The determinants and scope of public health interventions to tackle the global problem of hypertension.

BACKGROUND: Hypertension is a significant public health concern of world-wide distribution and is also the most common cardiovascular disease risk factor. Adequate control of blood pressure is a critical element in the prevention of hypertension induced-organ damage and life-threatening complications. Prevention of hypertension is possible and early detection and effective treatment can significantly reduce the incidence of adverse clinical outcomes.
METHODS: An extensive search of all materials related to the topic was carried out in PubMed, Medline, World Health Organization website and Google Scholar search engines. Keywords used in the search included hypertension, cardiovascular disease, public health, life-style modifications and awareness. Overall 51 articles were selected and analyzed.
RESULTS: Multiple socio-demographic and potential risk factors have been recognized in the causation and determining the long-term outcomes of the disease world-wide. As the natural history of hypertension is complex and etiology is multi-factorial the strategy to combat also should be multi-pronged based on the trends and magnitude of the disease in variable settings.
CONCLUSIONS: To conclude, although progress has been observed in the area of awareness, treatment and control, the need continues to be high for sustainable and cost-effective interventions that will ultimately halt and reverse the rising tide of hypertension prevalence. Population-based health education, dietary and life-style modification and pharmacological therapy are all effective measures to reduce the prevalence and increase the control rate of hypertension.

INTRODUCTION

Cardiovascular diseases are caused due to abnormalities in the heart and blood vessels and mainly comprise of conditions such as coronary heart disease, stroke, hypertension, peripheral vascular disease, rheumatic heart disease and heart failure.[1] Recent global trends reveal that the incidence of coronary heart disease has gradually decreased in most of the developed nations, but the scenario remains quite grim in developing nations that account for more than 60% of the global burden.[2]

Hypertension is a significant public health concern of world-wide distribution and is also the most common cardiovascular disease risk factor.[3] According to the World Health Organization (WHO), recent estimates show that hypertension affects more than a third of adults aged 25 and above, accounting for about a billion people world-wide and contributes to nearly 9.4 million deaths from cardiovascular diseases each year.[4] It is responsible for causation of 50% of coronary heart disease and almost two-thirds of strokes.[56] Further, it has been estimated that by the year 2030, 23 million cardiovascular deaths are projected to be due to hypertension, of which about 85% cases will be from low-resource settings and developing nations.[4]

Poorly managed hypertension results in a wide gamut of complications varying from atherosclerosis, damage to coronary arteries/heart/kidneys/visual system, heart failure, disability, poor quality of life and eventually death.[2789] Adequate control of blood pressure is a critical element in the prevention of hypertension-induced-organ damage and life-threatening complications. Prevention of hypertension is possible and early detection and effective treatment can significantly reduce the incidence of adverse clinical outcomes.[10111213] Thus implementation of effective primary and secondary prevention measures should be the most important goals in planning of health policy measures.[14]

General objective

The objective of the following study is to explore the magnitude of hypertension and its related complications world-wide.

Specific objectives

To identify the socio-demographic determinants and personal lifestyle related factors that can be attributed to the same.

To suggest feasible, cost-effective community-based and individual measures which, if implemented strategically, will reduce the burden of the disease.

METHODS

An extensive search of all materials related to the topic was carried out for the initial 15 days of October month in PubMed, Medline, WHO website and Google Scholar search engines. Relevant documents, reports, research articles focusing on the awareness, potential risk factors/determinants of hypertension and measures to combat the same published in the period 1997-2013 were included in the review.

Selection of studies

A total of 62 studies similar to current study objectives were identified initially, of which, 11 were excluded on account of irrelevance to the present study and due to the unavailability of the complete version of the articles. Overall 51 articles were selected based upon the suitability with the current review objectives and analyzed. A summary of articles with titles and various designs is shown in the Table 1. These identified articles were then re-grouped into different sections namely determinants, risk factors and factors hampering the utilization of health care services; Suggested interventions; Implications for practice and implications for research. Keywords used in the search include hypertension, cardiovascular disease, public health, life-style modifications and awareness.

