Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Philosophy (Ph.D.)


Community Health and Social Sciences


Sandra Echeverria

Committee Members

Elizabeth Kelvin

Terry Huang

Gavin George

Subject Categories

Cardiovascular Diseases | International Public Health | Public Health


Sub-saharan Africa; Mobile populations; Chronic health condition; Health care utilization; HIV


Background: Much of public health research in sub-Saharan Africa on mobile occupations, such as truck drivers and sex workers, has focused on HIV risk. However, evidence is emerging to suggest that the HIV epidemic among these groups is coupled with a high prevalence of chronic health conditions (CHC), specifically hypertension, diabetes, and obesity. For people living with HIV, increased risk of CHC may also be linked to HIV-related chronic inflammatory cascade. In Africa, there has been little research on CHC risk factors or patterns of healthcare utilization among mobile populations. Therefore, the objectives of this study are to examine the burden of CHC (hypertension and overweight status) among those in mobile groups, assess the relationship between HIV testing and screening of CHC (hypertension and diabetes), and investigate patterns of healthcare utilization in a cross-country network of clinics using electronic health records.

Methods: We used data from the electronic health record (EHR) system of the North Star Alliance, a non-governmental organization that runs a network of clinics in Eastern and Southern Africa. In Aim 1, we estimated prevalence ratios (PR) for hypertension (n=86,904) and overweight status (n=62,048) comparing truckers, sex workers and community residents and assessed joint effects with HIV status. Aim 2 (n=355,904) examined if HIV testing services were associated with screening for CHC (hypertension and diabetes). In our final study (Aim 3), we compared service utilization among mobile and non-mobile groups (n=267,425), specifically examining number of clinics visits (Incident Risk Ratio (IRR)), and estimating the PR for visiting multiple clinics, and clinics in different countries, and then examined joint effects including HIV status.

Results: In Aim 1, truckers had an increased probability of hypertension and overweight status relative to community residents. HIV-positive community residents had a lower probability of hypertension and overweight compared to HIV-negative community residents. HIV-negative truckers had a higher prevalence of hypertension and overweight and all sex workers, regardless of HIV status, had a lower prevalence of hypertension. Patients that were tested for HIV were less likely to have been screened for CHC than those who were not tested (Aim 2). Finally, in Aim 3, the number of clinic visits (IRR) was comparable among all groups, and population mobility was positively associated with use of services in multiple clinics, and mobile populations and community residents that were HIV-positive were more likely to use cross-country services.

Discussion: Findings suggest that mobile populations have a higher burden of CHC compared to non-mobile groups and HIV-negative truck drivers were more likely to have been diagnosed with CHC than all other population and HIV status groups. We found that screening for CHC was less likely among patients that were HIV tested, suggesting that HIV prevention and other healthcare services are still siloed. Mobile groups and community residents that were HIV-positive were also more likely to leverage services at multiple clinics and in different countries. Future research should explore specific work-related activities that impact the development of chronic health conditions in the context of HIV in Africa, and the potential to integrate HIV prevention services with screening for CHC. Further research is also needed to understand why HIV-positive community residents seek care in different clinics and countries, and how mobility or HIV-related stigma may shape health seeking behavior.

Available for download on Sunday, December 18, 2022