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 Table of Contents  
Year : 2023  |  Volume : 14  |  Issue : 1  |  Page : 29

Prevalence and correlates of cardiovascular health status among adults in Afghanistan: Results of a national survey in 2018

1 Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Bangkok, Thailand; Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa
2 Department of Psychology, University of the Free State, Bloemfontein, South Africa; Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan

Date of Submission07-Jun-2021
Date of Acceptance31-May-2022
Date of Web Publication17-Mar-2023

Correspondence Address:
Karl Peltzer
Department of Psychology, College of Medical and Health Science, Asia University, Taichung

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpvm.ijpvm_252_21

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Background: The aim of the study was to assess the prevalence and correlates of cardiovascular health (CVH) status among adults in Afghanistan. Methods: In a national cross-sectional household survey 3,447 adults completed CVH measurements in Afghanistan. Criteria for ideal CVH (ICVH) were physical activity, healthy diet, non-smoking, fasting blood glucose (<100 mg/dL), body mass index (<25 kg/m2), total cholesterol (<200 mg/dL), and blood pressure (<120/<80 mmHg). Results: More than one-third (34.3%) of participants had 5-7 ICVH, 45.7% 3-4 ICVH, and 20% had 0-2 ICVH. In adjusted logistic regression analysis, secondary or more education (AOR: 1.80, 95% CI: 1.22-2.66) was positively associated, and older age (45-69 years) (AOR: 0.33, 95% CI: 0.26-0.42), and urban residence (AOR: 0.67, 95% CI: 0.51-0.88) were inversely associated with 5-7 ICVH. Conclusions: The prevalence of ICVH was low in Afghan adults. Population measures may be used to improve CVH targeting identified associated factors.

Keywords: Adults, Afghanistan, cardiovascular health, population survey

How to cite this article:
Pengpid S, Peltzer K. Prevalence and correlates of cardiovascular health status among adults in Afghanistan: Results of a national survey in 2018. Int J Prev Med 2023;14:29

How to cite this URL:
Pengpid S, Peltzer K. Prevalence and correlates of cardiovascular health status among adults in Afghanistan: Results of a national survey in 2018. Int J Prev Med [serial online] 2023 [cited 2023 Sep 28];14:29. Available from: https://www.ijpvmjournal.net/text.asp?2023/14/1/29/371950

  Introduction Top

Almost one-third of global death can be attributed to cardiovascular diseases (CVDs), such as ischaemic heart disease and stroke.[1] Most of the CVD death (>75%) occur in low-resourced countries.[1] One in five individuals died from CVDs in 2016 in Afghanistan,[2] which is a low-income country with a low adult literacy rate (43%).[3]

Ideal cardiovascular health (ICVH) includes seven ideal health behaviors and factors, including physical activity, healthy diet, non-smoking, fasting blood glucose (<100 mg/dL), body mass index (<25 kg/m2), total cholesterol (<200 mg/dL), and blood pressure (<120/<80 mmHg).[4],[5] Studies showed that persons with a higher number of ICVH have a lower morbidity and mortality risk.[6] The ICVH status in Afghanistan is unknown, which, however, is needed for decision makers to enable them to provide specific preventive health policies to enhance CVH.

Global data from a systematic review show that 19.6% of the adult population had 5-7 ICVH, and 32.2% had 0-2 ICVH.[7] For example, in a national sample (≥20 years) in China 33.0% had 5-7 ICVH,[8] and in Nepal (15-69 years), 51.6% had 5-7 ICVH metrics.[9] Social and demographic factors associated with ICVH may include female gender,[7],[9] decreasing age,[7],[9],[10] socioeconomic status,[10] and rural residence.[11] The aim of the study was to assess the prevalence and correlates of CVH status among adults in Afghanistan in 2018.

  Method Top

Sample and procedures

This paper uses secondary data from the 2018 Afghanistan cross-sectional STEPS survey in 2018.[12] Using a three-stage cluster sampling approach (1:55 districts, 2: villages or blocks, and 3: households), a nationally representative sample of individuals 18-69 years was generated.[13] At the household level one adult (18-69 years) was randomly selected.[13] The “Ministry of Public Health Ethics Board” granted ethics approval, and participants gave written informed consent.[13] From 3,447 of 3,956 participants complete information was available on ICVH measures: “smoking status, body mass index (BMI), physical activity (PA), diet, total cholesterol (TC) and fasting blood glucose (FBG), and blood pressure (BP).”


Using the American Heart Association (AHA) classification,[4],[5] levels of ICVH for “smoking, BMI, PA, diet, TC, BP, and FBG” were assessed.

Cardiovascular health behavior

Smoking status: “poor if current smoker, intermediate if a past smoker, and ideal if self-report of never having smoked.”

