General practitioners' approach to hypertension in urban Pakistan: disturbing trends in practice

Assessment of knowledge and perception of prescribers towards rational medicine use in the Ashanti Region of Ghana

BACKGROUND

Prescribers must possess extensive knowledge and maintain a positive attitude towards the rational use of medicines to achieve desirable treatment outcomes and effectively prevent treatment failures, increased costs, drug toxicities, and interactions. The objective of this study was to evaluate prescribers' understanding and perception concerning the rational use of medicines in public hospitals. Additionally, the study aimed to identify the factors that influence rational prescribing practices.

METHODS

A structured data instrument was developed to collect demographic data and evaluate participants' knowledge and perception of rational medicine use, in line with the study objectives. Chi-squared statistics and Fisher's exact test were utilized to identify factors associated with good knowledge and perception among participants. Logistic regression was then employed to assess the strength of the associations, with odd ratios reported at a significant level of 0.05.

RESULTS

Out of 192 participants, 85.4% held a positive view of rational medicine use, stressing patient safety and recognizing risks like antimicrobial resistance and polypharmacy. Perception was influenced by factors such as prescriber profession, access to references, and drug bulletin updates. Additionally, 65.6% demonstrated good knowledge of rational medicine use, which was notably influenced by factors like using standard prescribing guidelines, having a functional Drug and Therapeutics Committee, prescriber profession, and the frequency of drug bulletin updates.

CONCLUSION

The study emphasizes the critical need to address knowledge gaps among healthcare professionals, especially nurses and other prescribers, to ensure the safe and effective use of medications. It highlights the positive influence of utilizing preferred prescribing references and the existence of functional Drug and Therapeutics Committees in hospitals on knowledge levels. However, the unexpected findings regarding the limited impact of frequent updates of drug bulletins require further investigation.

Addressing global disparities in blood pressure control: perspectives of the International Society of Hypertension

ABSTRACT

Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.

Prescribing Patterns of Antihypertensive Medications in Low- and Middle-Income Countries: A Systematic Review

Hypertension is highly prevalent, but its pharmacological management has not been well evaluated in low- and middle-income countries (LMICs). This review examined the prescribing patterns of antihypertensives in LMICs. Data were extracted from a total of 26 studies spanning the time period 2000 to 2018. In 10 studies, calcium channel blockers (CCBs) were the most frequently prescribed medication for managing hypertension (range = 33% to 72%); in six studies, renin angiotensin system (RAS) blockers (range = 25% to 83%); in five studies, diuretics (range = 39% to 99%); and in five studies, β-blockers (BBs; range = 26% to 49%) were the most commonly prescribed antihypertensive medications. Prescribing sedatives and sublingual administration of captopril for controlling hypertension was also reported in 3 studies. Only 10 studies presented their findings in light of national or international guidelines. This review calls for further antihypertensive utilization and dispensation studies and a better understanding of clinician's perception and practice of hypertension management guidelines in LMICs.

How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review

Background

We systematically reviewed the evidence on how primary healthcare workers obtain information during consultations to support decision-making for prescribing in low and lower middle-income countries.

Methods

We searched electronic databases, consulted the Healthcare Information For All network, hand searched reference lists, ran citation searches of included studies and emailed authors of identified papers. Two reviewers extracted data and appraised quality with relevant tools.

Results

Of 60 497 records found, 23 studies met our inclusion criteria. Fourteen studies were observational and nine were interventional. Frequently mentioned sources of information were books, leaflets, guidelines, aids and the internet. These sources were sometimes out of date and health workers reported being confused which to use. Internet access varied and even when it was available, use was limited by technical issues. Of the five electronic tools that were assessed, four had positive outcomes. Tools assisted prescribers with medicine selection and dosage calculations, which increased prescribing accuracy. The quality of reporting varied but was overall low.

Discussion

Studies indicated a lack of up-to-date and relevant medicine information in low and lower middle-income settings. Internet-based sources appeared to be useful when it is possible to download content for offline use and to update when there is internet access. Electronic tools showed promise, but their accuracy needs to be validated and they should focus on giving actionable advice to guide prescribers.

PROSPERO registration number

CRD42018091088.

How do primary healthcare workers in low-income and middle-income countries obtain information during consultations to aid safe prescribing? A systematic review protocol

INTRODUCTION

There is a wide variety in prescribing by primary healthcare workers in low-income and middle-income countries. While there is much information available, both online and offline, there is variation in quality and relevance to different settings. Acting on incorrect or out-of-date information can lead to inappropriate prescribing and impact on patient safety. The aim of this review is to systematically review the evidence on how primary healthcare workers obtain information during consultations to prescribe safely and appropriately.

METHODS AND ANALYSIS

We will identify relevant articles by searching electronic databases: Medline (Ovid), EMBASE (Ovid), Cochrane Central Register of Controlled Trials, CABI Global Health (Ovid), WHO global health library, POPLINE, Africa-Wide Information (Ebsco), Library, Information Science & Technology Abstracts (Ebsco), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform. Also, the Health Information For All network will be consulted and evidence databases (TRIP database, Epistemonikos, PDQ Evidence) will be searched. We will hand-search reference lists, run citation searches of included studies and email authors of identified papers. Observational and intervention studies involving primary healthcare workers in low-income and middle-income countries who prescribe and/or dispense medication will be included. The primary outcome is the proportion of healthcare workers obtaining information relevant to consultations from different sources. Secondary outcomes are the change in healthcare provider and patient knowledge or behaviour, adverse outcomes and use of resources. We will exclude studies focusing on secondary care. We anticipate a limited scope for meta-analysis and will provide a narrative overview of findings and tabular summaries of extracted data.

ETHICS AND DISSEMINATION

No ethics approval is required. Findings will be disseminated through the Healthcare Information For All network.

PROSPERO REGISTRATION NUMBER

CRD42018091088.

Physicians' knowledge, attitudes, and practice for hypertension management: A cross-sectional study in Hormozgan province, Iran

BACKGROUND

Hypertension is a common risk factor for developing cardiovascular, brain, and kidney disorders; and today, it affects about one billion people worldwide. Insufficient clinical knowledge of the practitioners and family physicians and not following the guidelines has led to the improper control of hypertension. This study intended to investigate the knowledge, attitude, and practice of general practitioners (GPs) about hypertension in Hormozgan province, Iran.

METHODS

This cross-sectional study used consecutive sampling method. A three-part researcher-made questionnaire was used to collect data on demographic, attitude, knowledge, and practice information from 220 GPs working in Hormozgan province.

RESULTS

The mean and standard deviation (SD) of scores on knowledge, practice, and attitude of GPs about hypertension management were (5.00 ± 0.50), (10.00 ± 0.02) and (9.00 ± 0.15), respectively; which present a proper state. Attending training courses and increased work experience have statistically significant effects on the knowledge and attitude of GPs (P < 0.050). The only exception was the area of practice, where there was no significant relationship between the practitioners’ work experience and their practice (P = 0.266).

CONCLUSION

The results of this study can be utilized by decision-makers and general medicine curriculum designers to plan effective training courses for medical graduates to be used in clinical settings for health promotions.

Doctors' Knowledge of Hypertension Guidelines Recommendations Reflected in Their Practice

Aim

To evaluate doctors' knowledge, attitude, and practices and predictors of adherence to Malaysian hypertension guidelines (CPG 2008).

Methods

Twenty-six doctors involved in hypertension management at Penang General Hospital were enrolled in a cross-sectional study. Doctors' knowledge and attitudes towards guidelines were evaluated through a self-administered questionnaire. Their practices were evaluated by noting their prescriptions written to 520 established hypertensive outpatients (20 prescriptions/doctor). SPSS 17 was used for data analysis.

Results

Nineteen doctors (73.07%) had adequate knowledge of guidelines. Specialists and consultants had significantly better knowledge about guidelines' recommendations. Doctors were positive towards guidelines with mean attitude score of 23.15 ± 1.34 points on a 30-point scale. The median number of guidelines compliant prescriptions was 13 (range 5–20). Statistically significant correlation (r_s = 0.635, P < 0.001) was observed between doctors' knowledge and practice scores. A total of 349 (67.1%) prescriptions written were guidelines compliant. In multivariate analysis hypertension clinic (OR = 0.398, P = 0.008), left ventricular hypertrophy (OR = 0.091, P = 0.001) and heart failure (OR = 1.923, P = 0.039) were significantly associated with guidelines adherence.

