Sex differences in suicidal ideation among adults with hypertension in sub-Saharan Africa using multi-country WHO STEPS data

Hypertension carries a psychological as well as a cardiovascular burden, yet how sex and lifestyle behaviours relate to suicidal ideation among adults living with hypertension remains poorly characterised in sub-Saharan Africa. We examined sex-patterned correlates of suicidal ideation within routinely surveyed populations of hypertensive adults across three countries. We analysed cross-sectional WHO STEPS data from hypertensive adults in Malawi (2009), Zambia (2017), and Cabo Verde (2020) ( n = 4762). Unweighted logistic regression with country fixed effects and standard errors estimated the association between sex and 12-month suicidal ideation. Five lifestyle behaviours were examined as effect modifiers via interaction terms, and an exploratory effect-decomposition assessed whether physical activity lay on an indirect pathway. The prevalence of suicidal ideation was 6.4% among women and 3.7% among men. Women had approximately twice the odds of suicidal ideation compared to men (adjusted odds ratio [aOR] = 2.06; 95% confidence interval [CI] 1.45–2.92; p < 0.001). In exploratory interactions, harmful alcohol use showed a stronger association with suicidal ideation in women than in men, although this interaction did not survive correction for multiple testing. Physical activity did not constitute a meaningful indirect pathway in this cross-sectional sample. Within hypertensive populations in three sub-Saharan African countries, women consistently reported higher odds of suicidal ideation than men. These associational findings motivate, but do not by themselves justify, evaluating sex-responsive mental-health screening within chronic-disease care in prospective studies.