North Karelia (Finland) hypertension detection project. Five-year follow-up of hypertensive cohort

Scaling a Community-Wide Campaign Intervention to Manage Hypertension and Weight Loss

Public health impacts can be achieved when evidence-based interventions are implemented to those most in need. Too often implementation never or slowly occurs. The community-wide campaign intervention Tu Salud ¡Si Cuenta! has evidence of improving health outcomes related to chronic disease among low-income, Latinos. Using the RE-AIM Framework, this study examined if the scaled-up version of the intervention is associated with improvements in hypertension and obesity in 12 locations. Each element of the RE-AIM framework was examined. For "Effectiveness," we examined outcomes overall and by implementing location. We used linear and logistic regression to assess if exposure in the intervention was associated with improvement in hypertension and weight loss. Participants were stratified into "low exposure" (2-3 outreach visits) vs. "high exposure" (4-5 outreach visits). Based on the RE-AIM Framework, the intervention "reached" its intended population of low-income Latinos, demonstrated "effectiveness" in improving hypertension and obesity, was "adopted" at a high level in all but one site, was "implemented" with fidelity to the intervention model with moderate success across locations, and showed high "maintenance" over time. For effectiveness specifically, we found that out of 5,019 participants, 2,508 (50%) had a baseline hypertensive blood pressure (BP) reading. Of the 2,508, 1,245 (49.9%) recovered to normal blood pressure or pre-hypertension stage by last follow-up. After adjusting for baseline BP and potential confounders in multivariable linear regression models, the high exposure group had significantly more reduction in systolic BP (adjusted mean difference in % change = -0.96; p = 0.002) and diastolic BP (adjusted mean difference in % change = -1.61; p < 0.0001) compared to the low exposure group. After controlling for baseline weight and other confounders, the high exposure group had significantly greater decrease in weight compared to the low exposure group (adjusted mean difference in % change = -1.28; p < 0.0001). Results from the multivariable logistic regression models indicated that compared to the low exposure group the high exposure group was more likely to achieve a clinically significant minimum 5% weight loss [adjusted odds ratio (OR) = 2.97; p < 0.0001). This study contributes evidence that a Community-Wide Campaign model holds promise for addressing hypertension and obesity among low-income Latinos.

Blood Pressure, Sodium Intake, and Hypertension Control: Lessons From the North Karelia Project

From the very beginning of the North Karelia Project, prevention, detection, and control of hypertension were included as key aims in the project. An intensive hypertension prevention and control program was established in North Karelia in 1972 that included community-based activities to reduce blood pressure levels in the entire population, detect people with hypertension, improve their treatment, establish standard diagnostic and therapeutic methods, and to monitor blood pressure levels, control of hypertension, and the performance of the health care. After the first 5 years of the project, most of these activities were also implemented on the national level. In late 1970s, work to reduce the salt intake was started, and substantial reductions have taken place in salt intake in the Finnish population. Remarkable improvements have been seen both in blood pressure levels and in treatment and control of hypertension in North Karelia and in the whole of Finland. Between 1972 and 2012 in North Karelia, the mean systolic blood pressure among 30- to 59-year-old men has decreased from 149 mm Hg to 135 mm Hg and among women from 153 mm Hg to 129 mm Hg. The decreases in mean diastolic blood pressure have been from 92 mm Hg to 84 mm Hg among men and from 92 mm Hg to 79 mm Hg among women.

The influence of health systems on hypertension awareness, treatment, and control: a systematic literature review

BACKGROUND

Hypertension (HT) affects an estimated one billion people worldwide, nearly three-quarters of whom live in low- or middle-income countries (LMICs). In both developed and developing countries, only a minority of individuals with HT are adequately treated. The reasons are many but, as with other chronic diseases, they include weaknesses in health systems. We conducted a systematic review of the influence of national or regional health systems on HT awareness, treatment, and control.

METHODS AND FINDINGS

Eligible studies were those that analyzed the impact of health systems arrangements at the regional or national level on HT awareness, treatment, control, or antihypertensive medication adherence. The following databases were searched on 13th May 2013: Medline, Embase, Global Health, LILACS, Africa-Wide Information, IMSEAR, IMEMR, and WPRIM. There were no date or language restrictions. Two authors independently assessed papers for inclusion, extracted data, and assessed risk of bias. A narrative synthesis of the findings was conducted. Meta-analysis was not conducted due to substantial methodological heterogeneity in included studies. 53 studies were included, 11 of which were carried out in LMICs. Most studies evaluated health system financing and only four evaluated the effect of either human, physical, social, or intellectual resources on HT outcomes. Reduced medication co-payments were associated with improved HT control and treatment adherence, mainly evaluated in US settings. On balance, health insurance coverage was associated with improved outcomes of HT care in US settings. Having a routine place of care or physician was associated with improved HT care.

CONCLUSIONS

This review supports the minimization of medication co-payments in health insurance plans, and although studies were largely conducted in the US, the principle is likely to apply more generally. Studies that identify and analyze complexities and links between health systems arrangements and their effects on HT management are required, particularly in LMICs. Please see later in the article for the Editors' Summary.

