Distribution of Prevalence and Impact Factors of Cardiovascular Diseases in Benin⋆ Aude-Elvis ODELOUI1†, Thierry Oscar Codjo EDOH2,3*†, Joel T. Hounsou1†, Jules Degila1†, Ahmed S. Albahri4,5† 1 Institute of Mathematics and Physics Sciences 2 RFW-Universität Bonn, Bonn, Germany 3 Ecole Supérieure Multinationale des Telecommunications; Dakar, Senegal 4 Technical College, Imam Ja’afar Al-Sadiq University, Baghdad, Iraq 5 Iraqi Commission for Computers and Informatics (ICCI), Baghdad, Iraq Abstract Cardiovascular diseases (CVDs) are among the leading causes of mortality worldwide, with an increasing prevalence in low- and middle-income countries, particularly in sub-Saharan Africa. This article, part of an ongoing study, utilizes artificial intelligence (AI) in predicting distribution of CVDs, evaluating their impact factors, and proposing strategies for mitigating the prevalence of CVDs. Aims and objectives: This part of the work focused only on understanding the contexts and impact factors of the different regional factors by answering the related research questions and finally testing the hypothesis on the statistical relationship between the prevalence and level and quality of medical equipment available in the care units as well as the level of access to early detection and prevention of CVDs in each region of the country. Research methodology: A mixed methods approach was used to collect data (QUAN+QUAL) in a cross- sectional field study. Studies and reports published between 2012, and the beginning of 2024 were searched in academic databases and libraries of the Beninese Ministry of Health (MoH). Studies and reports on the prevalence of CVDs worldwide, particularly in Benin, and reports on CVD (pre)-screening and prevention in Benin were identified. Furthermore, quantitative data were collected through a survey (using a semi- structured questionnaire) conducted at the National Program for the Prevention of Communicable Diseases (PNLMT). The study involved 466 participants sampled from different regions and 36 care units across the country. Results: People living in rural regions are more severely affected by these diseases. Erdely people (50+ years) are at risk of developing the disease, mostly in rural regions. The research hypotheses were supported by cross-sectional field research across different regions of Benin. The level of CVD incidence in Benin differs from region to region and is correlated with the level and quality of medical equipment in regional healthcare units and the extent to which early detection and prevention programs are implemented. However, analyzing the factors impacting the regional prevalence of CVDs from the computer sciences point of view reveals that awareness raising and early detection programs are poorly implemented. could be supported by digital campaigns (remote care) to raise awareness about cardiovascular diseases. Keywords Prevalence of disease, Artificial Intelligence, noncommunicable disease, cardiovascular diseases, Gamification, digital campaign 1. Introduction low awareness, and socio-economic challenges. Investigating the prevalence and distribution of CVDs in Cardiovascular diseases (CVDs) encompass a range of this region is critical for developing targeted heart and blood vessel disorders, including coronary interventions. artery disease, stroke, and hypertension. These Noncommunicable diseases (NCDs) are among the conditions are a significant public health concern, leading causes of many deaths worldwide. NCDs kill 41 especially in sub-Saharan Africa, where the burden is million people every year, accounting for 71% of all exacerbated by inadequate healthcare infrastructure, Cotonou’24: Conférence Internationale des Technologies de l’Information et de la Communication de l’ANSALB, June 27–28, 2024, Cotonou, BENIN 0009-0002-1962-0034 (Aude-Elvis ODELOUI), 0000-0002-7390-3396 ∗ Corresponding author. (Thierry EDOH), 0000-0001-7301-3919 (Jules DEGILA), 0000-0003-3335- † These authors contributed equally. 457X (A. S. ALBHRI) Aude-Elvis ODELOUI (aeodeloui@gmail.com), Thierry Oscar Codjo © 2024 Copyright for this paper by its authors. Use permitted under Creative Commons License Attribution 4.0 International (CC BY 4.0). EDOH (oscar.edoh@gmail.com), Joel T. Hounsou (joelhoun@gmail.com), Jules Degila (julesdegila@gmail.com), Ahmed . S. Albahri(ahmedbahri1978@gmail.com) CEUR ceur-ws.org Workshop ISSN 1613-0073 Proceedings deaths worldwide. Every year, more than 15 million infrastructure and equipment, individuals’ financial and people die from NCDs between the ages of 30 and 69; economic situations play an important role in their poor 85% of these "premature" deaths occur in low- and access to healthcare services and pharmaceutical care middle-income countries [1], [2]. [12]. In Benin, 51% of women live relatively close to a Worldwide, cardiovascular diseases, such as NCDs, hospital, over 13% of women live at least 30 kilometers are bearing a high burden of morbidity and mortality. from a hospital or comparable facility, and the rest have Approximately 30–45% of adults worldwide are little or no access to medical care [13], [14]. Many suffering from hypertension, the prevalence of which is regions in Benin have a low capacity to offer increasing [3], [4], [5]. In Benin, a low-income country, cardiovascular disease prevention, early detection, early the most common cardiovascular diseases (CVDs) are diagnosis, and management services (SARA survey1 - hypertension, obliteration of the arteries of the lower 2018-). limbs (AOMI), cerebrovascular accidents (CVA) and heart failure (HF). Blood pressure (BP) was never measured in approximately 68.2% of Beninese individuals, and more than half of those with elevated BP were unaware of their status [6]. Despite the availability of low-cost antihypertensive drugs in Benin, less than half of known hypertensive patients are treated, and less than one-third achieve blood pressure control at currently recommended targets [7]. Late diagnosis of hypertension and poor BP control increase the frequency of hypertensive complications. Access to stroke exploration tools remains a real problem, with high social inequalities and health insurance mainly benefiting wealthy people. In Benin, it is estimated that among patients, 109 (29.3%) have suffered from stroke without knowing it, 121 (32.5%) were diagnosed and had an electrocardiogram, and 31 (8.3%) benefited from a cardio ultrasound and 34 ultrasound scans of the neck vessels (9.1%) [8], [9]. This undoubtedly affects the prognosis of patients who do not receive optimal, specific treatment. Differences in the level of healthcare accessibility are a consequence of the medical structure of sub-Saharan African countries and weak health infrastructure. Figure 1 shows the pyramidal structure of the country public health system, where health units at low levels are poorly equipped Figure 1: Beninese public health system structure. with medical infrastructure [10]. Source [[15] Figure 1 updated]. The country has only a Access to healthcare in general, particularly to few university hospitals. The majority of the population cardiological care, is one of the main problems and is living relatively close to an medical primary care unit challenges facing the public healthcare system in Benin, a sub-Saharan country, due to its public health structure The lack of diagnostic and treatment services for and infrastructure [11]. Medical facilities are often far cardiac arrhythmias is common in most sub-Saharan from residential areas. Most rural populations live in African countries, leading to suboptimal care and a areas devoid of municipal infrastructure, such as streets heavy burden of premature cardiac death[16]. This fact and power supply systems. Access to healthcare is might be correlated with the prevalence of CVDs across therefore dependent on the availability of local medical the country since early disease detection and prevention resources. Access to healthcare therefore depends on require various strategies and technological support, where one lives. Therefore, compared with urban such as prescreening for diseases [17], eHealth and populations, rural populations face poor access to remote care infrastructures such as pervasive healthcare [11]. In addition to poor medical infrastructure [18], medical equipment such as ECGs 1 https://www.afro.who.int/sites/default/files/2018- %20Report%20of%20the%20Regional%20Director%20- 08/The%20 Work%20of%20 %202017-2018%20-%20%20web%20version.pdf WHO%20in%20the%20African%20Region%20%20- [19], [20] and other medical tools. The lack of medical 2. Theoretical and practical equipment might obstruct access to cardiac care provision. background, motivation, Telehealth care, in general, increases access to objectives, and hypotheses health care providers [21] and enables care provision in the case of limited physical contact, for example, during 2.1. Background the COVID-19 crisis [22], [23], [24]. Remote cardiac care, Cardiovascular diseases are among the leading as a discipline of telehealth care, extends access to noncommunicable diseases worldwide. Prior studies cardiologic care, including patient monitoring and investigating the prevalence of cardiovascular diseases education. Although the concept of telehealth care was (CVDs) in Benin have focused mostly on the national coined in 1948 in Chester, where physicians started prevalence of the disease or on hospitals in certain sending radiology images over the telephone and having contexts and/or cases. It is therefore difficult to provide remote consultation with other physicians2, telehealth adequate and sustainable solutions to mitigate poor is a relatively new topic in medicine and has gained access to CVD care services through early detection. more significance during the last COVID-19 pandemic. Prevention awareness-raising programs. Remote patient monitoring started in 1961, and in 1967, This section presents the outcomes of the literature ECGs were sent via telephone. review on the prevalence of CVDs worldwide, The overall objective of this ongoing study is using particularly in Benin, and early detection, prevention, artificial intelligence to investigate the distribution of and awareness-raising programs in the country. the prevalence of cardiac diseases across the country and their impact factors, to assist in the design of novel 2.1.1. Prevalence of Cardiovascular Diseases technology-based solutions to overcome poor medical The incidence of cardiac diseases in sub-African equipment and poor access to CVD care services, countries is high[4]; in particular, blood pressure is implement digital campaigns and enable them to approximately 27% in sub-Saharan Africa[5]. sustainably mitigate the prevalence of CVDs across the Many research studies have addressed the country. Early detection and management of cardiac prevalence of CVDs with a focus on cases such as the diseases, particularly in regions with poor medical prevalence of CVDs among certain population groups resources, can help public health system providers and inpatients suffering from certain diseases. These reduce the disease prevalence. The present study, studies have focused on determining CVD risk factors therefore, specifically aimed to investigate the in selected populations. Witchakorn et al. investigated distribution and causes of disease prevalence in each the incidence of CVDs among HIV patients in Asia- region of the country using AI. Pacific regions. A high prevalence of CVDs was found Artificial intelligence (AI) has emerged as a powerful among HIV patients compared with non-HIV patients. tool in healthcare, offering advanced capabilities in data Despite this result, the study concluded that a gap exists analysis, predictive modeling, and decision-making in HIV/CVD research [25]. According to this study, HIV support. By leveraging AI, researchers and healthcare seems to be a factor impacting the incidence of CVD. providers can gain deeper insights into the distribution Similarly, Huynh Van Minh et al. investigated the of CVDs, identify key impact factors, and design more prevalence of hypertension in a population of people effective strategies to reduce the burden of these aged ≥ 18 years in Vietnam [7], and Jérôme Boombhi et diseases. This article examines the potential of AI in this al. investigated the prevalence of CVDs and factors context and discusses the role of information technology associated with blood pressure (BP) in a population of in enhancing these efforts. hypertensive black patients in two hospitals in The goal of investigating the distribution of cardiac Cameroon and found that an alarming prevalence of disease incidence is, on the one hand, regarding the CVDs and a sedentary lifestyle in the population in structure of the Beninese public health structure to Cameroon were the main CVD risk factors [4]. Camille assess the relation between medical equipment Lassale et al. investigated the prevalence among people (un)availability in cardiac care services and disease using traditional medicine (TM) in 12 African countries. prevalence in each region and, on the other hand, factors The study revealed that the proportion of people with to be technologically addressed to reduce the prevalence. high BP using TM matches the incidence of CVDs in sub-Saharan Africa reported in the literature [5]. 