Conclusion

Doctors' knowledge of guidelines is reflected in their practice. The gap between guidelines recommendations and practice was seen in the pharmacotherapy of uncomplicated hypertension and hypertension with left ventricular hypertrophy, renal disease, and diabetes mellitus.

Awareness of hypertension guidelines and the diagnosis and evaluation of hypertension by primary care physicians in Nigeria

BACKGROUND

The availability of numerous hypertension guidelines seems not to have impacted significantly on the burden of hypertension. We evaluated awareness of hypertension guidelines among primary-care physicians (PCPs) in Nigeria and its relationship to hypertension diagnosis and work up.

METHODS

Anonymous self-administered questionnaires were filled in by PCPs categorised into two groups: hypertension guideline aware (GA) and unaware (GU).

RESULTS

The 403 participating PCPs had a mean age and experience of 40 ± 11.34 and 14 ± 11.10 years, respectively, with 46.7% (n = 188) of them being GA. Out of the 19 questions assessed, GA and GU PCPs performed better in seven and two questions, respectively, while the two subgroups had a similar performance in 10 questions. The performance of the PCPs in government and private practice was similar.

CONCLUSIONS

There is a gap between guideline recommendations and hypertension care in Nigeria that is further widened by PCPs' unawareness of the guidelines. Popularising hypertension guidelines among PCPs may significantly improve hypertension care and reduce the burden of disease.

Multicomponent intervention versus usual care for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: study protocol for a cluster randomized controlled trial

BACKGROUND

High blood pressure (BP) is the leading attributable risk for cardiovascular disease (CVD). In rural South Asia, hypertension continues to be a significant public health issue with sub-optimal BP control rates. The goal of the trial is to compare a multicomponent intervention (MCI) to usual care to evaluate the effectiveness and cost-effectiveness of the MCI for lowering BP among adults with hypertension in rural communities in Bangladesh, Pakistan and Sri Lanka.

METHODS/DESIGN

This study is a stratified, cluster randomized controlled trial with a qualitative component for evaluation of processes and stakeholder feedback. The MCI has five components: (1) home health education by government community health workers (CHWs), (2) BP monitoring and stepped-up referral to a trained general practitioner using a checklist, (3) training public and private providers in management of hypertension and using a checklist, (4) designating hypertension triage counter and hypertension care coordinators in government clinics and (5) a financing model to compensate for additional health services and provide subsidies to low income individuals with poorly controlled hypertension. Usual care will comprise existing services in the community without any additional training. The trial will be conducted on 2550 individuals aged ≥40 years with hypertension (with systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, based on the mean of the last two of three measurements from two separate days, or on antihypertensive therapy) in 30 rural communities in Bangladesh, Pakistan and Sri Lanka. The primary outcome is change in systolic BP from baseline to follow-up at 24 months post-randomization. The incremental cost of MCI per CVD disability-adjusted life years averted will be computed. Stakeholders including policy makers, provincial- and district-level coordinators of relevant programmes, physicians, CHWs, key community leaders, hypertensive individuals and family members in the identified clusters will be interviewed.

DISCUSSION

The study will provide evidence of the effectiveness and cost-effectiveness of MCI strategies for BP control compared to usual care in the rural public health infrastructure in South Asian countries. If shown to be successful, MCI may be a long-term sustainable strategy for tackling the rising rates of CVD in low resourced countries.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02657746 . Registered on 14 January 2016.

Management of arterial hypertension in Cotonou city, Benin: general practitioners' knowledge, attitudes and practice

OBJECTIVE

We aimed to assess the management of hypertensive patients by general practitioners in Cotonou city.

METHODS

This was a cross-sectional study based on a multicentre survey conducted from 1 May to 31 July 2011. We recruited all consenting general practitioners who worked in public and private centres in Cotonou city. We used the 7th report of the Joint National Committee to assess the management of hypertension by general practitioners. A tested and validated self-questionnaire was used to collect the data on hypertension management by general practitioners.

RESULTS

In eight centres that approved the study, 41 general practitioners were included. The definition of hypertension was known by 20 (48.8%) practitioners. Only 25 (61.0%) could describe the conditions for blood pressure measurement. Ten of them were unable to list half of the minimum recommended tests for hypertension, and the majority (92.7%) did not have any idea of global cardiovascular risk. The blood pressure goal was known by only 18 (43.9%) practitioners. Lifestyle (82.9%) and monotherapy (70.7%) were the therapeutic modalities most prescribed. Antihypertensive agents commonly used by practitioners were calcium channel blockers (82.9%), angiotensin converting enzyme inhibitors (53.7%) and diuretics (36.6%). The general practitioners referred their patients to cardiologists mainly for uncontrolled hypertension (63.4%) and the onset of acute complications (56.1%).

CONCLUSION

The general practitioners' knowledge of hypertension was insufficient and their management did not reflect international guidelines.

Information needs of Botswana health care workers and perceptions of wikipedia

BACKGROUND

Since the UN Human Rights Council's recognition on the subject in 2011, the right to access the Internet and information is now considered one of the most basic human rights of global citizens [1,2]. Despite this, an information gap between developed and resource-limited countries remains, and there is scant research on actual information needs of workers themselves. The Republic of Botswana represents a fertile ground to address existing gaps in research, policy, and practice, due to its demonstrated gap in access to information and specialists among rural health care workers (HCWs), burgeoning mHealth capacity, and a timely offer from Orange Telecommunications to access Wikipedia for free on mobile platforms for Botswana subscribers.

OBJECTIVES

In this study, we sought to identify clinical information needs of HCWs of Botswana and their perception of Wikipedia as a clinical tool.

METHODS

Twenty-eight facilitated focus groups, consisting of 113 HCWs of various cadres based at district hospitals, clinics, and health posts around Botswana, were employed. Transcription and thematic analysis were performed for those groups.

RESULTS

Access to the Internet is limited at most facilities. Most HCWs placed high importance upon using Botswana Ministry of Health (MoH) resources for obtaining credible clinical information. However, the clinical applicability of these materials was limited due to discrepancies amongst sources, potentially outdated information, and poor optimization for time-sensitive circumstances. As a result, HCWs faced challenges, such as loss of patient trust and compromises in patient care. Potential solutions posed by HCWs to address these issues included: multifaceted improvements in Internet infrastructure, access to up-to-date information, transfer of knowledge from MoH to HCW, and improving content and applicability of currently available information. Topics of clinical information needs were broad and encompassed: HIV, TB (Tuberculosis), OB/GYN (Obstetrics and Gynecology), and Pediatrics. HCW attitudes towards Wikipedia were variable; some trusted Wikipedia as a reliable point of care information resource whereas others thought that its use should be restricted and monitored by the MoH.

CONCLUSIONS

There is a demonstrated need for accessible, reliable, and up-to-date information to aid clinical practice in Botswana. Attitudes towards Wikipedia as an open information resource tool are at best, split. Therefore, future studies are necessary to determine the accuracy, currency, and relevancy of Wikipedia articles on the health topics identified by health care workers as areas of information need. More broadly speaking, future efforts should be dedicated to configure a quality-controlled, readily accessible mobile platform based clinical information application tool fitting for Botswana.

Undiagnosed and uncontrolled hypertension among the adults in rural Bangladesh: findings from a community-based study

OBJECTIVES

This article reports the prevalence and prediction factors of undiagnosed and uncontrolled hypertension among the adults in rural Bangladesh.

METHODS

A cross-sectional study of the major noncommunicable disease risk factors was conducted in rural surveillance sites of Bangladesh in 2005. In addition to the self-report questions on risk factors, height, weight, and blood pressure were measured using standard protocols of the WHO STEPwise approach to Surveillance. Undiagnosed hypertension was defined when people reported no hypertension but were found hypertensive when measured, and uncontrolled hypertension was defined when people reported receiving antihypertensive treatment but their blood pressure was above the normal range when measured.

