Approaches to the Management of Hypertension in Resource-Limited Settings: Strategies to Overcome the Hypertension Crisis in the Post-COVID Era

National and Regional Trends in the Prevalence of Hypertension in South Korea Amid the Pandemic, 2009-2022: Nationwide Study of Over 3 Million Individuals

BACKGROUND

Understanding the association between hypertension prevalence and socioeconomic and behavioral variables during a pandemic is essential, and this analysis should extend beyond short-term trends.

OBJECTIVE

This study aims to examine long-term trends in the prevalence of participants diagnosed with and receiving treatment for hypertension, using data collected by a nationally representative survey from 2009 to 2022, which includes the COVID-19 pandemic era.

METHODS

A nationwide, population-based, cross-sectional study used data collected from the South Korea Community Health Survey between 2009 and 2022. The study sample comprised 3,208,710 Korean adults over a period of 14 years. We aimed to assess trends in the prevalence of participants diagnosed with and receiving treatment for hypertension in the national population from 2009 to 2022, with a specific focus on the COVID-19 pandemic, using weighted linear regression models.

RESULTS

Among the included 3,072,546 Korean adults, 794,239 (25.85%) were aged 19-39 years, 1,179,388 (38.38%) were aged 40-59 years; 948,097 (30.86%) were aged 60-79 years, and 150,822 (4.91%) were aged 80 years or older. A total of 1,426,379 (46.42%) were men; 761,896 (24.80%) and 712,264 (23.18%) were diagnosed with and received treatment for hypertension, respectively. Although the overall prevalence over the 14-year period increased, the upward trends of patients diagnosed with and receiving treatment for hypertension decreased during the COVID-19 pandemic era compared with the prepandemic era (β difference for trend during vs before the pandemic -.101, 95% CI -0.107 to -0.094 vs -.133, 95% CI -0.140 to -0.127). Notably, the trends in prevalence during the pandemic were less pronounced in subgroups of older adults (≥60 years old) and individuals with higher alcohol consumption (≥5 days/month).

CONCLUSIONS

This nationwide representative study found that the national prevalence of participants diagnosed with and receiving treatment for hypertension increased during the prepandemic era. However, there was a marked decrease in these trends during the prepandemic era, compared with the pandemic era, particularly among specific subgroups at increased risk of negative outcomes. Future studies are needed to evaluate the factors associated with changes in the prevalence of hypertension during the COVID-19 pandemic.

The impact of the COVID-19 pandemic on the socioeconomic gradient of hypertension

The COVID-19 pandemic has brought into sharp focus the impact of socioeconomic factors on hypertension outcomes. This review examines the implications of the pandemic on the socioeconomic gradient of hypertension and explores the physiological and pathophysiological processes underlying this relationship. Changes in socioeconomic factors have disproportionately affected individuals with lower socioeconomic status, leading to adverse hypertension outcomes. The pandemic-related stressors, coupled with social isolation and disrupted daily routines, have contributed to elevated stress levels among individuals, particularly those with lower socioeconomic status. Equitable access to healthcare, enhancing health literacy and patient empowerment, and addressing social determinants of health are essential components of hypertension management strategies. By recognizing the specific challenges faced by individuals with lower socioeconomic status and implementing targeted interventions, public health efforts can help reduce the socioeconomic gradient of hypertension.

HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings

Background

HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. It is implemented in 24 countries and over 2,000 primary healthcare facilities. This paper describes the results of a multicomponent, stepwise, quality improvement intervention designed by the HEARTS in the Americas to support advances in hypertension treatment protocols and evolution towards the Clinical Pathway.

Methods

The quality improvement intervention comprised: 1) the use of the appraisal checklist to evaluate the current hypertension treatment protocols, 2) a peer-to-peer review and consensus process to resolve discrepancies, 3) a proposal of a clinical pathway to be considered by the countries, and 4) a process of review, adopt/adapt, consensus and approval of the clinical pathway by the national HEARTS protocol committee. A year later, 16 participants countries (10 and 6 from each cohort, respectively) were included in a second evaluation using the HEARTS appraisal checklist. We used the median and interquartile scores range and the percentages of the maximum possible total score for each domain as a performance measure to compare the results pre and post-intervention.

Results

Among the eleven protocols from the ten countries in the first cohort, the baseline assessment achieved a median overall score of 22 points (ICR 18 -23.5; 65% yield). After the intervention, the overall score reached a median of 31.5 (ICR 28.5 -31.5; 93% yield). The second cohort of countries developed seven new clinical pathways with a median score of 31.5 (ICR 31.5 -32.5; 93% yield). The intervention was effective in three domains: 1. implementation (clinical follow-up intervals, frequency of drug refills, routine repeat blood pressure measurement when the first reading is off-target, and a straightforward course of action). 2. treatment (grouping all medications in a single daily intake and using a combination of two antihypertensive medications for all patients in the first treatment step upon the initial diagnosis of hypertension) and 3. management of cardiovascular risk (lower BP thresholds and targets based on CVD risk level, and the use of aspirin and statins in high-risk patients).