2 https://blog.prevounce.com/history-of-remote-patient- monitoring-how-it-began-and-where-its-going In Benin, the prevalence of blood pressure was 25% et al., 2019),, which was conducted in Benin, revealed in 2015 (Houehanou et al., 2022a).. Many previous similar awareness ratios and revealed differences studies have investigated the prevalence of CVDs such between men and women in terms of disease awareness. as blood pressure in Benin, with a focus on nationwide It was also reported in [8] that approximately 50% of cardiac disease incidence [26], geographical region [3], people involved in a study of four sub-Saharan African [27], or cardiac disease in certain population groups [8]. countries were not aware of their hypertension; in [9], The distribution of CVD incidence in geographical 77.5% of the study participants were unaware of their regions in Benin has been less investigated. In 2011, D.S. state. In [4], the authors state that the subjects are not Houinato et al. investigated the prevalence of CVDs and aware of risk factors such as obesity and others. Based associated risk factors. The study revealed that on these findings, it is worth investigating the extent to department (region) and profession are not associated which disease awareness-raising campaigns or with the prevalence of hypertension (HT) while age and programs are implemented in Benin. obesity are significantly associated to HT [9]. Similarly, The national implementation of the WHO Michael Ekholuenetale et al. investigated heart diseases PACKAGE OF ESSENTIAL NONCOMMUNICABLE among women in Benin and reported a high prevalence (PEN) DISEASE INTERVENTIONS (WHOPEN) strategy of heart and lung diseases in rich environments, unlike is still sporadic. However, in 2023, the WHO founded an Houinato et al., who reported that geographical regions information campaign on cardiovascular and diabetes are associated with heart and lung diseases among prevention in three departments, namely, Attacora, women of reproductive age [8]. To the best of our Donga, and Mono. Many other awareness-raising knowledge, this study is the only one that has campaigns and early detection programs were investigated the prevalence of heart disease in conducted in the same year (2023). However, all these geographical regions. However, only women and heart campaigns were addressed to some employees of some diseases were considered among CVD patients. This fact national institutions. According to Amidou A. Salmane, makes our study novel. the MoH is working on a strategy for public awareness The prevalence of CVDs in Benin is estimated to be campaigns and early detection programs that could 27.5% for hypertension, 3.9% for lower limb artery benefit the entire population. obligation, 4.6% for stroke, and 1.0% for heart failure3. Despite the adoption of WHOPEN, the country Hypertension affects 25.9% of Beninese adults lacks a sustainable implementation of early disease according to a national survey conducted in 2015 by the detection and prevention programs. Ministry of Health using stepwise methodology from To the best of our knowledge, and according to the the World Health Organization [26], [28]; different risk literature review on early detection and cardiological and impact factors were investigated. However, we disease prevention programs in Benin, no program found no studies that investigated the impact of the exists. However, according to Amidou A. Salmane5, the level of medical equipment in healthcare units and Ministry of Health (MoH) has adopted the WHO disease awareness among the population. package of essential noncommunicable (PEN) disease interventions for primary health care (WHOPEN), a 2.1.2. Early detection and prevention of strategy for primary disease prevention and early cardiovascular diseases detection defined by the World Health Organization According to the information collected in the latest (WHO). SARA survey4 (2018), some regions in Benin have a low Educating people in Benin on risk factors for all capacity to offer cardiovascular disease prevention, cardiac diseases, detecting cardiac diseases early and earlier detection, diagnosis, and management services. developing better strategies to manage cardiac diseases Disease prevention requires knowledge about the might assist in reducing the risk of developing and disease (health literacy) [17]. Most of the reviewed reducing the prevalence of cardiac diseases[29], which articles reported an average level of CVD awareness is obviously caused by poor access to cardiac screening among the studied populations; in [26], awareness was for early detection, diagnosis, and treatment. However, slightly greater than half. The TAHES study (Desormais the Beninese public health structure is facing infrastructural challenges[11] that could challenge the 3 https://benin.un.org/fr/298-oms-r%C3%A9duire-la- 4 https://www.afro.who.int/sites/default/files/2018- pr%C3%A9valence-des-maladies-non-transmissibles- 08/The%20 Work%20of%20 WHO%20in%20the%20African%20Region%20%20- au-benin %20Report%20of%20the%20Regional%20Director%20- %202017-2018%20-%20%20web%20version.pdf 5 PNLMNT: National Program for the Prevention of Communicable Diseases efficiency of initiatives to reduce the prevalence of 2.2.2. Research objectives, questions, and cardiac diseases in Benin. hypotheses 2.2. Research Motivation, Objectives, The primary objective of this ongoing study is to investigate to what extent information technology could Questions, and Hypotheses assist in mitigating (reduce) the incidence of CVDs in the 2.2.1. Motivation country’s geographical regions. Therefore, our steps toward this goal are to determine the causes underlying This section discusses the research motivation or gap. the prevalence and analyze them in the computer Most prior research on the prevalence of CVDs in sciences. Benin has focused on the following: This part of the research, therefore, aims to do the 1. Determining the prevalence of certain CVDS, following: such as hypertension, in a certain group of 1. The prevalence of disease and impacting individuals revealed that individuals suffering