RESULTS

The prevalence of undiagnosed hypertension was 11.1%, increasing with age to 22.7% among those aged 60 years and above. Among the hypertensive patients receiving treatment, 54.9% were found to be uncontrolled (34.5% among 25-39 years and 67.9% among 60+ years). Increasing age and higher BMI were significantly positively associated with undiagnosed hypertension in multivariate analysis. Increasing age and more wealth have significant independent association with uncontrolled hypertension.

CONCLUSION

High prevalence of undiagnosed hypertension, and more than 50% of the treated hypertension being uncontrolled puts a great challenge ahead for Bangladesh, a resource-poor setting. Regular health check or health screening along with implementation of hypertensive guidelines should be reinforced.

The approach of general practitioners in Lagos to the detection and evaluation of hypertension

INTRODUCTION

Hypertension (HTN) control is a major public health and clinical challenge. A number of guidelines exist globally to assist in tackling this challenge. The aim of this study was to determine conformity of the HTN detection and evaluation practices of a sample of Lagos-based general practitioners (GPs) to international guidelines.

METHODS

Self-administered structured questionnaires were used to collect data from a cohort of GPs attending continuing medical education programs in Lagos.

RESULTS

Out of the 460 GPs that were approached, 435 agreed to participate in the study, with questionnaires from 403 GPs analyzed. The average age and number of years post-registration of the GPs were 40.0 ± 11.3 years and 14.3 ± 11.1 years, respectively. Two thirds (n = 269) were in private practice. Their daily average total and HTN patients' loads were 17.4 ± 14.3 and 4.4 ± 3.5, respectively. Awareness of HTN guidelines was 46.7% (n = 188), while 18.1% (n = 73) was able to name one or more HTN guidelines. The approaches of these GPs to the detection and evaluation of HTN and their relationships to the GPs' experience were heterogeneous.

DISCUSSION

The approach of the GPs to detection and evaluation of HTN though heterogeneous is unsatisfactory and may partly contribute to poor HTN control in Nigeria. Strengthening the capacity of GPs in this regard through continuous medical education may greatly improve HTN control.

International dissemination of evidence-based practice, open access and the IACAPAP textbook of child and adolescent mental health

Dramatic changes have occurred in both publishing and teaching in the last 20 years stemming from the digital and Internet revolutions. Such changes are likely to grow exponentially in the near future aided by the trend to open access publishing. This revolution has challenged traditional publishing and teaching methods that-largely but not exclusively due to cost-are particularly relevant to professionals in low and middle income countries. The digital medium and the Internet offer boundless opportunities for teaching and training to people in disadvantaged regions. This article describes the development of the IACAPAP eTextbook of child and adolescent mental health, its use, accessibility, and potential impact on the international dissemination of evidence-based practice.

Control of Blood Pressure and Risk Attenuation: Post Trial Follow-Up of Randomized Groups

Background

Evidence on long term effectiveness of public health strategies for lowering blood pressure (BP) is scarce. In the Control of Blood Pressure and Risk Attenuation (COBRA) Trial, a 2 x 2 factorial, cluster randomized controlled trial, the combined home health education (HHE) and trained general practitioner (GP) intervention delivered over 2 years was more effective than no intervention (usual care) in lowering systolic BP among adults with hypertension in urban Pakistan. However, it was not clear whether the effect would be sustained after the cessation of intervention. We conducted 7 years follow-up inclusive of 5 years of post intervention period of COBRA trial participants to assess the effectiveness of the interventions on BP during extended follow-up.

Methods

A total of 1341 individuals 40 years or older with hypertension (systolic BP 140 mm Hg or greater, diastolic BP 90 mm Hg or greater, or already receiving treatment) were followed by trained research staff masked to randomization status. BP was measured thrice with a calibrated automated device (Omron HEM-737 IntelliSense) in the sitting position after 5 minutes of rest. BP measurements were repeated after two weeks. Generalized estimating equations (GEE) were used to analyze the primary outcome of change in systolic BP from baseline to 7- year follow-up. The multivariable model was adjusted for clustering, age at baseline, sex, baseline systolic and diastolic BP, and presence of diabetes.

Findings

After 7 years of follow-up, systolic BP levels among those randomised to combined HHE plus trained GP intervention were significantly lower (2.1 [4.1–0.1] mm Hg) compared to those randomised to usual care, (P = 0.04). Participants receiving the combined intervention compared to usual care had a greater reduction in LDL-cholesterol (2.7 [4.8 to 0.6] mg/dl.

Conclusions

The benefit in systolic BP reduction observed in the original cohort assigned to the combined intervention was attenuated but still evident at 7- year follow-up. These findings highlight the potential for scaling-up simple strategies for cardiovascular risk reduction in low- and middle- income countries.

Trial Registration

ClinicalTrials.gov NCT00327574

Current trends in treatment of hypertension in Karachi and cost minimization possibilities

OBJECTIVE

This study finds out drug usage trends in Stage I Hypertensive Patients without any compelling indications in Karachi, deviations of current practices from evidence based antihypertensive therapeutic guidelines and looks for cost minimization opportunities.

METHODS

In the present study conducted during June 2012 to August 2012, two sets were used. Randomized stratified independent surveys were conducted in doctors and general population - including patients, using pretested questionnaires. Sample sizes for doctors and general population were 100 and 400 respectively. Statistical analysis was conducted on Statistical Package for Social Science (SPSS). Financial impact was also analyzed.

RESULTS

On the basis of patients' doctors' feedback, Beta Blockers, and Angiotensin Converting Enzyme Inhibitors were used more frequently than other drugs. Thiazides and low-priced generics were hardly prescribed. Beta blockers were prescribed widely and considered cost effective. This trend increases cost by two to ten times.

CONCLUSION

Feedbacks showed that therapeutic guidelines were not followed by the doctors practicing in the community and hospitals in Karachi. Thiazide diuretics were hardly used. Beta blockers were widely prescribed. High priced market leaders or expensive branded generics were commonly prescribed. Therefore, there are great opportunities for cost minimization by using evidence-based clinically effective and safe medicines.

Conceptualising a New Knowledge Management Logic Model for Global Health: A Case-Study Approach

Over the past few decades, knowledge management (KM) has become well-established in many fields, particularly in business. Several KM models have been at the forefront of promoting KM in businesses and organisations. However, the applicability of these traditional KM models to the global health field is limited by their focus on KM processes and activities with few linkages to intended outcomes. This paper presents the new Knowledge Management for Global Health (KM4GH) Logic Model, a practical tool that helps global health professionals plan ways in which resources and specific KM activities can work together to achieve desired health program outcomes. We test the validity of this model through three case studies of global and field-level health initiatives: an SMS-based mobile phone network among community health workers (CHWs) and their supervisors in Malawi, a global electronic Toolkits platform that provides health professionals access to health information resources, and a netbook-based eHealth pilot among CHWs and their clients in Bangladesh. The case studies demonstrate the flexibility of the KM4GH Logic Model in designing various KM activities while defining a common set of metrics to measure their outcomes, providing global health organisations with a tool to select the most appropriate KM activities to meet specific knowledge needs of an audience. The three levels of outcomes depicted in the model, which are grounded in behavioural theory, show the progression in the behaviour change process, or in this case, the knowledge use process, from raising awareness of and using the new knowledge to contributing to better health systems and behaviours of the public, and ultimately to improving the health status of communities and individuals. The KM4GH Logic Model makes a unique contribution to the global health field by helping health professionals plan KM activities with the end goal in mind.

Hemodialysis patients profile at Dow University of Health Sciences, Karachi. Pakistan

Objectives: To determine the frequency of diseases contributing to End Stage Renal Failure (ESRF) and to determine the frequency of seropositivity for hepatitis B and hepatitis C in our patients.

Methods: This is an observational study of two years duration from January 2012 till December 2013, done at Dow university of Health Sciences. Sample size is 189 by convenient method. Data collection is retrospective. Inclusion criteria includes all patients ever hemodialysed at DIMC with age 14 or above. Exclusion criteria is age below 14. Data maintained and analyzed on SPSS version 16. All categorical data in percentages and numeric data is given in frequencies and mean with Standard deviation.

