and urban Cameroon. Obesity. 2008, 16 (5): 1144-1147.
Christensen DL, Eis J, Hansen AW, Larsson MW, Mwaniki DL, Kilonzo B, Tetens I, Boit MK, Kaduka L, Borch-Johnsen K: Obesity and regional fat distribution in Kenyan populations: impact of ethnicity and urbanization. Ann Hum Biol. 2008, 35 (2): 232-249.
Siminialayi I, Emem-Chioma P, Dapper D: The prevalence of obesity as indicated by BMI and waist circumference among Nigerian adults attending family medicine clinics as outpatients in Rivers State. Niger, J Med. 2008, 17 (3): 340-345.
Dugas LR, Carstens MA, Ebersole K, Schoeller DA, Durazo-Arvizu RA, Lambert EV, Luke A: Energy expenditure in young adult urban informal settlement dwellers in South Africa. Eur J Clin Nut. 2009, 63 (6): 805-7. 10.1038/ejcn.2008.75.
Holdsworth M, Gartner A, Landais E, Maire B, Delpeuch F: Perceptions of healthy and desirable body size in urban Senegalese women. International journal of obesity. 2004, 28 (12): 1561-1568.
Holdsworth M, Delpeuch F, Landais E, Gartner A, Eymard-Duvernay S, Maire B: Knowledge of dietary and behaviour-related determinants of non-communicable disease in urban Senegalese women. Public Health Nutr. 2006, 9 (8): 975-981.
Duda R, Jumah N, Hill A, Steffah J, Birtwum R: Assessment of the ideal body image of women in Accra, Ghana. Trop Doct. 2007, 37 (4): 241-244.
Duda R, Jumah N, Hill A, Seffah J, Biritwum R: Interest in healthy living outweighs presumed cultural norms for obesity for Ghanaian women. Health Qual Life Outcomes. 2006, 20 (4): 44-10.1186/1477-7525-4-44.
Townsend M, Peerson J, Love B, Achterberg C, Murphy S: Food insecurity is positively related to overweight in women. J Nutr. 2001, 131: 1738-1745.
Chaput JP, Gilbert JA, Tremblay A: Relationship between food insecurity and body composition in Ugandans living in urban Kampala. J Am Diet Assoc. 2007, 107 (11): 1978-1982.
Ormel J, Von Korff M, Burger H, Scott K, Demyttenaere K, Huang Y, Posada-Villa J, Pierre Lepine J, Angermeyer MC, Levinson D: Mental disorders among persons with heart disease-results from World Mental Health surveys. Gen Hosp Psychiatry. 2007, 29 (4): 325-334.
Laabes EP, Thacher TD, Okeahialam BN: Risk factors for heart failure in adult Nigerians. Acta Cardiol. 2008, 63 (4): 437-443.
Puepet F, Ohwovoriole A: Prevalence of risk factors for diabetes mellitus in a non-diabetic population in Jos, Nigeria. Niger J Med. 2008, 17 (1): 71-74.
Christensen DL, Friss H, Mwaniki DL, Kilonzo B, Boit MK, Omondi B, Kaduka L, Borch-Johnsen K: Prevalence of glucose intolerance and associated risk factors in rural and urban populations of different ethnic groups in Kenya. Diabetes Res Clin Pract. 2009, 84 (3): 303-10.
Schneider M, Norman R, Parry C, Bradshaw D, Pluddemann A: South African comparative risk assessment collaborating group. Estimating the burden of disease attributable to alcohol use in South Africa. S Afr Med J. 2000, 97 (8): 664-672.
Schneider M, Bradshaw D, Steyn K, Norman R, Laubscher R: Poverty and non-communicable diseases in South Africa. Scand J Public Health. 2009, 37 (2): 176-186.
Verdier F, Fourcade L: Changes in cardiovascular risk factors in developing countries. Med Trop. 2007, 67 (6): 552-558.
Townsend L, Flisher AJ, Gilreath T, King G: A systematic literature review of tobacco use among adults 15 years and older in sub-Saharan Africa. Drug and Alcohol Dependence. 2006, 84 (1): 14-27. 10.1016/j.drugalcdep.2005.12.008.
Seck M, Diouf I, Acouetey L, Wade K, Thiam M, Diatta B: Profile of patients admitted for myocardial infarction at the emergency reception facility of Principal Hospital in Dakar, Senegal. Med Trop. 2007, 67 (6): 569-572.
Seyoum B, Abdulkadir J, Berhanu P, Feleke F, Worku Y, Ayana G: Profile of coronary artery risk factors in Ethiopian diabetic patients. East Afr Med J. 1999, 76 (7): 105-107.
Awah PK, Kengne AP, Fezeu LL, Mbanya JC: Perceived risk factors of cardiovascular diseases and diabetes in Cameroon. Health Educ Res. 2008, 23 (4): 612-620.
Kiawi E, Edwards R, Shu J, Unwin N, Kamadjeu R, Mbanya JC: Knowledge, attitudes, and behavior relating to diabetes and its main risk factors among urban residents in Cameroon: a qualitative survey. Ethn Dis. 2006, 16 (2): 503-509.
Pakenham-Walsh N, Bukachi F: Information needs of health care workers in developing countries: a literature review with a focus on Africa. Hum Resour Health. 2009, 8 (7): 30-10.1186/1478-4491-7-30.
Whiting DR, Hayes L, Unwin NC: Diabetes in Africa. Challenges to health care for diabetes in Africa. J Cardiovasc Risk. 2003, 10: 103-110.