factors in geographical regions of the country from CVD are unaware of the disease [3], [8], were assessed. [9], [27] 2. The number and quality of medical equipment 2. CVD risk factors such as obesity and cardiologic units in the districts were assessed. comorbidities[25], [30] 3. Districts were classified according to their 3. Predicting the regional prevalence of CVDs scores (prevalence and equipment level as well based on collected historical data (risk factors, as prediction and prevention programs), and technical platform level, access to diseases the prevalence of districts with similar medical prevention programs, etc.,) equipment levels, screening, and control It is well known in the literature that individuals’ programs was compared. disease awareness, also called health literacy, can be 4. Collected data were used to predict the improved by educating them on disease risk factors and regional prevalence of the CVDs pre-symptoms. Knowing the risks of disease could drive Regarding the identified research gap, we define the individuals to prevent the disease [31], [32] by following research hypothesis as follows: their health and lifestyle. We found in previous studies [33], [34] that health or medical education might impact H1. The level of prevalence in geographical regions is individual health outcomes. It is, therefore, trivial that statistically related to the level of population accessibility knowing and having a good lifestyle may impact the to early disease detection (prescreening), prevention prevalence of the disease in a region. programs and the number and quality of existing Early detection of a disease requires access to care cardiology equipment in regional care units. services, whereas medical equipment is needed. It is well known in the literature that access to care services is not sufficient to impact individual health outcomes. The 3. Methodology and Study Design quality-of-care services is another factor that amplifies 3.1. Study methodologies health outcomes. Therefore, it is worth investigating the role that the level and quality of medical equipment This study used quantitative and qualitative mixed- could play in the prevalence and/or incidence of method research to collect data from several targets diseases. All prior studies are limited in this regard. spread throughout Benin to identify and explain why To the best of our knowledge, no previous study has certain regions are facing a higher incidence and assessed the impact of medical equipment, early disease incidence of cardiovascular disease than others. detection and prevention, and the implementation of A total of 398 studies published between 2012 and disease awareness campaigns on the prevalence of the beginning of 2024 were identified in dedicated CVDs in geographical regions of the country. Therefore, academic databases (PubMed, ScienceDirect, Web of this study was motivated by this research gap and Science, CINAHL, Google Scholar, Scopus). Studies on aimed to answer the question of “to what extent factors the incidence of cardiac diseases in Benin were such as the level and quality of medical equipment, early identified and included in the study to assess the disease detection and prevention, and disease awareness prevalence and impact factors of cardiac diseases. raising campaigns could impact the level of geographical Reports from the Beninese Ministry of Health were prevalence”. also reviewed. Random forest was used on the collected data (rate of risk factors in each, medical equipment level, prevention programs, etc.) for predicting the regional ended questions (quantitative research) were used to prevalence by classification. assess the level of perception, prevalence, and involvement in the management of CVD in Benin. The 3.2. Sampling overall survey period runs from February 2023 to November 2023. The country is divided into 12 departments called The survey used a web-based information-gathering “prefectures” and 77 districts called “communes”. form distributed via social networks to healthcare Representative districts were selected in each professionals, facility users, friends, and relatives department following our selection criteria. The throughout Benin. selection criterion for each region was at least a Illiterate people, on the other hand, were helped to university hospital if it existed and/or was a well-visited complete the questionnaire. healthcare unit with at least a minimum level of A further qualitative survey consisting of open- cardiovascular medical equipment and cardiologists. On ended questions with a focus group of healthcare the other hand, care units in rural areas have CVD professionals, including cardiology specialists, was medical equipment, such as ECG devices. conducted to analyze the outcomes of the mixed- The participants (cardiologic patients living in large methods study. This involved discussions during a cities and rural regions) and cardiac care units were workshop with professionals from each department, sampled to investigate the distribution of CVD across including a cardiologist (if possible), a general Benin and to highlight the regions where there is a need practitioner and a health center manager (nurse or for infrastructure, medical equipment, and staff midwife). acquisition. The aim of this workshop is to analyze the  A total of 466 participants (patients) quantitative results obtained after presenting the participated in the survey from the start to the results of the quantitative mixed-method study and to finish of the survey. Of these, 192 were women, explain, from care professionals’ perspectives, the 54.2% lived in rural areas and 44.3% lived in difference in prevalence between regions with the same urban areas. It should be noted, however, that level of CVD medical equipment. 1.6% of these women did not specify their The following questions were addressed during the living environment. discussions:  Similarly, there were 265 men, 66.4% of whom 1. What are the difficulties faced in caring for lived in rural areas and 32.5% in urban areas, patients in general and those suffering from while 1.1% did not specify their living cardiovascular disease in particular? environment. In addition, 09 people who 2. How do you explain the difference in the level participated in the survey did not specify their prevalence of cardiovascular disease in regions gender. where there are no treatment facilities?  