Conclusion

This study confirms that this intervention was feasible, acceptable, and instrumental in achieving progress in all countries and all three domains of improvement: implementation, blood pressure treatment, and cardiovascular risk management. It also highlights the challenges that prevent a more rapid expansion of HEARTS in the Americas and confirms that the main barriers are in the organization of health services: drug titration by non-physician health workers, the lack of long-acting antihypertensive medications, lack of availability of fixed-doses combination in a single pill and cannot use high-intensity statins in patients with established cardiovascular diseases. Adopting and implementing the HEARTS Clinical Pathway can improve the efficiency and effectiveness of hypertension and cardiovascular disease risk management programs.

COVID-19 pandemic and hypertension: an updated report from the Japanese Society of Hypertension project team on COVID-19

The number of reported cases with coronavirus disease 2019 (COVID-19) has exceeded 620 million worldwide, still having a profound impact on people's health and daily lives since its occurrence and outbreak in December 2019. From the early phase of the COVID-19 pandemic, there has been a concern that the rapid spread of this communicable disease can negatively influence non-communicable diseases. Accumulating data indicate that the restriction on the access to medical care, psychological distress, and life-style changes triggered by the pandemic have indeed affected blood pressure control in hypertensive patients. Since our previous report in 2020 that summarized the findings of the literature related to COVID-19 and hypertension, there has been a considerable progress in our understanding of the association between these two disorders; nonetheless, there are remaining challenges and emerging questions in the field. In this article, we aim to summarize the latest information on the impact of the pandemic on blood pressure control, the use of the renin-angiotensin system inhibitors in patients with COVID-19, and the blood pressure changes as one of the possible post-acute sequelae of COVID-19 (also known as long COVID). We also summarize the evidence of telemedicine and COVID-19 vaccination in hypertensive subjects, based on data available as of June 2022.

Influence of COVID-19 on treatment adherence and psychological well-being in a sample of hypertensive patients: a cross-sectional study

OBJECTIVE

The COVID-19 pandemic has caused a global health crisis. This situation has affected the general population, especially the most vulnerable populations such as individuals with cardiovascular diseases. The main objective of this study was to analyse adherence to treatment and psychological well-being in hypertensive patients before and after the COVID-19 lockdown in Spain.

METHODS

A cross-sectional study was performed in a Basic Health Area of Toledo, Spain. Adherence and psychological well-being (resilience, self-esteem, and health-related quality of life [HRQoL]) were measured in hypertensive patients, a group of patients before the COVID-19 lockdown and, in another group after the COVID-19 lockdown using a heteroadministered and anonymous questionnaire. A factorial multivariate analysis of variance (MANOVA) was applied for the outcome variables using pre- and post-COVID-19 lockdown assessment, gender, and age (< 65 years-old vs. ≥ 65 years-old) as independent variables. Univariate F follow-up tests were conducted within the multivariate significant overall differences.

RESULTS

The sample of the present study included 331 hypertensive patients. The mean age was 67.68 years (SD = 10.94). Women comprise 53.5% of the sample and men account for the remaining 46.5%. A total of 144 questionnaires were collected before the COVID-19 pandemic and 187 questionnaires were collected after the onset of the pandemic and once the lockdown was over. MANOVA showed significant main effects for pandemic lockdown (F = 13.383, p < 0.001,) age group (F = 3.74, p = 0.003) and gender (F = 8.85, p < 0.001). Therapeutic adherence decreased after the lockdown (F = 15.393, p < 0.001). However, scores on resilience (F = 17.771, p < 0.001), self-esteem (F = 4.789, p = 0.029), and physical component of HRQoL (F = 13.448, p < 0.001) increased after the lockdown. Regarding age, the univariate test showed a significant effect for the physical component of HRQoL, with scores decreasing in those aged ≥ 65 years (F = 9.375, p = 0.002). Regarding gender, women scored lower on resilience (F = 20.280 p < 0.001), self-esteem (F = 18.716, p < 0.001), the physical component of HRQoL (F = 5.722, p = 0.017), and the mental component of HRQoL (F = 28.912, p < 0.001).

CONCLUSIONS

The COVID-19 pandemic had a negative effect on treatment adherence of hypertensive patients in Spain. However, variables related to psychological well-being have increased in these patients, which may serve as a protective factor against pandemic stress.

Follow-up conditions of care and associated factors among adult hypertensive patients during COVID-19 at West Arsi public health facilities, Southeastern Ethiopia: A multi-center cross-sectional study

Background

Coronavirus disease (COVID-19) is a viral-borne infection caused by the SARS-CoV-2 virus. Aside from the morbidity and mortality effects, it leaves the majority of hypertensive patients untreated and vulnerable to uncontrolled hypertension.

Objective

The purpose of this study was to assess follow-up conditions of care and its associated factors among adult hypertensive patients during COVID-19 in public health facilities of West Arsi, Southeastern Ethiopia.