Beran D, Yudkin JS, de Courten M: Access to care for patients with insulin-requiring diabetes in developing countries. Case studies of Mozambique and Zambia. Diabetes Care. 2005, 28: 2136-2140.
Goudge J, Gilson L, Russel lS, Gumede T, Mills A: Affordability, availability and acceptability barriers to health care for the chronically ill: longitudinal case studies from South Africa. BMC Health Serv Res. 2009, 9 (9): 75-
Watkins P, Alemu S: Delivery of diabetes care in rural Ethiopia: an experience from Gondar. Ethiop Med J. 2003, 41 (1): 9-17.
Ohene-Buabeng K, Matowe L, Plange-Rhule J: Unaffordable drug prices: the major cause of non-compliance with hypertension medication in Ghana. J Pharm Pharm Sci. 2004, 7 (3): 350-352.
Thorogood M, Connor MD, Hundt GL, Tollman SM: Understanding and managing hypertension in an African sub-district: a multidisciplinary approach. Scand J Public Health Suppl. 2007, 69: 52-59.
de-Graft Aikins A: Healer shopping in Africa: new evidence from rural-urban qualitative study of Ghanaian diabetes experiences. BMJ. 2005, 331 (7519): 737-
Winston C, Patel V: Use of traditional and orthodox health services in urban Zimbabwe. Int J Epidemiol. 1995, 24 (5): 1006-1012.
Pinkoane MG, Greeff M, Koen MP: Policy makers' perceptions and attitudes regarding incorporation of traditional healers into the national health care delivery system. Curationis. 2008, 31 (4): 4-12.
Pinkoane MG, Greeff M, Williams MJ: The patient relationship and therapeutic techniques of the South Sotho traditional healer. Curationis. 2005, 28 (4): 20-30.
Abo KA, Fred-Jaiyesimi AA, Jaiyesimi AE: Ethnobotanical studies of medicinal plants used in the management of diabetes mellitus in South Western Nigeria. J Ethnopharmacol. 2008, 115 (1): 67-71.
Risenga P, Botha A, Tjallinks J: Shangaan patients and traditional healers management strategies of hypertension in Limpopo Province. Curationis. 2007, 30 (1): 77-84.
Hundt GL, Stuttaford M, Ngoma B, SASPI Team: The social diagnostics of stroke-like symptoms: healers, doctors and prophets in Agincourt, Limpopo Province, South Africa. J Biosoc Sci. 2004, 36 (4): 433-443.
Sengwana M, Puoane T: Knowledge, beliefs and attitudes of community health workers about hypertension in the Cape Peninsula, South Africa. Curationis. 2004, 27 (1): 65-71.
Peltzer K, Khoza LB, Lekhuleni ME, Madu SN, Cherian VI, Cherian L: Concepts and treatment for diabetes among traditional and faith healers in the northern province, South Africa. Curationis. 2001, 24 (2): 42-47.
Niang C: The Dimba of Senegal: A support group for women. Reproductive Health Matters. 1994, 4: 39-45. 10.1016/0968-8080(94)90007-8.
Dutta-Bergman M: The unheard voices of Santalis: Communicating about health from the margins of India. Communication Theory. 2004, 14: 237-263. 10.1111/j.1468-2885.2004.tb00313.x.
Achebe C: Things fall apart. 1958, London: Heinemann
de-Graft Aikins A: Strengthening quality and continuity of diabetes care in rural ghana: a critical social psychological approach. J Health Psychol. 2004, 9 (2): 295-309.
Awah P, Unwin N, Phillimore P: Diabetes Mellitus: Indigenous naming, indigenous diagnosis and self-management in an African setting: the example from Cameroon. BMC Endocr Disord. 2009, 9: 5-
Kagee A, Le Roux M, Dick J: Treatment adherence among primary care patients in a historically disadvantaged community in South Africa: a qualitative study. J Health Psychol. 2007, 12 (3): 444-460.
Airhihenbuwa C: Healing our differences - the crisis of global health and the politics of identity. Lanham, Maryland. 2007
Airhihenbuwa CO: Health and Culture: Beyond the Western pardigm. 1995, Thousand Oaks, CA: Sage
Airhihenbuwa C: Of culture and multiverse: renouncing "the universal truth" in health. Journal of Health Education. 1999, 30 (3): 267-273.
Ijarotimi O, Keshinro O: Nutritional knowledge, nutrients intake and nutritional status of hypertensive patients in Ondo State, Nigeria. Tansania Journal of Health Research. 2008, 10 (2): 59-67.
Sharma S, Mbanya J, Cruickshank K, Cade J, Tanya A, Cao X, Hurbos M, Wong M: Nutritional composition of commonly consumed composite dishes from the Central Province of Cameroon. International Journal of Food Sciences and Nutrition. 2007, 58 (6): 475-485. 10.1080/09637480701288454.
Boeck F: 'When hunger goes around the land:' hunger and food among the Aluund of Zaire. Man. 1994, 29 (2): 257-282. 10.2307/2804474.
Okoror TA, Airhihenbuwa CO, Shisana O, Zungu-Dirwayi N, Smith E, Brown D, Louw J: "My mother told me I must not cook anymore" - Food, Culture, and the Contexts of HIV and AIDS related Stigma in Three Communities in South Africa. International Quarterly of Community Health Education. 2008, 28 (3): 201-213. 10.2190/IQ.28.3.c.
Gwede C, McDermott R: AIDS in Sub-Saharan Africa: Implications of health education. AIDS Education and Prevention. 1992, 4 (4): 350-361.