Participant Care Unit (N = 36), which provides 3. How do you explain the difference in the level cardiological care, was selected according to prevalence of cardiovascular disease in regions predefined criteria. The most visited care units where treatment facilities are available? in the department were selected. 4. What can be done to achieve the same level of care in all regions of Benin? 3.3. Data sources, collection, and extraction 3.3.1. Mixed Methods Research Questions for To explain the reasons underpinning the discrepancy in Descriptive Research Designs cardiological care service provision across the country,  Prevalence of cardiac disease and people’s mixed-method research (quantitative followed by perceptions qualitative data collection to explain the outcomes of the quantitative study) and a qualitative survey were After assessing disease prevalence, people in the conducted. selected regions were asked about their disease The kobotoolbox tool was used to develop an online awareness, blood pressure control and participation in data collection form. Participants can answer questions screening programs. about discrepancies in CVD medical care services across the country. Online questionnaires, telephone interviews and face-to-face interviews with open-ended questions (qualitative research, generally subjective) and closed- 3.3.2. Mixed Methods Research Questions for Causal-Comparative Research Designs 1. Prevalence of cardiac disease and healthcare professional perceptions Health professionals were asked about factors related to the level of disease prevalence in their regions. Furthermore, they were asked about the adherence of the population to medical control for early detection and treatment. 2. Challenges and Issues Facing Screening Programs The medical equipment level was assessed where health care professionals were asked about challenges and issues faced in providing screening programs to detect the disease early and thus prevent it early. The questions mainly focused on the medical equipment level of the care unit and how the population is empowered to take part in the program. 3.3.3. Mixed Methods Research Questions for Experimental Research Designs 1. Effect of remote cardiological care in regions with a high prevalence The effect will be assessed in the frame of an upcoming 4. Findings empirical study. This section presents the results of the study on the level and quality of medical equipment in healthcare units, 2. Effects of a Smart pervasive screening system access to medical care for CVD, and the level of CVD on prevalence incidence in geographical regions with their associated The effect will be assessed in the frame of an upcoming impact factors and, in addition, the strategy for early empirical study. disease detection, prevention and awareness campaigns in the country. 3.4. Data analysis We did not, unlike past studies, make any difference between the different CVDs in the scope of this study. Table 1 summarizes the data analyses carried out. 4.1. Prevalence in geographical regions Table 1 Summary of the data analysis processes A total of 159 people out of 466 interviewed suffer from cardiovascular disease, 39% of whom are women and 61% of whom are men (Figure 2). The greatest proportions of participants suffering from the disease were recorded in Donga (70%), Plateau (70%), Atacora (63%) and Alibori (56%). On the other hand, the lowest proportions of participants suffering from the disease were recorded in the Ouémé (8.4%), Borgou (10.4%) and Littoral (20%) departments. The other departments have a significant proportion: 40.0% for Zou, 37.5% for Mono, 36.0% for Atlantique, 31.6% for Couffo, and 30.0% for Collines. The departments of Alibori and Atacora account for 27% and 25.2%, respectively, of the country's disease burden. The latter contribute more to the emergence of the disease in the country, while Zou's share of sufferers algorithms like decision trees, random forests, and in Benin is the lowest (1.3%). This share is not as neural networks. negligible for the other departments: 11.3% for One of the primary challenges in predicting CVD Atlantique, 9.4% for Littoral, 4.4% for Ouémé, 3.8% for prevalence is the quality and availability of data. Many Couffo and Mono, 3.1% for Borgou and 1.9% for predictive models rely on high-quality, longitudinal Collines. data, which may not be available in all regions. Elderly individuals (50+) are mostly affected by this Additionally, data discrepancies, especially in low- disease. People living in rural Benin are more affected. resource settings, can lead to inaccurate predictions. In Alibori, 65.1% of people are affected by the disease in Random forest aa supervised learning algorithm rural areas, compared with 30.2% in urban areas. The requesting a labeled data set where people are remaining 4.7% of the population represents the number diagnosed as suffering or not from CVDs was used. of people in Alibori whose place of residence is not Independent features included in the labeled data set specified. The rural areas of the Atacora department are 1) rate of the CVDs risk factors (12 levels), 2) medical accounted for 92.5% of the department's patients, equipment level of each medical unit (5 levels), level of compared with only 7.5% in urban areas. The other the accessibility to CVDs care (2 levels), level of the departments where rural areas broke the record were accessibility to prevention services or prescreening. Collines (66.7% vs. 33.3% in urban areas), Couffo (83.3% vs. 16.7% in urban areas), Donga (85.7% vs. 14.3% in 4.3. Medical equipment urban areas), Littoral (66.7% vs. 33.3% in urban areas), The level of medical equipment is determined by the Ouémé (57.1% vs. 42.9% in urban areas) and Plateau amount and quality of medical equipment, such as ECG (85.7% vs. 14.3% in urban areas). On the other hand, this devices (Figure 3). trend was reversed in the departments of Atlantique Blood pressure equipment is available in almost all (72.2% in urban areas vs. 27.8% in rural areas), Borgou health centers. The full range of diagnostic equipment (100% in urban areas) and Mono (66.7% in urban areas required for the proper management of patients vs. 33.3% in rural areas), where urban areas recorded a suffering from CVD is available only in the departments greater proportion than did rural areas. of Borgou, Littoral and Ouémé, which have special status in Benin. Level of Prevalence in geographical Using documentation on the organization of Benin's regions healthcare system and information from the National