Body Mass Index (BMI) was determined by using standardized anthropometric measurements.[13] BMI was “defined poor if ≥30 kg/m2, intermediate as 25.0–29.9 kg/m2, and ideal BMI is <25 kg/m2.”

Healthy diet: “Poor healthy diet is defined as <2 servings of fruit and vegetables (FV)/day, intermediate as 2-<4.5 FV/day, and an ideal diet as ≥4.5 FV servings/day.”[14]

Physical activity (PA): “Poor = None, Intermediate = 1–149 min/wk moderate intensity or 1–74 min/wk vigorous intensity or 1–149 min/wk moderate + vigorous, ideal = ≥150 min/wk moderate intensity or ≥75 min/wk vigorous intensity or ≥150 min/wk moderate + vigorous.” PA was sourced from the “Global Physical Activity Questionnaire.”[15]

Cardiovascular health factors

Total cholesterol (TC): poor is “TC ≥240 mg/dL, intermediate is TC 200–239 mg/dL or treated to TC <200 mg/dL and ideal TC is <200 mg/dL and without any cholesterol-lowering medication.” TC levels were determined by an enzymatic method.[13]

Blood pressure (BP) (mean of 2 of 3 readings): poor is “BP ≥140/≥90 mmHg, intermediate is systolic BP 120–139 mmHg or diastolic BP 80–89 mmHg or treated to BP <120/<80 mmHg, and ideal BP is defined as BP <120/<80 mmHg and without any antihypertensive medication.”[13]

Fasting blood glucose (FBG): poor is “glucose ≥126 mg/dL, intermediate is glucose 100–125 mg/dL or treated to <100 mg/dL, and ideal is <100 mg/dL and without any glucose-lowering medication.” FBG levels were determined by glucose oxidase method.[13]

The seven CVH components were each classified as 1 = ideal, and 0 = not ideal, and grouped into 0-2, 3-4, and 5-7 ICVH without any previous CVD.

History of CVD was based on a positive response to the question, “Have you ever had a heart attack or chest pain from heart disease (angina) or a stroke (cerebrovascular accident or incident)?”[12]

Social and demographic information consisted of educational level, sex, age, residence status, and number of adult members in household (as indicator for economic status).[13],[16]

Statistical procedures

Differences in proportions were calculated using Pearson Chi-square tests and Student's t-tests for men differences. Logistic regression was used to estimate predictors of 5-7 ICVH. P < 0.05 was considered significant. Using “STATA software version 14.0 (Stata Corporation, College Station, TX, USA)” statistical analyzes were applied, considering the multi-stage sampling and weighting of the data.

  Results Top


The participants were 3,447 18-to-69-year-olds (median age: 32 years; IQR 23-43), 55.4% were male, 59.9% had no education, 56.3% resided in urban areas, and 60.1% had ≥5 adult household members. Compared to men, women had lower education, higher self-reported hypertension, higher BMI, total cholesterol and FBG [see [Table 1]].
Table 1: Sample characteristics of participants aged 18-69 years, Afghanistan, 2018

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Proportion of ICVH

One in five (20%) of respondents had 0-2 ICVH, 45.7% had 3-4 ICVH, and 34.3% had 5-7 ICVH; 0.5% had zero, 3.7% one, 8.5% two, 20.1% three, 29.6% four, 27.5% five, 10.0% six, and 0.25 all seven ICVH. A significant larger proportion of women had ideal smoking, ideal diet, and ideal blood pressure than men, while men had significantly higher ideal BMI, physical activity, and total cholesterol than women. [see [Table 2]].
Table 2: Cardiovascular health (CVH) metrics distribution (prevalence, %)

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Associations with 5-7 ICVH

In adjusted logistic regression analysis, secondary or more education (Adjusted Odds Ratio-AOR: 1.80, 95% Confidence Interval-CI: 1.22-2.66) was positively, and older age (45-69 years) (AOR: 0.33, 95% CI: 0.26-0.42), and urban residence (AOR: 0.67, 95% CI: 0.51-0.88) were inversely associated with 5-7 ICVH [see [Table 3]].
Table 3: Associations with meeting 5-7 ideal cardiovascular health metrics