The impact of a 6-year comprehensive community trial on the awareness, treatment and control rates of hypertension in Iran: experiences from the Isfahan healthy heart program

Objectives

We aimed to evaluate the changes over time in the prevalence, awareness, treatment, and control rate of hypertension in intervention and reference areas of a comprehensive community trial with reference area.

Methods

Data from independent sample surveys before and after implementation of the program (2001 vs.2007) were used to compare differences in the intervention and references areas over time. Hypertension was defined as blood pressure ≥140/90 mmHg in non-diabetic patients and ≥130/80 mmHg in diabetic individuals and or taking antihypertensive medications. Interventional activities included educational strategies at population level as well as for hypertensive patients, their families and health professionals.

Results

The study population of the baseline survey included 6175 (48.7% males) in the interventional area and 6339 (51.3% male) in the reference area. The corresponding figures in the post-intervention phase was 4717 (49.3% male) in the interventional area and 4853 (50.7% male) individuals in the reference area. The prevalence of hypertension had a non-significant decrease from 20.5%to 19.6%, in the interventional area whereas in the reference area, it increased from 17.4% to 19.6% (P = 0.003). If we consider Bp ≥ 140/90 in diabetic and non-diabetic patients as hypertension definition, the prevalence of hypertension in the interventional areas had a non-significant decrease from 18.9% in 2001 to 17.8% in 2007, whereas in the reference area, it had a significant rise from 15.7% to 17.9% (P = 0.002) respectively. Awareness, treatment and control rates of hypertension had better improvement in urban and rural part of the interventional area compared to reference area. The awareness, treatment, and control rates of hypertension increased significantly in the age groups of more than 40 years, as well as in all groups of body mass index in interventional areas without significant change in the reference area. Mean systolic blood pressure of study population in the interventional area decreased from 116.13 ±19.37 to 112.92 ± 18.27 mmHg (P < 0.001) without significant change in reference area.

Conclusions

This comprehensive and integrated program of interventions was effective in tackling with the prevalence of hypertension, and may improve the awareness, treatment and control rates of this disorder in a developing country setting.

Factors associated with changes in serum cholesterol during a community-based hypertension programme

A cohort of 1019 male and 1232 female hypertensives, aged 25-59 years, based on a random population sample, was followed for five years during a community-based cardiovascular prevention programme. A small mean reduction in serum cholesterol level was found. The observed changes in casual serum cholesterol values were partly due to the regression to the mean. The reductions were most marked in elderly people and in those with high baseline serum cholesterol values. The partial regressions of the cholesterol change were computed in subgroups by age, sex and baseline serum cholesterol level. Changes in weight in men and in age in women were the strongest independent predictors of the change in serum cholesterol. Changes in dietary fat intake were also associated with the change in serum cholesterol. Only a small part of the total variation in the change in serum cholesterol was explained by the regression models. The results indicate that reduction of the serum cholesterol level among hypertensive persons, especially men, was caused by changes in their dietary habits.

Long-term effects of cessation of smoking on body weight, blood pressure and serum cholesterol in the middle-aged population with high blood pressure

Smoking habits are continuously changing in the population. Cessation of smoking is not only often difficult but may lead to undesired consequences, esp. to weight gain. A random sample of 2283 persons with mild hypertension was followed up for 5 years in Eastern Finland and examined at the community-based cardiovascular program. During that time 30% of those smoking initially stopped smoking. Men gained weight on the average 3.6 kg upon stopping smoking (p less than 0.001) after controlling for age, change in fat and sugar intake and change in physical activity at leisure time). In women cessation of smoking was not related to weight changes. There was no evidence in this follow-up that smoking or cessation of smoking would have any independent impact on blood pressure or serum total cholesterol level.

Factors associated with changes in body weight during a five-year follow-up of a population with high blood pressure

In 1972 a cardiovascular disease prevention programme was started in North Karelia in Eastern Finland. At the outset of the programme a random sample comprising 10940 persons aged 25 to 59 years was studied. Those subjects whose systolic blood pressure was greater than or equal to 175 and/or diastolic greater than or equal to 100 mmHg or who were undergoing antihypertensive treatment, were re-examined in 1977. Their body weight was measured both in 1972 and 1977. The changes in their physical activity, smoking and eating habits were also interviewed. The men aged 25 to 49 years had increased their body mass index by 0.4 kg/m2 and the men aged 50 to 59 years by 0.2 kg/m2, on average. In women (aged 25 to 49 years) body mass index had increased by 0.5 kg/m2 but decreased in the age group 50 to 59 years by 0.2 kg/m2, on average. In men the change in body weight exerted the strongest partial regression on the change in smoking, age and physical activity (both in leisure time and at work). In women aged 25 to 49 years the reasons for increased body weight were the same as in men. In older women, aged 50 to 59 years the decrease in body weight was associated with age, change in amount of smoking and initiation of antihypertensive drug therapy.