Health Development Plan (PNDS) and the 2018 edition 80,0 30,0 of the Health Statistics Yearbook and then exploited in 60,0 20,0 the context of this work, it was found that the 40,0 healthcare system is organized into several types of 20,0 10,0 health facilities (FS) for the care of populations. These 0,0 0,0 SFs can be categorized according to departments as Atlantiq… Alibori Atacora Borgou Couffo Donga Zou Littoral Mono Oueme Plateau Collines follows: Level of medical equiment in geographical Percentage of respondents suffering from regions the disease 100,0 Share of each department in the country in 80,0 Tensiome-ter Number of devices relation to the disease Figure 2: Prevalence level in each selected region 60,0 40,0 MAPA 4.2. Prediction of the prevalence Predictive analytics encompasses a variety of statistical 20,0 and machine learning techniques used to forecast future 0,0 Holtel outcomes based on historical data. In the context of CVDs, predictive models typically analyze patient data, including demographic, clinical, and lifestyle factors, to Regions predict the likelihood of developing cardiovascular Figure 3: Medical equipment in the different regions. conditions. These models range from traditional Most of the care units are poorly equipped. Tensimeter regression analyses to more complex machine learning is the main equipment available at these units. Table 2 summarizes the content Error! Reference source not found. and classifies the medical As summarized in Table 3, care units in Borgou, equipment. Littoral, and Ouémé are highly equipped and show a low cardiac disease incidence, while Atlantic and Mono Table 2 departments, which are equipped with almost all Medical equipment availability per department devices, show an average prevalence. The department of Zou, with average medical equipment, shows an average prevalence level. Moreover, Donga and Alibori, which have low levels of medical equipment, have a low prevalence. These results confirm that the level of prevalence is associated with the level of medical equipment and infrastructure in the region. However, even though the medical equipment available for the Department of Attacora* is like that available for the departments of Atlantique and Mono, it is highly prevalent. This could be explained by the fact that either 1. The existing medical equipment is defective. or 2. Qualified staff to use the equipment is missing, or 3. The population is visiting other closer care units in another neighboring department. For example, Atacora and Borgou are neighboring departments, and Borgou has a low incidence of CVDs. 4. People mostly use traditional medicine. Lassale C et al. stated in [5] that “The overall proportion (24%) shows that self­reported use of TM is common in patients with diagnosed hypertension and matches the literature with a mean prevalence of published studies in sub- Saharan Africa of 27%.” The case of the Department of Atacora revealed that the quality of medical equipment, the availability of qualified medical staff, and other factors are associated with the prevalence. In the department of Collines and Couffo, although it has very low-level medical equipment, it has an average prevalence. This could be explained by the fact that the medical staff regularly raise awareness at home The regional prevalence of CVDs revealed a with only the basic type of device (tension device) they discrepancy between geographical regions (Table 3). have or that there could be other causal factors that another study could identify. Table 3 Categorization of care units based on medical equipment 4.4. Early detection and screening programs The country lacks appropriate campaigns for raising public awareness. In 2021, USAID collaborated with the government through the National Program for the Prevention of Communicable Diseases (PNLMT). The partnership aims to launch digital technology in the Onchocerciasis Detection and Public Awareness  A total of 24.7% said they lived more than 5 km Campaign6. from the nearest health center. We found that the country has not implemented public awareness-raising campaigns for cardiovascular disease, and no early detection or prevention programs have been properly implemented. We deduce that University Hospitals (HUs), whether departmental or zone hospitals, are located within a radius of 40 km of the Faculties of Health Sciences (FSS) or medical schools. According to this categorization, most cardiology services are available in hospitals of classes 1, 2 and 3. Specialty services such as cardiology are mostly available only in hospitals of these classes. They are in urban areas, more specifically in the special- status towns of Cotonou (Littoral), Porto-Novo (Ouémé) and Parakou (Borgou). 4.5. Access to cardiological care According to these quantitative results, the major accessibility difficulties encountered by patients are poor road conditions, excessive loss of time in line, no time for consultations, and no money for the consultation. All these difficulties become minor in the departments of Borgou, Littoral and Ouémé. Figure 4 presents the different causes of poor access to healthcare services. Regarding patients' statements on difficulties accessing care (multiple-choice question), the survey Figure 4: Causes of poor care access. The main cause of results revealed the following: poor access to CVD care is the lack of care units at the residence place of the patients. Therefor, they face  Eighteen percent said they had no money to financial and economic issues to visit the next medical make regular trips to the hospital for clinical unit appointments.  A total of 26.2% said they had no money to pay 5. Analysis and Discussion for consultations or medical procedures on a regular basis. 5.1. Analysis  A total of 4.9% declared that they had mobility This section analyzes the results obtained above, with a problems for reasons of health or old age. This view to determining the extent to which improving the makes it difficult to reach the health center to technical platform for cardiology care using new maintain appointments. technologies could have an impact on the cardiac health  A total of 26.8% said they had no time to of affected populations, irrespective of their maintain regular clinic appointments. geographical and socioeconomic situation.  