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  Discussion Top

In this national sample of 18-to-69-year-olds in Afghanistan, the prevalence of 5-7 ICVH (34.3%), was higher than globally (19.6%),[7] in Iran (16%),[17] similar to China (33.0%),[8] and lower than in Nepal (51.6%).[9] The proportion of ideal TC (87.2%), ideal smoking (85.1%), and ideal FGP (78.9%) were the highest and healthy diet (3.3%) and ideal BP (31.5%) were the lowest in this study, which compares with global results.[7] The estimates of ideal PA (55.3%) and ideal BMI (57.1%) in this study seem higher than global figures of PA (40.6%) and BMI (40.3%).[7] In local studies in Afghanistan, a lower prevalence of ideal BMI has been observed, e.g., in Kabul (25-70 years, in 2015) (42.4%),[18] in Jalalabad (25-65 years) (42.6%),[19] and in five major cities (25-70 years) (47.3%).[20] The low prevalence of ideal PA (31.5%) in this national study seems to be confirmed in local studies, e.g., in five major cities in Afghanistan (25-70 years, 32.4% hypertension),[19] and in Kabul (≥40 years, 46.2% hypertension).[18] The prevalence of poor smoking among men (14.5%) and among women (2.6%) in this study compares with a study in five major cities in Afghanistan (14.1% among men and 2.7% among women).[20]

In line with previous studies,[7],[9],[10],[11] the prevalence of ICVH decreased with age, and increased with higher education, and those residing in rural areas. Unlike some previous studies,[7],[9],[10] this study did not find significant sex and economic status (proxy adult household members) differences in the prevalence of ICVH. The overall nonsignificant sex differences may be attributed to a higher rate of ideal smoking, ideal diet, and ideal BP among women than men, and a higher rate of ideal BMI, PA, and TC among men than women. To improve ICVH in the Afghan adult population, multidisciplinary interventions are needed targeting CVH behaviors, such as health promotion of diet, weight control, physical activity, and smoking cessation, as well as screening and management of high blood pressure and blood sugar.[17],[20]

Study limitations

In contrast to the five components of the AHA healthy diet, this study only assessed one component (fruit and vegetable consumption), and future studies all components should be included. The measure of household income had too many missing cases, and we could therefore not include a better measure of economic status. Additional limitations refer to the cross-sectional design of the study and the self-report of some parts of data collected.

  Conclusion Top

We found a low proportion of ICVH among the adult population in Afghanistan. Interventions targeting both the general population and identified risk groups should be implemented to improve ICVH in Afghanistan.


“The data source, the World Health Organization NCD Microdata Repository (URL: https://extranet.who.int/ncdsmicrodata/index.php/catalog), is hereby acknowledged.”

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization (WHO). Cardiovascular diseases (CVDs), 2017. Available from: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds). [Last accessed on 2020 Nov 11].  Back to cited text no. 1
World Health Organization-Noncommunicable Diseases (NCD) Country Profiles, Afghanistan, 2018. Available from: https://www.who.int/nmh/countries/afg_en.pdf?ua=1. [Last accessed on 2020 Nov 25].  Back to cited text no. 2
World Factbook. Afghanistan. Available from: https://www.cia.gov/library/publications/the-world-factbook/geos/af.html. [Last accessed on 2021 Nov 25].  Back to cited text no. 3
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Younus A, Aneni EC, Spatz ES, Osondu CU, Roberson L, Ogunmoroti O, et al. Systematic review of the prevalence and outcomes of ideal cardiovascular health in US and Non-US populations. Mayo Clin Proc 2016;91:649-70.  Back to cited text no. 6
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Machado LBM, Silva BLS, Garcia AP, Oliveira RAM, Barreto SM, Fonseca MJM, et al. Ideal cardiovascular health score at the ELSA-Brasil baseline and its association with sociodemographic characteristics. Int J Cardiol 2018;254:333-7.  Back to cited text no. 10
van Nieuwenhuizen B, Zafarmand MH, Beune E, Meeks K, Aikins AD, Addo J, et al. Ideal cardiovascular health among Ghanaian populations in three European countries and rural and urban Ghana: The RODAM study. Intern Emerg Med 2018;13:845-56.  Back to cited text no. 11
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Pengpid S, Peltzer K. Ideal cardiovascular health in a nationally representative population-based sample of adults in Malawi. Glob Heart 2021;16:24. doi: 10.5334/gh. 986.  Back to cited text no. 14
Armstrong T, Bull F. Development of the World Health Organization global physical activity questionnaire (GPAQ). J Public Health 2006;14:66-70.  Back to cited text no. 15
Melki IS, Beydoun HA, Khogali M, Tamim H, Yunis KA, National Collaborative Perinatal Neonatal Network (NCPNN). Household crowding index: A correlate of socioeconomic status and inter-pregnancy spacing in an urban setting. J Epidemiol Community Health 2004;58:476-80.  Back to cited text no. 16
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Saeed KM. Burden of hypertension in the capital of Afghanistan: A cross-sectional study in Kabul city, 2015. Int J Hypertens 2017;2017:3483872. doi: 10.1155/2017/3483872.  Back to cited text no. 18
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  [Table 1], [Table 2], [Table 3]


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