Entrevista

5.4.1

IMPLICATIONS FOR PRACTICE AND POLICY

The elderly, overweight/obese, non-educated and urban settlers present opportunities for targeted health promotion and preventive interventions in LMICs. Given the high burden of infectious diseases in these countries, it might be economically justified to implement intervention programs for hypertension in higher-risk populations alone. However, the occurrence of hypertension in the general population remains unacceptably high, which poses an ethical dilemma to relying on high-risk strategies only in these settings; countries in the Middle East and North Africa region may even not have sufficient evidence to implement public health interventions in certain high-risk populations such as the elderly.

Health inequalities associated with hypertension have been recognized as an important public health issue in low- and middle-income countries (Cappuccio et al.,

2004; Gupta et al., 2012; Jeemon et al., 2012). Addressing the wider social determinants of the disease is therefore crucial to its control in these countries. Failure to address these issues portends additional threats to the sustainability of public health infrastructure, especially alongside the prevailing effects of infectious disease epidemics. For instance, in countries such as Egypt, Senegal and Maldives, where education is protective against hypertension, resources, though limited, can be deployed more effectively to achieve a significant reduction in the proportions of adolescents and adults without formal education.

In countries where being employed was associated with hypertension (such as Albania, Armenia, Azerbaijan Ukraine, Uzbekistan, Egypt and Senegal), country-wide policies that ensure that employers of labour conform to international ethical standards in dealing with their employees must be enforced as a matter of public health in order to prevent job strain or other stressors that may be associated with hypertension and its complications.

The geographical variations of hypertension observed in Albania, Egypt and Lesotho will provide policy makers with information on how to allocate resources so that the

Page | 147 amount of attention given to the districts within these countries is directly proportional to the district prevalence of hypertension and the magnitudes of its associations with spatial and non-spatial factors. Policy makers and public health planners in LMICs may adopt the WHO global action plan targets (see Box 2) as a guide to tackling health disparities associated with hypertension at the district level. This is especially important within the contexts of other low- and middle-income countries where hypertension constitutes considerable economic burden (WHO, 2014b). Although, by definition, LMICs have a low GDP, which consequently reduces spending on health expenditure, however, considering that hypertension is associated with a much larger disability adjusted life years in LMICs, compared to high income countries, the cost-effective solution would be to prioritize government spending on health care over sectors of the economy that do not require urgent reforms. Interventions that could be useful for preventing hypertension in districts considered hotspots for hypertension are summarized in Table 5.1.

Population-wide strategies such as reduction in dietary salt intake from processed foods are warranted in these low-resource settings, because they have been proven to be cost-effective means to shift blood pressure distribution at the population level, thus reducing the burden of cardiovascular disease associated with the epidemic of hypertension (Agyemang et al., 2006; Duda et al., 2007; Erhun et al.,

2005; Kamadjeu et al., 2006; Kenge et al., 2007; Niakara et al., 2007). Specifically, population-wide salt reduction through legislation, voluntary agreements with food industries and mass media campaigns are evidence-based cost-effective strategies for reducing hypertension prevalence in low- and middle-income countries, potentially preventing millions of years lost to the disease as a result of ill-health, disability or premature death (Omuemu et al. 2007).

Overall, the findings could be useful for the design of screening and treatment programs for hypertension in low- and middle-income countries. Early screening and initial management in primary care centers is key to tackling the burden of hypertension in low- and middle-income countries. Given that doctor to patient ratios tend to be low in these countries, building the capacity of non-physician health workers (such as community health extension workers) on basic screening

Page | 148 procedures, initial management and timely referral to secondary or tertiary health facilities where necessary could be useful.

The use of home blood pressure monitors should be encouraged and taught to patients at first contact in primary care centers. Home-based blood pressure monitoring is considered to be as accurate a blood pressure measurement as ambulatory blood pressure monitoring (National Institute for Health and Care Excellence, 2011). Given the relatively high costs in low- and middle-income countries, home blood pressure monitors could be subsidized by the governments of these countries, or by international donor agencies.

Box 2: Voluntary targets of the WHO Global Action Plan.

a. 25% reduction in the prevalence of hypertension

b. A 25% relative reduction in risk of premature mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases.

c. At least 10%relative reduction in the harmful use of alcohol, as appropriate, within the national context.

d. A 10% relative reduction in prevalence of insufficient physical activity. e. A 30% relative reduction in mean population intake of salt/sodium.

f. A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years.

g. A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances. Halt the rise in diabetes and obesity.

h. At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes.

i. An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major non-communicable diseases in both public and private facilities.

Page | 149

Table 5.1: Interventions for prevention of hypertension in LMICs

Risk factor for hypertension Preventive measure

Unhealthy diet and physical activity  Creating enabling environments for population- based salt reduction strategies

 Implementing salt reduction and iodine fortification strategies

 Formulating strategies for monitoring and evaluating population sodium consumption and sources of sodium in diets

 Replacing trans-fat with polyunsaturated fat in diets

 Creating awareness among the population about the benefits of healthy diet and increased physical activity

Tobacco use  Increasing taxes on tobacco

 Banning tobacco advertisements, promotion, and sponsorships

 Smoke free legislation for public and work places should be enforced

 Disseminating information about the harmful effects of tobacco through health warnings on tobacco products

Harmful alcohol use  Increasing taxes on alcohol

 Restricting retail access to alcohol and alcoholic beverages

 Banning alcohol advertisements, promotion, and sponsorships

5.4.2

IMPLICATIONS FOR FUTURE RESEARCH

This research has provided a valuable platform to plan further investigations around the epidemiology and management of hypertension in low-and middle-income countries by laying a foundation for intensifying prevention efforts in those districts where hypertension is most burdensome, and investigating local drivers of hypertension within high-risk populations in these hotspots.

Page | 150 As highlighted in the limitations above, there was a paucity of information on other important variables such as social stress, job stain, physical activities, dietary patterns, sleep problems and medication adherence. Therefore, there is a need for more comprehensive country-specific data on hypertension and its determinants in low-and middle-income countries to account for the impact of these non-spatial factors on hypertension prevalence in low- and middle-income settings. Of note, the dearth of evidence on the social epidemiology of hypertension in low- and middle- income countries cannot be overemphasized. For instance, variations in social trust and violence and how they might drive hypertension prevalence within low- and middle-income countries remain largely unknown, even though these factors are highly pertinent in these countries.

In none of the studies or the datasets was ambulatory blood pressure measurement used to assess hypertension, even though ABPM represents the gold standard method for measuring blood pressure and diagnosing hypertension. More studies assessing hypertension using ABPM) are needed in low -and middle-income countries in order to ascertain the true prevalence of hypertension within study samples.

Finally, there is a need for studies to accurately predict future trends of hypertension prevalence estimates in low- and middle-income countries. For instance, national point prevalence surveys could provide a cost-effective approach for monitoring trends of hypertension prevalence in these countries.

Page | 151

CHAPTER SIX: CONCLUSIONS

This chapter summarises the important findings, while taking into account future plans for dissemination as well as reflection on the entire process involved with producing the thesis.