Result: Total number of patients included in study were 189, Males were 94/189 (49.7%), females were 95/189 (50.3%), Male to female ratio was 0.98: 1.0. Mean age was 51.88+15.2, range was14-86 years. Patients started on Hemodialysis were found to have hypertension in 40.2%, both diabetes and hypertension was present in 42.8%, diabetes alone in 3.1% of patients as likely etiology of renal failure. Seropositivity for HBV was found 4/189(2.1%) and HCV in 31/189(16.4%) at initiation of Hemodialysis.

Conclusion: Hypertension alone is an important disease found in patients with renal failure as likely cause followed by diabetes. Hepatitis C positivity at start of hemodialysis is 16%.

Approach to hypertension among primary care physicians in the West Region of Cameroon: substantial room for improvement

OBJECTIVE

This study was conducted to assess the knowledge and approach of primary care physician (PCP) towards the management of hypertension in Cameroon.

METHODS

In 2012 we surveyed 77 PCPs among the 111 working in the West region of Cameroon. We used a standardized questionnaire assessing practices regarding the detection, evaluation and treatment of hypertension, and source of information about updates on hypertension.

RESULTS

Participants had a mean duration of practice of 10.1 (SD 7.6) years, and received an average of 10.5 (SD 5.8) patients daily. Most of the PCPs (80.5%, n=62) measured blood pressure (BP) for all adult patients in consultation, however, only 63.6% (n=49) used correct BP thresholds to diagnose hypertension. Sixty-seven PCPs (87.0%) ordered a minimal work-up for each newly diagnosed hypertensive patient, but only the work-up offered by 8 (10.4%) PCPs was adequate. Regarding treatment, the most commonly prescribed medications as monotherapy were loop diuretics (49.3%). Bitherapy mostly included the combination of a diuretic with other drug classes. Most of PCPs used incorrect target BP, with a general tendency of using higher target levels. PCPs received updates on hypertension management mostly through drug companies representatives (53.2%, n=41). Up to 97.4% were willing to receive continuing medical training on hypertension.

CONCLUSIONS

PCPs' knowledge and management of hypertension is poor in this region of Cameroon. Our data point to a need for continually updating the teaching curricula of medical schools with regard to the management of hypertension, and physicians in the field should receive continuing medical education.

Awareness and Approach towards Hypertension Management among General Practitioners of Western Vadodara

BACKGROUND

Hypertension (HTN) is a major risk factor contributing to premature mortality from cardiovascular and cerebrovascular disease.To decrease morbidity and mortality from HTN, timely diagnosis of the disease and its complications, urgent treatment and referrals are required. General Practioners (GPs) are the first tier of the health care system in India and have a wide scope of practice. It is important to know the awareness and approach of primary care physicians to hypertension in their daily practice as compared to standard practice recommendations and guidelines, to identify targets for improvements. With this objective we decided to interview them personally and analyse their approach.

MATERIALS AND METHODS

We conducted a cross-sectional survey in 80 general practitioners (GPs) of the western part of Vadodara city with the use of a questionnaire prepared from JNC-7 guidelines and standard medical books. Seventy seven [97.55%] GPs completed the questionnaire and their responses were statistically analysed.

RESULTS

Twenty percent of GPs were not applying BP cuff properly for BP measurement. Only 18% and 16.6 % could diagnose isolated diastolic hypertension (IDH) and isolated systolic hypertension respectively (ISH) and 21% and 29% would have considered treatment of IDH and ISH respectively.48% consider treating pre-hypertension using non-pharmacological measures. Only 21% use thiazide diuretics for uncomplicated HTN and 50% use beta-blockers in coronary artery disease patients.

CONCLUSION

In our study, most of the GPs in western Vadodara are well aware and updated about the initial lab investigations,non-pharmacological measures and complications of HTN but lack an effective approach towards history taking for HTN,technique for measurement of blood pressure, diagnosis and treatment of IDH and ISH. Pre-hypertension and systolic and diastolic hypertension is under-treated and thiazide diuretics are underutilized. This study can be used to identify targets and approaches to improve hypertension management at the primary care level.

Prevalence, determinants, and management of chronic kidney disease in Karachi, Pakistan - a community based cross-sectional study

BACKGROUND

Chronic kidney disease (CKD) is increasing being recognized as a global public health problem. However, there is dearth of information on the prevalence, determinants, and management of CKD from low- and middle-income countries. The objectives of the study were to determine the 1) prevalence of CKD; 2) socio-demographic and clinical factors associated with CKD; and 3) the existing management of these patients with regards to blood pressure control, and use of antihypertensive medications.

METHODS

We conducted a cross-sectional study on 2873 participants aged ≥ 40 years in 12 representative communities in Karachi, Pakistan. The primary outcome was clinically significant CKD defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 estimated by CKD-EPI (CKD Epidemiology Collaboration) Pakistan equation (0.686 × CKD-EPI1.059) or urinary albumin to creatinine ratio ≥ 3 mg/mmol (i.e. KDOQI CKD stage G3, A2 or worse).

RESULTS

The overall prevalence (95% CI) of CKD was 12.5% (11.4 - 13.8%). The factors independently associated with CKD were older age, hypertension, diabetes, elevated systolic blood pressure, raised fasting plasma glucose, raised triglycerides, and history of stroke (p<0.05 for each). About 267 (74.4%, 69.5 - 78.8%) adults with CKD had concomitant hypertension. Of these, 130 (48.7%, 42.6 - 54.9%) were on antihypertensive medications, and less than 20% had their BP controlled to conventional target of ≤ 140/90 mm Hg, and only 16.9% (12.6 - 21.9%) were on blockers of renin-angiotensin system alone or in combination with other drugs.

CONCLUSIONS

Clinically significant CKD is common among Pakistani adults. The conventional risk factors for CKD and poor control of blood pressure among patients with CKD highlight the need to integrate CKD prevention and management in the primary care infrastructure in Pakistan, and possibly neighbouring countries.

Drug attitude and adherence: a qualitative insight of patients with hypertension

The study is aimed to explore the perceptions and experiences of hypertensive patients toward medication use and adherence. The study was qualitative in nature conducted at Sandamen Provisional Hospital of Quetta city, Pakistan; a public hospital catering to the health needs of about 40% of the population. A qualitative approach was used to gain an in-depth knowledge of the issues. Sixteen patients were interviewed, and the saturation point was achieved after the 14(th) interview. All interviews were audio-taped, transcribed verbatim, and were then analyzed for thematic contents by the standard content analysis framework. Thematic content analysis yielded five major themes. (1) Perceived benefits and risks of medications, (2) physician's interaction with patients, (3) perception toward traditional remedies, (4) layman concept toward medications, and (5) beliefs toward hypertension and its control. The majority of the patients carried specific unrealistic beliefs regarding the long-term use of medication; yet these beliefs were heavily accepted and practiced by the society. The study indicated a number of key themes that can be used in changing the beliefs and experiences of hypertensive patients. Physician's attitude, patient's past experiences, and knowledge related to hypertension were noted as major contributing factors thus resulting in nonadherence to therapy prescribed.

General practitioners' knowledge and approach to chronic kidney disease in Karachi, Pakistan

Due to lack of adequate number of formally trained nephrologists, many patients with chronic kidney disease (CKD) are seen by general practitioners (GPs). This study was designed to assess the knowledge of the GPs regarding identification of CKD and its risk factors, and evaluation and management of risk factors as well as complications of CKD. We conducted a cross-sectional survey of 232 randomly selected GPs from Karachi during 2011. Data were collected on a structured questionnaire based on the kidney disease outcomes and quality initiative recommendations on screening, diagnosis, and management of CKD. A total of 235 GPs were approached, and 232 consented to participate. Mean age was 38.5 ± 11.26 years; 56.5% were men. Most of the GPs knew the traditional risk factors for CKD, i.e., diabetes (88.4%) and hypertension (80%), but were less aware of other risk factors. Only 38% GPs were aware of estimated glomerular filtration rate in evaluation of patients with CKD. Only 61.6% GPs recognized CKD as a risk factor for cardiovascular disease. About 40% and 29% GPs knew the correct goal systolic and diastolic blood pressure, respectively. In all, 41% GPs did not know when to refer the patient to a nephrologist. Our survey identified specific gaps in knowledge and approach of GPs regarding diagnosis and management of CKD. Educational efforts are needed to increase awareness of clinical practice guidelines and recommendations for patients with CKD among GPs, which may improve management and clinical outcomes of this population.