Table 1

Some of the investigated studies in present article

RESULTS

Hypertension: Determinants, risk factors and factors hampering the utilization of health care services

Multiple socio-demographic and potential risk factors such as older age;[151617] male gender;[11819] poor educational status;[162021] income;[15] socioeconomic status;[2223] race;[24] ethnic differences;[25] role of heredity and genetics;[2627] urban-rural areas disparity;[3] urbanization;[25] poor awareness among the general population about the risk factors and compliance to treatment;[2829] presence of co-existing diseases like diabetes mellitus;[15162230] stress;[31] obesity/overweight/increased body mass index and waist circumference/hypercholesterolemia;[16293233] dietary practices and more consumption of saturated fats;[343536] excessive salt consumption;[373839] alcohol;[3540] tobacco;[4142] physical inactivity;[43] not undergoing regular screening activities;[44] lack of trust on physicians;[26] improper and incomplete management of hypertension;[29] poor health care seeking behavior;[4546] and perceived barriers among people at community level such as limited resources – availability of trained manpower, access to the health system/cultural expectations and values;[474849] have been recognized in the causation and determining the long-term outcomes of the disease worldwide.

Suggested interventions

Although hypertension is a preventable condition, the asymptomatic nature of this disease renders it under-diagnosed and consequently undertreated, despite its very high prevalence. As the natural history of hypertension is complex and its etiology being multi-factorial, the strategy to combat it also should be multi-pronged based on the trends and magnitude of the disease in variable settings.[1] The need of the hour is to formulate a comprehensive and integrated approach to facilitate early detection in both high risk and the general population and thus minimize the incidence of complications.[50] Implementation of other measures such as improving the socioeconomic/literacy status;[162023] creating an enabling environment for increasing awareness of community about risk factors;[2829] encouraging adults to get tested for blood pressure;[1] advocating regular screening activities;[44] developing community-based interventions and strategies as a part of primary prevention measures;[147485051] secondary prevention and targeted interventions towards high-risk groups;[29] facilitating active involvement of health workers;[1] orienting private practitioners through a health professional education program;[5253] fostering early detection of clinical cases and timely implementation of cost-effective secondary prevention measures to prevent long-term complications;[315152] involving voluntary organizations and multiple sectors;[52] encouraging consumption of a diet rich in fruits, vegetables, tubers and legumes;[34] advocating lifestyle modification measures like weight control, increased physical activity, limited alcohol intake, no tobacco use, and reduced dietary saturated fat and salt intake;[1135374054] universal adoption of WHO cardiovascular risk prediction charts;[50] and therapeutic administration of bioactive natural constituents obtained from food sources;[55] can be strategically planned according to the particular setting and prevailing cultural perceptions. The above suggested measures can be implemented in a comprehensive, yet flexible manner for the benefit of both the general population and those in high-risk group.

Implications for practice

The findings of the current review clearly reflect the necessity for a comprehensive national program for non-communicable diseases well backed by intensive health awareness campaigns to spread information about the potential risk factors and the sequel of inadequately managed cases of hypertension. Specific guidelines should be formulated and implemented for management of hypertensive patients depending on their blood pressure levels. All the physicians from the public health sector and the private sector including practitioners from other disciplines who are treating hypertensive patients should be trained in the appropriate and adequate management of hypertension. The outreach health workers should also be trained and empowered in different aspects of life-style modifications with special emphasis on the conceptual understanding of each of them so that they can spread the message to each and every household during their routine home visits. Strong political will is desired for establishing a network between of international agencies and national agencies for to ensuring ensure external supervision and monitoring.

Implications for research

The need of the hour is to deepen community-based qualitative and quantitative studies to further estimate the level of awareness, knowledge and practices among the general population regarding potential risk factors and importance of life-style modifications in different settings. In each of such studies a conscious attempt should be made by the researchers to identify the perceived gaps or the barriers that are restricting community members from availing routine screening services. Research should also be conducted to explore the role of dietary factors and physical inactivity in the causation of hypertension. This has to be followed-up with designing of a comprehensive diet and exercise schedules for people with different needs.

CONCLUSIONS

Although progress has been observed in the area of awareness, treatment and control, the need continues to be high for sustainable and cost-effective interventions that will ultimately halt and reverse the rising tide of hypertension prevalence. Population-based health education, dietary and life-style modification and pharmacological therapy are all effective measures to reduce the prevalence and increase the control rate of hypertension. Government should advocate the implementation of comprehensive strategies for raising awareness about potential risk factors in the general population, maintaining optimal body weight, dietary modifications, abstaining from smoking and drinking and implementing aggressive antihypertensive interventions in the elderly.