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The “Rule of Halves” Does Not Apply in Peru: Awareness, Treatment, and Control of Hypertension and Diabetes in Rural, Urban, and Rural-to-Urban Migrants

Lerner, Alana G. PhD*†; Bernabe-Ortiz, Antonio MD, MPH*‡; Gilman, Robert H. MD*§¶; Smeeth, Liam PhD, MBBS*‖; Miranda, J. Jaime MD, PhD***

Critical Pathways in Cardiology: June 2013 - Volume 12 - Issue 2 - p 53–58
doi: 10.1097/HPC.0b013e318285ef60
Original Articles

Objective: To determine the awareness, treatment, and control of hypertension and diabetes by migration status.

Design: Cross-sectional study, secondary analyses of the PERU MIGRANT study.

Patients: Rural, rural-to-urban migrants, and urban participants.

Main Outcome Measures: Awareness, treatment, and control of hypertension and diabetes mellitus were calculated using weights to account for participant’s group size.

Results: Of 205 of the 987 (weighted prevalence 24.1%, 95% confidence interval: 21.1%–27.1%) participants identified as hypertensive, 48.3% were aware of their diagnosis, 40% of them were receiving treatment, and 30.4% of those receiving treatment were controlled. Diabetes was present in 33 of the 987 (weighted prevalence 4.6%, 95% confidence interval: 3.1%–6%), and diabetes awareness, treatment, and control were 71.1%, 40.6%, and 7.7%, respectively. Suboptimal control rates, defined as those not meeting blood pressure or glycaemia targets among those with the condition, were 95.1% for hypertension and 97% for diabetes. Higher awareness, treatment, and control rates, for both hypertension and diabetes, were observed in rural-to-urban migrants and urban participants compared with rural participants. However, treatment rates were much lower among migrants compared with the urban group.

Conclusions: These results identify major unmet needs in awareness, treatment, and control of hypertension and diabetes. Particular challenges are lack of awareness of both hypertension and diabetes in rural areas, and poor levels of treatment and control among people who have migrated from rural into urban areas.

Supplemental Digital Content is available in the text.

From the *CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN; Epidemiology Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru; §Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Área de Investigación y Desarrollo, A.B. PRISMA, Lima, Peru; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and **Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.

A.G.L. conducted literature search and wrote the initial draft of this article. A.B.-O. led the statistical analyses and provided critical inputs to various drafts. R.H.G. and L.S. participated in the design of the study, actively supported the fieldwork phase of the study and provided critical input during data analysis and interpretation of results. J.J.M. conceived and conducted the original study, developed the idea for this secondary analysis, and contributed to drafting various versions of this article. All authors read and approved the final article. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. J.J.M. is the guarantor of the study.

All authors declare that 1) no support from any organization for the submitted work other than the funding grant; 2) no relationships with any organization that might have an interest in the submitted work in the previous 3 years; 3) their spouses, partners, or children do not have financial relationships that may be relevant to the submitted work; and 4) no nonfinancial interests that may be relevant to the submitted work.

The PERU MIGRANT Study was funded by the Wellcome Trust (GR074833MA). L.S. is supported by a Wellcome Trust Senior Research Fellowship in Clinical Science. The CRONICAS Center of Excellence in Chronic Diseases at Universidad Peruana Cayetano Heredia is funded by the National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, under contract No. HHSN268200900033C. The funder had no role in study design; data collection, analysis, or interpretation; in writing the report; or in the decision to submit the article for publication. The researchers are all independent from the funding source.

This work was supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Center, National Eye Institute, National Heart, Blood, and Lung Institute, National Institute of Dental and Craniofacial Research, National Institute On Drug Abuse, National Institute of Mental Health, National Institute of Allergy and Infectious Diseases, and National Institutes of Health Office of Women’s Health and Research through the Fogarty International Clinical Research Scholars and Fellows Program at Vanderbilt University (R24 TW007988) and the American Relief and Recovery Act.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Corresponding author: J. Jaime Miranda, PhD, CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Miraflores, Lima, Peru. E-mail:

© 2013 by Lippincott Williams & Wilkins