Non-communicable diseases and injuries in Pakistan: strategic priorities

Non-communicable diseases, including cardiovascular diseases, cancers, respiratory diseases, diabetes, and mental disorders, and injuries have become the major causes of morbidity and mortality in Pakistan. Tobacco use and hypertension are the leading attributable risk factors for deaths due to cardiovascular diseases, cancers, and respiratory diseases. Pakistan has the sixth highest number of people in the world with diabetes; every fourth adult is overweight or obese; cigarettes are cheap; antismoking and road safety laws are poorly enforced; and a mixed public-private health-care system provides suboptimum care. Furthermore, almost three decades of exposure to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation have contributed to a high prevalence of mental health disorders. Projection models based on the Global Burden of Disease 2010 data suggest that there will be about 3·87 million premature deaths by 2025 from cardiovascular diseases, cancers, and chronic respiratory diseases in people aged 30-69 years in Pakistan, with serious economic consequences. Modelling of risk factor reductions also indicate that Pakistan could achieve at least a 20% reduction in the number of these deaths by 2025 by targeting of the major risk factors. We call for policy and legislative changes, and health-system interventions to target readily preventable non-communicable diseases in Pakistan.

Access to essential medicines in Pakistan: policy and health systems research concerns

INTRODUCTION

Inadequate access to essential medicines is a common issue within developing countries. Policy response is constrained, amongst other factors, by a dearth of in-depth country level evidence. We share here i) gaps related to access to essential medicine in Pakistan; and ii) prioritization of emerging policy and research concerns.

METHODS

An exploratory research was carried out using a health systems perspective and applying the WHO Framework for Equitable Access to Essential Medicine. Methods involved key informant interviews with policy makers, providers, industry, NGOs, experts and development partners, review of published and grey literature, and consultative prioritization in stakeholder's Roundtable.

FINDINGS

A synthesis of evidence found major gaps in essential medicine access in Pakistan driven by weaknesses in the health care system as well as weak pharmaceutical regulation. 7 major policy concerns and 11 emerging research concerns were identified through consultative Roundtable. These related to weaknesses in medicine registration and quality assurance systems, unclear and counterproductive pricing policies, irrational prescribing and sub-optimal drug availability. Available research, both locally and globally, fails to target most of the identified policy concerns, tending to concentrate on irrational prescriptions. It overlooks trans-disciplinary areas of policy effectiveness surveillance, consumer behavior, operational pilots and pricing interventions review.

CONCLUSION

Experience from Pakistan shows that policy concerns related to essential medicine access need integrated responses across various components of the health systems, are poorly addressed by existing evidence, and require an expanded health systems research agenda.

What do Libyan doctors perceive as the benefits, ethical issues and influences of their interactions with pharmaceutical company representatives?

Introduction

Evidence suggests that 80-90% of doctors in most countries across the world are frequently visited by pharmaceutical company representatives (PCRs). The objective of study to examine perceptions of Libyan doctors between August and October 2010, regarding the benefits, ethical issues and influences of their interactions with (PCRs).

Methods

An anonymous questionnaire was circulated to 1,000 Libyan doctors in selected public and private practice settings in Tripoli, Benghazi and Sebha.

Results

The major benefits of PCR visits reported in the 608 evaluable responses were; receiving new information about products (94.4%). The majority of doctors (75%) were not against the provision of gifts but were more comfortable if it was “cheap” (51%) and had educational value (51%). Doctors who received more printed materials, simple gifts or drug samples were less likely to disapprove of accepting gifts (p5]. Effective marketing can positively influence an individual's attitude towards a product and because there is an association between attitude, intention and behaviour [6], persuasive communication can generate a positive attitude and increase the potential for influence [7]. PCRs can accomplish behaviour change because they directly communicate with prescribers. During a visit they attempt to raise awareness of their products, provide product information and encourage a favourable attitude towards their company and product [8]. They employ verbal persuasion techniques and also provide other incentives such as gifts, free drug samples and sponsored educational events [2]. The provision of promotional gifts can be seen as a friendship building technique to reinforce the communication nexus between PCRs and doctors but it can also potentially erode professional barriers [9]. Contact between a PCR and a medical practitioner is therefore viewed by drug companies as a vital part of their marketing strategy and frequent visits, together with written promotional materials, gifts and other incentives, can help alter behaviour even if the initial attitudes towards a product were weak or unclear [10].

Review of community-based interventions for prevention of cardiovascular diseases in low- and middle-income countries

BACKGROUND

An increasing burden of cardiovascular disease (CVD) is occurring in low- and middle-income countries (LMICs) as a result of urbanisation and globalisation. Low rates of awareness and treatment of risk factors worsen the prognosis in these settings. Prevention of CVD is proven to be cost effective and should be the main intervention. Insight into prevention programmes in LMIC is important in addressing the rising levels of these diseases.

OBJECTIVE

To evaluate the effectiveness of the community-based interventions for CVD prevention programmes in LMIC.

DESIGN

A literature review with searches in the databases of PubMed, EMBASE, CINAHL, LILACS, African Index Medicus and Google Scholar between 1990 and May 2012.

RESULTS

Twenty-six studies involving population-based and high-risk interventions have been included in this review. The content of the population intervention was mainly health promotion through media and health education, and the high-risk approach focused often on education of patients, training of health care providers and implementing treatment guidelines. A few studies had a single intervention on exercising or salt reduction. Most studies showed a significant reduction of cardiovascular risk ranging from lifestyle changes on diet, smoking and alcohol to biomedical outcomes like blood pressure, glucose levels or weight. Some studies showed improved management of risk factors like increased control of hypertension or adherence to medication.

CONCLUSION

There have been effective community-based programmes aimed at reducing cardiovascular risk factors in LMIC but these have generally been limited to the urban poor. Health education with a focus on diet and salt, training of health care providers and implementing treatment guidelines form key elements in successful programmes.

Informal allopathic provider knowledge and practice regarding hypertension in urban and rural Bangladesh

OBJECTIVES

Describe informal allopathic practitioner (IAP) knowledge and practice about management of hypertension and identify gaps in IAP knowledge and practice amenable to interventions.

METHODS

A cross sectional descriptive survey of 642 IAPs in Kamalapur (urban) and Mirsarai (rural) Bangladesh was conducted from March to April, 2011. Using a structured, pre-tested questionnaire sociodemographic, training, knowledge and practice data about management of hypertension was collected. Comparative statistics were preformed to show differences between urban and rural practitioners using SAS 8.0.

FINDINGS

99.4% of IAPs were male, mean age was 37.5 (12.5 SD) years. Greater than 65% correctly identified the upper limit of normal blood pressure. 50.2% underestimated lower limit of systolic hypertension. 79.8% allowed age to affect their treatment approach. As blood pressure increased, willingness to treat with medication decreased and tendency to refer increased. Sedative/sleeping pills, antidepressants, and beta blockers were the most commonly prescribed medications for prehypertension (58.7%, 50.3% and 53.7% respectively), stage I hypertension (55.0%, 38.6%, 49.8% respectively) and stage II hypertension (42.4%, 23.7%, and 28.8% respectively). Rural IAPs were more likely than urban IAPs to treat (84.7% vs 77.7%), order tests (27.1% vs 6.0%) and write prescriptions (60.4% vs 18.7%).

CONCLUSION

While IAPs are crucial to Bangladesh's pluralistic healthcare system, gaps in knowledge and practice could cause unnecessary harm. To include IAPs in the public sector's fight against the chronic disease epidemic, interventions aimed at standardizing IAPs knowledge and practice will be essential. Successfully utilizing IAPs will have beneficial implications not only for Bangladesh, but for all developing countries.