A total of 46.6% mentioned the difficulty of maintaining clinical appointments due to poor 5.1.1. One factor impact on the prevalence of road conditions. CVDs  A total of 24.7% said they lost too much time in 5.1.1.1. Impact of medical equipment on cardiac line with hospital consultations. disease incidence  Hypothesis testing 6 https://www.usaid.gov/benin/news/feb-14-2022- onchocerciasis-control-campaign-goes-digital-reach- millions-benin H1: The regional distribution of cardiovascular disease 5.1.1.2. Impact of cardiac disease prevention, shows a statistical relationship between the prevalence of screening programs, and the disease and the level and quality of medical equipment early detection on disease used for cardiology diagnosis and management, depending incidence on the region. H2: The incidence of cardiac disease is significantly related to early cardiovascular disease detection, prevention programs, and diseases awareness campaigns.  Hypothesis Testing While the khi-deux test carried out on the collected data reveals a weak relationship between the prevalence of CVDs in certain geographical regions (example Atacora) (p<10%), place of residence and suffering from the disease are significantly related (p<1%). Though, the hypothesis could be partially rejected since the statistical relationship between both elements is weak and seems to be affected by further factor(s). 5.1.2. Two factors impact on the prevalence of CVDs H3. The level of prevalence in geographical regions is statistically related to the level of population accessibility to early disease detection (prescreening), prevention programs and the number and quality of existing cardiology equipment in regional care units. All geographical regions severely lack pre- screening, prevention, and disease awareness campaigns. The analysis of variance (2-way ANOVA) shows that the prevalence of CVD in geographical regions depends on two independent factors. The analysis reveals high prevalences of CVD in regions The F test statistic (23.23057) is greater than the F with high levels of medical equipment but of poor critical (3.31583). Based on the test statistics, there is quality and benefiting from pre-screening campaigns sufficient evidence to reject the null hypothesis, and the (example of Attacora). P value of 8,04E-07 is less than the alpha α = 0.05. 5.2. Discussion  Rejection of the hypothesis The present study investigated the prevalence of CVDs The medical equipment level is not the sole factor in geographical regions and the statistical relationship impacting the regional disease incidence. The between CVD incidence and medical equipment. It departments of Coline and Couffo have a moderate further investigates factors (e.g., early disease detection disease prevalence, and their care units are less equipped and treatment) amplifying the effects of medical than the department of Attacora, which has a high equipment on the incidence of CVDs and additional disease prevalence (Table 2). factors, such as disease awareness raising campaigns, The high disease prevalence in Attacora could be which impact disease prevention and individuals’ health explained by the poor quality of medical equipment in lifestyle behaviors. its care units. However, why do the departments of The integration of AI and information technology in Colline and Couffo, which have poor medical CVD management holds immense promise, particularly equipment, have a moderate disease incidence, while in low-resource settings. AI-driven solutions can Atlantique and Mono, which have high medical enhance the accuracy of CVD risk assessments, improve equipment, have the same disease prevalence? patient outcomes through personalized interventions, and reduce healthcare costs by preventing costly complications. However, several challenges must be addressed to fully realize the potential of AI in this context. These include the need for high-quality data, robust infrastructure, and trained personnel to The results revealed that the full range of CVD medical implement and maintain AI systems. equipment is available only in the departments of Moreover, ethical considerations related to data Borgou, Littoral and Ouémé, which are in classes 1, 2, privacy and algorithmic bias must be carefully managed and 3, respectively. However, certain care units own the to ensure that AI-driven interventions are equitable and full range of medical equipment but are classified as do not exacerbate existing health disparities. Despite classes 2 and 3 because of the low amount of equipment these challenges, the potential benefits of AI in reducing in each category (Mapa, ECG device, etc.). This situation CVD prevalence are significant, particularly in regions not only disadvantages populations affected by like sub-Saharan Africa, where the burden of these cardiovascular disease and located in rural areas but also diseases is growing rapidly. reveals the uneven distribution of these services, thereby disadvantaging their geographical accessibility 5.2.1. Theoretical Contribution to care. The study highlighted four factors, namely, the level and According to the results and analysis, the regional quality of medical equipment, early disease detection, prevalence of CVD is associated with people’s place of disease prevention and health lifestyle behavior, and residence and the level and quality of medical disease awareness raising campaigns, as building blocks equipment, which supports early disease detection and impacting the regional prevalence level. Furthermore, treatment. Regions with low levels and/or low-quality the fourth building block, disease awareness raising CVD medical equipment are mostly affected by the campaigns, directly amplifies the effect of the third disease (with a high prevalence, we investigated the building block (diseases prevention). The level and incidence of CVDs in these regions to obtain a complete quality of medical equipment supports and impacts the picture of the issues). effect of the second building block (early disease Although urban regions are favored over rural detection and treatment). the level of the prevalence. regions, there is a difference between urban regions Figure 5Error! Reference source not found. shows (CHUD of Porto-Novo and CHD of Abomey; CHUZ of the theoretical model of the ecosystem for the Abomey Calavi and CHZ of Kandi); the same is true for prevalence of CVDs. rural regions. This could be explained by the uneven distribution of infrastructure and facilities for the diagnosis and management of specialty care, particularly for cardiovascular disease patients. According to Amidou A. Salmane (PNLMNT), in 2023, a public