Good knowledge about hypertension is linked to better control of hypertension; a multicentre cross sectional study in Karachi, Pakistan

BACKGROUND

According to the National Health survey only 3% of the population has controlled hypertension. This study was designed to elucidate the knowledge about hypertension in hypertensive patients at three tertiary care centers in Karachi. Secondly we sought to compare the knowledge of those with uncontrolled hypertension and controlled hypertension.

METHODS

It was a cross-sectional study conducted at The Aga Khan University hospital (AKUH), Ziauddin Hospital (ZH) and Civil hospital, Karachi (CHK. All diagnosed Hypertensive patients (both inpatients and outpatients) coming to a tertiary care hospital in Pakistan aged > 18 years were included. Patients were categorized into 2 groups: controlled and uncontrolled hypertension based on their initial BP readings on presentation Uncontrolled Hypertension was defined as average BP ≥ 140/90 mm Hg in patients on treatment. Controlled Hypertension (HTN) was defined as average BP <140/90 mm Hg in patients on treatment. Standardized methods were used to record BP in the sitting position. Knowledge was recorded as a15 item question. Primary outcome was knowledge about hypertension.

RESULTS

A total of 650 participants were approached and consented 447 were found eligible. 284(63.5%) were from Aga Khan University, 101(22.6) from Dow University of health sciences and 62(13.9) were from Ziauddin University. Mean (SD) age of participants was 57.7(12) years, 50.1(224) were men. Controlled hypertension was present in 323(72.3) and uncontrolled hypertension was present in 124(27.4). The total mean (SD) Knowledge score was 20.97(4.93) out of a maximum score of 38. On comparison of questions related to knowledge between uncontrolled and controlled hypertension, there was statistically significant different in; meaning of hypertension (p <0.001), target SBP(p0.001), target DBP(p 0.001), importance of SBP versus DBP, improvement of health with lowering of blood pressure (p 0.002), high blood pressure being asymptomatic (p <0.001), changing lifestyle improves blood pressure(p 0.003),hypertension being a lifelong disease (<0.001), lifelong treatment with antihypertensives(<0.001) and high blood pressure being part of aging(<0.001). On comparison of knowledge as a composite score between uncontrolled and controlled hypertensive; Mean (SD) score was 21.85(4.74) v18.67 (4.70) (p value: < 0.001). On multivariate analysis; gender β (95% CI) 1.67(0.75, 2.59) p <0.001, uncontrolled blood pressure; -2.70(-3.76,-1.67) p <0.001, Sindhi ethnicity; -1.79(-3.25,-3.27) p 0.01 and pukhtoon ethnicity; -2.72(-4.13,-1.32) p <0.001 were significantly associated with knowledge score.

CONCLUSION

Knowledge about hypertension in hypertensive patients is not adequate and is alarmingly poor in patients with uncontrolled hypertension. More emphasis needs to be made on target blood pressure and need for taking antihypertensives for life to patients by physicians.

Hypertension and cardiovascular disease in South Asia: No end in sight

South Asia is undergoing remarkable economic development, industrialization, and globalization with rapidly changing lifestyles resulting in increasing prevalence of obesity, hypertension, and coronary artery disease. It is estimated that in the year 2000, India had 41.5 million people with hypertension and the burden is projected to increase by another 5 million by the year 2025. Recent studies indicate that there is lack of awareness, underdiagnosis, and suboptimal control of elevated blood pressure. Asia is also emerging as an epicenter of diabetes. In India alone, there were approximately 23 million diabetics in the year 2000, and this burden is expected to rise to 57 million by 2025. Diabetes occurs at an early age in Indians with a lower body mass index and abdominal obesity as a striking feature. It is well documented that coronary artery disease occurs prematurely and pursues a malignant course in patients with South Asian background. Extensive information is now available about the epidemiology and risk factors of coronary disease in Asians. There is an enormous task ahead and herculean efforts are needed to prevent the epidemic.

Towards a collective understanding of the information needs of health care providers in low-income countries, and how to meet them

Poor knowledge among health care providers (including health workers and citizens) leads to poor health outcomes. This article discusses current linear research-to-practice paradigms and argues that these approaches are not meeting the needs of health care providers in low- and middle-income countries. It suggests a broader, needs-led approach. This approach must look beyond perceived needs and identify actual needs in relation to knowledge and practice, including learning needs and point-of-use needs. The article argues that systems thinking is required. The availability of reliable, appropriate health care information for providers is dependent on the integrity of the global health care knowledge system, which embraces health professionals, policymakers, researchers, publishers, librarians, information specialists, and others. Three intrinsic weaknesses of the system need to be addressed: communication among stakeholders; an evolving, collective understanding of the system's components and how they interrelate; and effective advocacy to raise awareness of this issue and the need for funders and governments to support collective efforts to strengthen the knowledge system. This can be done at the country level but must be accompanied by an international effort including knowledge networks such as Healthcare Information for All by 2015 involving diverse individuals and organizations.

Diagnosis of chronic conditions with modifiable lifestyle risk factors in selected urban and rural areas of Bangladesh and sociodemographic variability therein

Background

Bangladesh suffers from a lack of healthcare providers. The growing chronic disease epidemic's demand for healthcare resources will further strain Bangladesh's limited healthcare workforce. Little is known about how Bangladeshis with chronic disease seek care. This study describes chronic disease patients' care seeking behavior by analyzing which providers diagnose these diseases.

Methods

During 2 month periods in 2009, a cross-sectional survey collected descriptive data on chronic disease diagnoses among 3 surveillance populations within the International Center for Diarrheal Disease Research, Bangladesh (ICDDR, B) network. The maximum number of respondents (over age 25) who reported having ever been diagnosed with a chronic disease determined the sample size. Using SAS software (version 8.0) multivariate regression analyses were preformed on related sociodemographic factors.

Results

Of the 32,665 survey respondents, 8,591 self reported having a chronic disease. Chronically ill respondents were 63.4% rural residents. Hypertension was the most prevalent disease in rural (12.4%) and urban (16.1%) areas. In rural areas chronic disease diagnoses were made by MBBS doctors (59.7%) and Informal Allopathic Providers (IAPs) (34.9%). In urban areas chronic disease diagnoses were made by MBBS doctors (88.0%) and IAP (7.9%). Our analysis identified several groups that depended heavily on IAP for coverage, particularly rural, poor and women.

Conclusion

IAPs play important roles in chronic disease care, particularly in rural areas. Input and cooperation from IAPs are needed to minimize rural health disparities. More research on IAP knowledge and practices regarding chronic disease is needed to properly utilize this potential healthcare resource.

Risk factor profiles of South Asians with cerebrovascular disease

BACKGROUND

There is a paucity of population based data about the coexistent proportions of risk factors for stroke in South Asians.

METHODS

In this cross sectional survey performed in an urban slum, individuals 35 years of age or older were invited for participation through a simple random sample drawn from baseline census data. For each participant a systematic history and examination was performed to confirm the following risk factors: diabetes, hypertension, obesity, tobacco use, coronary artery disease, family history of coronary artery disease and/or stroke. Cerebrovascular events (stroke and TIA) were verified by a vascular neurologist. We report the association of risk factor groups and the presence of contemporaneous cerebrovascular event.

RESULTS

Five hundred and forty-five individuals (49.4% females) participated in the study. One hundred and nineteen (21.8%) individuals had a cerebrovascular event (stroke and /or TIA). Obesity was found to be the predominant risk factor, occurring in 310 individuals (56.9%), followed by total hypertension (284; 52.1%) and tobacco use respectively (213; 39%). Cerebrovascular event increased in percentage with quantitative increase in risk factors. Cerebrovascular event prevalence was 14.3% with one risk factor, 22% with two, 27% with three, 33% with four, and 86% with five risk factors respectively. The combination of 4 risk factors (hypertension, diabetes, obesity and cigarette smoking) conferred the highest odds of having cerebrovascular event at 4.9 (P 0.03).

CONCLUSION

South Asians in an urban slum often have multiple modifiable risk factors for cerebrovascular event, increasing numbers of risk factors increase the risk of stroke and TIA.

Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial

BACKGROUND

Evidence on economically efficient strategies to lower blood pressure (BP) from low- and middle-income countries remains scarce. The Control of Blood Pressure and Risk Attenuation (COBRA) trial randomized 1341 hypertensive subjects in 12 randomly selected communities in Karachi, Pakistan, to 3 intervention programs: (1) combined home health education (HHE) plus trained general practitioner (GP); (2) HHE only; and (3) trained GP only. The comparator was no intervention (or usual care). The reduction in BP was most pronounced in the combined group. The present study examined the cost-effectiveness of these strategies.

METHODS AND RESULTS

Total costs were assessed at baseline and 2 years to estimate incremental cost-effectiveness ratios based on (1) intervention cost; (2) cost of physician consultation, medications, diagnostics, changes in lifestyle, and productivity loss; and (3) change in systolic BP. Precision of the incremental cost-effectiveness ratio estimates was assessed by 1000 bootstrapping replications. Bayesian probabilistic sensitivity analysis was also performed. The annual costs per participant associated with the combined HHE plus trained GP, HHE alone, and trained GP alone were $3.99, $3.34, and $0.65, respectively. HHE plus trained GP was the most cost-effective intervention, with an incremental cost-effectiveness ratio of $23 (95 confidence interval, 6-99) per mm Hg reduction in systolic BP compared with usual care, and remained so in 97.7 of 1000 bootstrapped replications.

CONCLUSIONS

The combined intervention of HHE plus trained GP is potentially affordable and more cost-effective for BP control than usual care or either strategy alone in some communities in Pakistan, and possibly other countries in Indochina with similar healthcare infrastructure.

Spectrum of antihypertensive therapy in South Asians at a tertiary care hospital in Pakistan

Background

Despite available guidelines on hypertension (HTN), use of antihypertensives is variable. This study was designed to ascertain frequency of patients on monotherapy and > 1 antihypertensive therapy and also to ascertain proportion of patients on diuretic therapy.

Methods

It was a crossectional study conducted on 1191 adults(age > 18 yrs)hypertensive patients selected by computerized International Classification of Diseases -9-coordination and maintenance (ICD-9-CM) presenting to a tertiary care hospital in Pakistan. Data on demographics, comorbids, type of antihypertensive drug, number of antihypertensive drug and mean duration of antihypertensive drug was recorded over 1.5 year period (2008-09). Blood pressure was recorded on admission. Primary outcome was use of combination therapy and secondary outcome was use of diuretic therapy.

Results

A total of 1191 participants were included. Mean age(SD) was 62.55(12.47) years, 45.3%(540) were males. Diabetes was the most common comorbid; 46.3%(551). Approximately 85% of patients had controlled hypertension. On categorization of anti hypertensive use into 3 categories;41.2%(491) were on monotherapy,32.2%(384) were on 2 drug therapy,26.5%(316) were on ≥3 drug therapy. Among those who were on monotherapy for HTN;34%(167) were on calcium channel blockers,30.10%(148) were on beta blockers, 22.80%(112) were on Angiotensin converting enzyme (ACE) inhibitors,12%(59) were on diuretics and 2.20%(11) were on Angiotensin receptor blockers(ARB). Use of combination antihypertensive therapy was significantly high in patients with ischemic heart disease(IHD)(p < 0.001). Use of diuretics was in 31% (369) patients. Use of diuretics was significantly less in patients with comorbids of diabetes (p 0.02), Chronic kidney disease(CKD)(p 0.003), IHD (p 0.001) respectively

Conclusion

Most patients presenting to our tertiary care center were on combination therapy. Calcium channel blocker is the most common anti hypertensive drug used as monotherapy and betablockers are used as the most common antihypertensive in combination. Only a third of patients were on diuretic as an antihypertensive therapy.

Improving General Practitioners’ Knowledge Regarding Blood Pressure Measurement in Selected Cities of Pakistan Through Workshop

The objective of this study was to evaluate enhancement in the knowledge of general practitioners (GPs), from the urban cities in the province of Sindh, Pakistan, regarding blood pressure measurement through workshop. This was a quasi-experimental study that involved GPs from 5 cities of Sindh province, Pakistan. The GPs were required to complete a pretested self-administered questionnaire before and after the workshop session. The questionnaire included few demographic variables and 17 questions based on the American Heart Association recommendations. The mean pretest and posttest scores were compared using Student’s t test. A total of 350 GPs returned completed questionnaires, with a preponderance of males (n = 264, 75.4%) than females (n = 86, 24.6%). The mean correct responses increased significantly after the workshop session from 8 ± 2.1 to 14 ± 2.5 ( P = .01). The knowledge of GPs was almost doubled after the workshop and was significantly different for variables such as qualification, affiliation with teaching hospital, and number of years of practice ( P = .001). This survey, a representation of GPs from the Sindh province, indicated a significant doubling in knowledge after the workshop, proving that continuing medical education sessions play an important role in increasing awareness and staying updated.

Prescribing patterns and predictors of high-level polypharmacy in the elderly population: A prospective surveillance study from two teaching hospitals in India

BACKGROUND

Polypharmacy has been reported to increase the risks for inappropriate prescribing, adverse drug reactions, geriatric syndromes, and morbidity and mortality in elderly populations in the United States and Europe. Data on prescribing patterns and polypharmacy in the elderly population in India are limited.

OBJECTIVES

The aims of this study were to assess prescribing patterns and to determine the predictors of high-level polypharmacy in the elderly population in 2 tertiary care hospitals in India.

METHODS

This prospective surveillance study used medical records from patients aged 60 to 95 years admitted to the medicine wards of the 2 tertiary care hospitals between January 2008 and June 2009. Data on medication prescribing from admission through discharge were reviewed. Diseases were coded using the World Health Organization (WHO) International Classification of Diseases, 10th Revision, and medications were coded using the WHO Anatomical, Therapeutic, and Chemical classification. Concordance of prescribing with the indications in the product labeling as listed in the American Hospital Formulary Services Drug Information 2007 was determined. The prevalences of polypharmacy (5-9 medications) and high-level polypharmacy (>or=10 medications) were determined. Bivariate analysis and multivariate logistic regression analysis were used to determine the influential predictors of high-level polypharmacy during hospital stays.

RESULTS

Data from 814 patients were included (493 [60.6%] men, 321 [39.4%] women; median age, 66 years [range, 60-95 years]). Systemic antibacterials were the most commonly prescribed therapeutic class of medications (574 [70.5%]), and pantoprazole was the most commonly prescribed medication (498 [61.2%]). The majority (7/10 [70.0%]) of the most commonly prescribed medications were prescribed as indicated. Medications prescribed "off-label" included pantoprazole (432/498 [86.7%]), ceftriaxone (212/259 [81.9%]), and atorvastatin (109/237 [46.0%]). Polypharmacy and high-level polypharmacy were prescribed in 366 (45.0%) and 370 (45.5%) patients, respectively. On multivariate logistic regression analysis, multiple (>or=3) diagnoses (odds ratio [OR] = 1.55; 95% CI, 1.16-2.08; P = 0.003), angina pectoris (OR = 2.58; 95% CI, 1.50-4.37; P < 0.001), and a length of stay >or=10 days (10-<15 days, OR = 3.14; 95% CI, 2.09-4.71; P < 0.001; and >or=15 days, OR = 5.74; 95% CI, 2.43-13.51; P < 0.001) were found to be predictors of high-level polypharmacy during hospital stays.

CONCLUSIONS

The campaign for rational drug use in hospitalized elderly patients in India should promote pantoprazole, ceftriaxone, and atorvastatin prescribing in concordance with their indications. Interventions to reduce the high-level polypharmacy in the elderly during their stays in tertiary care hospitals in India should focus on patients with >/=3 diagnoses, angina pectoris, and/or >or=10 days of hospital stay.

Community based lifestyle intervention for blood pressure reduction in children and young adults in developing country: cluster randomised controlled trial

OBJECTIVE

To assess the effectiveness of a community based lifestyle intervention on blood pressure in children and young adults in a developing country setting.

DESIGN

Cluster randomised controlled trial.

SETTING

12 randomly selected geographical census based clusters in Karachi, Pakistan.

PARTICIPANTS

4023 people aged 5-39 years.

INTERVENTION

Three monthly family based home health education delivered by lay health workers.

MAIN OUTCOME MEASURE

Change in blood pressure from randomisation to end of follow-up at 2 years.

RESULTS

Analysed using the intention to treat principle, the change in systolic blood pressure (adjusted for age, sex, and baseline blood pressure) was significant; it increased by 1.5 (95% confidence interval 1.1 to 1.9) mm Hg in the control group and by 0.1 (-0.3 to 0.5) mm Hg in the home health education group (P for difference between groups=0.02). Findings for diastolic blood pressure were similar; the change was 1.5 mm Hg greater in the control group than in the intervention group (P=0.002).

CONCLUSIONS

Simple, family based home health education delivered by trained lay health workers significantly ameliorated the usual increase in blood pressure with age in children and young adults in the general population of Pakistan, a low income developing country. This strategy is potentially feasible for up-scaling within the existing healthcare systems of Indo-Asia.

TRIAL REGISTRATION

Clinical trials NCT00327574.

Hypertension in the developing world: challenges and opportunities

Hypertension is a major public health problem and a leading cause of death and disability in developing countries. One-quarter of the world's adult population has hypertension, and this is likely to increase to 29% by 2025. Modeled projections indicate an increase to 1.15 billion hypertensive patients by 2025 in developing countries. There is variability in the global prevalence of hypertension: hypertension is present in approximately 35% of the Latin American population, 20%-30% of the Chinese and Indian population, and approximately 14% in Sub-Saharan African countries. This heterogeneity has been attributed to several factors, including urbanization with its associated changes in lifestyle, racial ethnic differences, nutritional status, and birth weight. Compounding this high burden of hypertension is a lack of awareness and insufficient treatment in those with hypertension. The public health response to this challenge should drive greater promotion of awareness efforts, studies of risk factors for hypertension, and understanding of the impact of lifestyle changes. Also important are efforts to develop multipronged strategies for hypertension management in developing nations.

Information needs of health care workers in developing countries: a literature review with a focus on Africa

Health care workers in developing countries continue to lack access to basic, practical information to enable them to deliver safe, effective care. This paper provides the first phase of a broader literature review of the information and learning needs of health care providers in developing countries. A Medline search revealed 1762 papers, of which 149 were identified as potentially relevant to the review. Thirty-five of these were found to be highly relevant. Eight of the 35 studies looked at information needs as perceived by health workers, patients and family/community members; 14 studies assessed the knowledge of health workers; and 8 looked at health care practice. The studies suggest a gross lack of knowledge about the basics on how to diagnose and manage common diseases, going right across the health workforce and often associated with suboptimal, ineffective and dangerous health care practices. If this level of knowledge and practice is representative, as it appears to be, it indicates that modern medicine, even at a basic level, has largely failed the majority of the world's population. The information and learning needs of family caregivers and primary and district health workers have been ignored for too long. Improving the availability and use of relevant, reliable health care information has enormous potential to radically improve health care worldwide.

The Burden of Stroke in Pakistan

Epidemiologic literature on stroke burden, patterns of stroke is almost non existent from Pakistan. However, several hospital-based case series on the subject are available, mainly published in local medical journals. Despite the fact that true stroke incidence and prevalence of stroke in Pakistan is not known, the burden is assumed to be high because of highly prevalent stroke risk factors (hypertension, diabetes mellitus, coronary artery disease, dyslipidemia and smoking) in the community. High burden of these conventional stroke risk factors is further compounded by lack of awareness, poor compliance hence poor control, and inappropriate management/treatment practices. In addition certain risk factors like rheumatic valvular heart disease may be more prevalent in Pakistan. We reviewed the existing literature on stroke risk factors in community, the risk factor prevalence among stroke patients, patterns of stroke, out come of stroke, availability of diagnostic services/facilities related to stroke and resources for stroke care in Pakistan.

Characteristics of TIA and its management in a tertiary care hospital in Pakistan

BACKGROUND

Transient ischemic attack (TIA) is described as a brief episode of neurological dysfunction caused by focal brain ischemia, with clinical symptoms typically lasting less than an hour, and without evidence of acute infarction. Recent studies depict TIA as a particularly unstable condition. Risk of stroke is greater than 10% in the first 90 days after an index TIA. The presentation, prognosis and intervention for TIA have not been reported in South-Asians in a developing country.

METHOD

A retrospective chart review was done for 158 patients who were admitted with the diagnosis of TIA, as defined by ICD 9 code 435, from January 2003 to December 2005 at the Aga Khan University Hospital, Karachi, Pakistan. The data was entered and analyzed in SPSS version 14.0.

FINDINGS

Among 158 patients, 57.6% were male and 41.1% were female. The common presenting symptoms were motor symptoms (51.3%), speech impairment (43%), sensory impairment (34.8%) and loss of balance/vertigo (29.1%). The median delay in presenting to the hospital was 4 hours. Those with motor symptoms were found to present earlier. The study showed that only 60.8% of all the patients presenting with TIA received any immediate treatment out of which 44.7% received aspirin. Neuroimaging was used in 91.1% of the patients. Of all the TIA patients 9.1% converted to stroke with 50% doing so within the first 24 hours.

CONCLUSION

The natural history of TIA from this developing nation is comparable to international descriptions. A large percentage of patients are still not receiving any immediate treatment as recommended in available guidelines, even in a tertiary care hospital.

Effect of general practitioner education on adherence to antihypertensive drugs: cluster randomised controlled trial

OBJECTIVE

To determine the impact of a simple educational package for general practitioners on adherence to antihypertensive drugs.

DESIGN

Cluster randomised controlled trial.

SETTING

Six randomly selected communities in Karachi, Pakistan.

PARTICIPANTS

200 patients with hypertension taking antihypertensive drugs; 78 general practitioners.

INTERVENTION

Care by general practitioners specially trained in management of hypertension compared with usual care.

MAIN OUTCOME MEASURE

Correct dosing, defined as percentage of prescribed doses taken, measured with electronic medication event monitoring system (MEMS) bottle.

RESULTS

200 patients were enrolled, and 178 (89%) successfully completed six weeks of follow-up. Adherence was significantly greater in the special care group than in the usual care group (unadjusted mean percentage days with correct dose 48.1%, 95% confidence interval 35.8% to 60.4%, versus 32.4%, 22.6% to 42.3%; P=0.048). Adherence was also higher among patients who had higher levels of education (P<0.001), were encouraged by family members (P<0.001), believed in the effect of drugs (P<0.001), and had the purpose of the drugs explained to them (P<0.001).

CONCLUSIONS

Special training of general practitioners in management of hypertension, emphasising good communication between doctors and patients, is more effective than usual care provided in the communities in Karachi. Such simple interventions should be adopted by other developing countries that are now facing an increasing burden of hypertension.

TRIAL REGISTRATION

Clinical trials NCT00330408 [ClinicalTrials.gov].

Hypertension and kidney disease in Asia

PURPOSE OF REVIEW

Communicable diseases were traditionally the major cause of public health concern in Asian countries, most of which were less developed. With industrialization and associated lifestyle changes during the past few decades, however, noncommunicable diseases similar to those that affect Western societies have emerged in Asian countries. The purpose of the review was to examine recent evidence about the burden and factors associated with hypertension and chronic kidney disease (CKD) in Asian countries.

RECENT FINDINGS

Hypertension has become one of the leading causes of mortality in Asia. Although its prevalence continues to rise, it remains under-diagnosed and under-treated. CKD is becoming increasingly common mainly due to an increase in risk factors such as high blood pressure, diabetes, and obesity. Treatment of advanced CKD is overwhelmingly burdensome in a resource poor environment. Barriers to early detection of CKD in Asians include the fact that equations to estimate the glomerular filtration rate have not been validated in this population, and the uncertainty about appropriate glomerular filtration rate cutoff values to define CKD.

SUMMARY

Concerted efforts are needed to develop and implement cost-effective strategies for prevention and treatment of hypertension and CKD in Asian countries. More research is needed on these conditions in these populations.