awareness raising campaign was rolled out in three departments, namely, Attacora, Donga, and Mono. The objectives of the campaign were as follows:  Raising disease awareness  Early detection of the disease  Increased involvement of healthcare professionals in  upgrading the technical platform (medical equipment) This campaign had a positive effect on the disease prevalence in these departments. A more in-depth analysis of the situation revealed that prevention, early detection, and public awareness campaigns combined with high-quality medical equipment impact the disease incidence. According to Amidou A. Salmane, the campaign failed to upgrade/improve the technical platform in Attacora. This fact explains why despite the pre-screening and prevention as well as diseases awareness campaign, Attacora is still showing a high Figure 5: Relationships between the number of building disease level, while the department of Zou shows a blocks and the level of regional prevalence middle level of prevalence. The departments of Colline and Couffo are thought  Level and quality of medical equipment to be less equipped but show a middle level of prevalence. They benefit from the high quality of the The relationship between early disease detection and existing medical equipment and local campaigns. disease prevention is well documented. We noted that prescreening individuals at high risk of NCDs impacts  Access to CVD care their health status (T. Edoh, 2018; T. Edoh et al., 2018).. Recent studies [37], [38], [39] have shown that early Studies [11], [12], [13], [35], [36] that we conducted from disease detection enhances disease prevention through early 2010 to 2017 to 2020 revealed poor access to health appropriate early medical treatment, which the present care services in Benin. These issues remain unclear, and study identified as a building block impacting the there is a slight need for improvement. This study prevalence of disease. focused on the level of access to CVD care. Enormous The results show that the country lacks early CVD difficulties remain in resolving the issue of affordability detection campaigns despite the presence of WHOPEN. regarding cardiological care. In addition to consultation However, the analysis revealed that the lack of early fees, patients face costs such as medical costs and disease detection campaigns is one of the factors transportation to care units. All these costs are some of affecting the regional prevalence level. Regional care the factors that impact access to CVD care. The units with high-quality medical equipment in their transportation costs increase when the patient needs to entirety have a low prevalence rate, and medical visit a remote care unit because the one closer to him or equipment supports care units in early disease detection her lacks appropriate medical equipment and/or procedures. adequate healthcare staff. Launching artificial intelligence-based noninvasive Table 4 summarizes the obstacles to adequate access pervasive disease prescreening could help to overcome to CVD care. the issues of poor medical equipment in certain regions and thus increase the rate of pervasive early detection of Table 4 Obstacles to accessing CVD care the disease. Mohammad Shafiquzzaman Bhuiyan et al. conducted their recent study [39] on the use of machine learning in the early detection of lung cancer by “… there's a positive development in using machine learning for early-stage detection, which proves highly effective in diagnosing this disease”.  Promising disease awareness campaigns The rationality of health perceptions depends on the social and educational values of individuals. Compared with illiterate people, well-educated people mostly self- educate about diseases and have greater health literacy [34], [40]. Educating people about disease increases their awareness level and empowers them to follow a healthy lifestyle[41], [42]. However, following a healthy lifestyle may positively impact the prevalence of diseases. However, the country has not implemented the WHOPEN initiative, and only sporadic awareness- raising campaigns have taken place at some institutions. The results and analysis have shown that the level and/or quality of medical equipment does not effectively impact the prevalence of diseases. Further factors that might co-impact the prevalence of disease have determined health literacy as an amplifier of the effect of medical equipment. However, disease awareness- raising campaigns should be considered building blocks to amplify the effects of medical equipment that supports early disease detection and treatment.  Predicting the regional prevalence of  Early disease detection and prevention CVDs The classifier with high sensibility identifies the diseases. Information technology plays a crucial role in prevalence of CVDs, ranking the independent features supporting these efforts, providing the infrastructure according to their importance to predict the prevalence and tools necessary to implement AI-driven solutions. of the disease. The rate of the risk factors is the most Future research should focus on overcoming the important feature. challenges associated with AI implementation and exploring new ways to harness the potential of AI in 5.2.2. Practical Contribution CVD management. The present study identified four building blocks that The study results reveal a discrepancy between the impact the incidence of CVDs in geographical regions. different regions of the country in terms of the Addressing these 4 levers simultaneously could prevalence of CVDs, where rural regions are more significantly reduce prevalence rates. severely affected by the disease than are urban regions or large cities. The different regional prevalences of 5.2.3. Implications for future research CVDs are impacted by the level and quality of medical equipment, and the early disease detection or Analysis from a computer sciences point of view prescreening of medical equipment could support and revealed a lack of information or health education increase awareness of the programs implemented in the material about CVDs to increase awareness about these region. However, early detection (prescreening) and diseases. The adoption of digital disease awareness- prevention programs are poorly implemented. Regions raising campaigns could assist in overcoming this gap are facing poor accessibility awareness-raising and enhancing people’s healthy lifestyle behaviors. 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