Methods

A health facility-based retrospective cross-sectional study was conducted among 423 adult hypertensive patients in the West Arsi public health facilities from July 5 to August 6, 2021. A systematic random sampling technique was used to recruit the study participants. A pretested structured face-to-face interviewer and medical records were used to collect sociodemographic variables, basic clinical features, and follow-up data. The follow-up conditions of care were assessed using 12 items with "yes or no" questions. Then, based on the mean value of the items, the follow-up conditions of care were dichotomized into good and poor. As a result, the follow-up condition was good if the score was greater or equal to the mean, and poor unless otherwise. To investigate parameters related with follow-up conditions of care, bivariable and multivariable logistic regression analyses were used. A 95% confidence interval and a p-value of 0.05 were used to indicate a significant association.

Results

The rate of poor follow-up conditions of care during COVID-19 was 29% (95% confidence interval: 24.9-33.4%), according to this study. Age ≥ 60 years (AOR = 3.55; 95% CI: 2.09-6.03), transportation problem (AOR = 2.43; 95% CI: 1.28-4.61), fear of COVID-19 (AOR = 3.34; 95% CI: 1.59-7.01), co-morbidity (AOR = 1.93; 95% CI: 1.14-3.26) and physical distancing (AOR = 2.43; 95% CI: 1.44-4.12) were significantly associated with poor follow-up conditions of care.

Conclusions

In our study, 29% of the participants had poor follow-up care conditions. When compared to WHO recommendations, the findings of this study may explain poor follow-up care conditions. To enhance patients' follow-up treatment, evidence-based target interventions should be designed and executed, taking into account individuals at high risks, such as those over the age of 60 and those with comorbidities, and identifying additional risk factors.

HEARTS en las Américas: innovaciones para mejorar el manejo de la hipertensión y del riesgo cardiovascular en la atención primaria

La Iniciativa Mundial HEARTS. es la iniciativa emblemática de la Organización Mundial de la Salud para reducir la carga de las enfermedades cardiovasculares, la principal causa de muerte y discapacidad en todo el mundo. La Iniciativa HEARTS en las Américas es la adaptación regional que propone usar HEARTS como modelo para el manejo del riesgo de enfermedades cardiovasculares, incluida la hipertensión, y la diabetes en la atención primaria de salud en la Región de las Américas para el año 2025. Esta iniciativa está iniciando su sexto año de aplicación y ya incluye a 22 países y 1 380 centros de atención primaria de salud. Este informe tiene tres objetivos. En primer lugar, describir cómo surgió la Iniciativa HEARTS en las Américas y cuáles son sus principales elementos. En segundo lugar, resumir las principales innovaciones logradas para catalizar la iniciativa y mantener su aplicación. Entre estas innovaciones se encuentran: a) la introducción de factores impulsores del control de la hipertensión; b) el desarrollo de una vía clínica integral y práctica; c) la elaboración de una estrategia para mejorar la precisión de la medición de la presión arterial; d) la creación de un marco de seguimiento y evaluación; y e) la elaboración de un conjunto estandarizado de recursos de capacitación y formación. En tercer lugar, en este informe se examinan las futuras prioridades de la iniciativa. El objetivo de poner en marcha estas soluciones innovadoras y pragmáticas es crear un sistema de salud más efectivo y trasladar el enfoque de los programas cardiovasculares y de hipertensión del nivel de atención altamente especializada a la atención primaria de salud. Además, HEARTS en las Américas puede servir como modelo para unas prácticas más integrales, efectivas y sostenibles en la prevención y el tratamiento de las enfermedades no transmisibles.

HEARTS in the Americas: innovations for improving hypertension and cardiovascular disease risk management in primary care

Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.

Estimating the gap between demand and supply of medical appointments by physicians for hypertension care: a pooled analysis in 191 countries

INTRODUCTION

With a growing number of people with hypertension, the limited number of physicians could not provide treatment to all patients. We quantified the gap between medical appointments available and needed for hypertension care, overall and in relation to hypertension treatment cascade metrics.

METHODS

Ecological descriptive analysis. We combined country-year-specific data on hypertension prevalence, awareness, treatment and control (from Non-Communicable Disease Risk Factor Collaboration) and number of physicians (from WHO). We estimated from 1 to 12 medical appointments per year for patients with hypertension. We assumed that physicians could see 25 patients per day, work 200 days/year and dedicate 10% of their time to hypertension care.

RESULTS

We studied 191 countries. Forty-one countries would not have enough physicians to provide at least one medical appointment per year to all the population with hypertension; these countries were low/lower middle income and in sub-Saharan Africa or East Asia and Pacific. Regardless of the world region, ≥50% of countries would not have enough physicians to provide ≥8 medical appointments to their population with hypertension. Countries where the demand exceeded the offer of medical appointments for hypertension care had worse hypertension diagnosis, treatment and control rates than countries where the demand did not exceed the offer. There were positive correlations between the physician density and hypertension diagnosis (r=0.70, p<0.001), treatment (r=0.70, p<0.001) and control (r=0.59, p<0.001).

CONCLUSIONS

Where physicians are the only healthcare professionals allowed to prescribe antihypertensive medications, particularly in low and middle-income countries, the healthcare system may struggle to deliver antihypertensive treatment to patients with hypertension.

COVID-19 pandemic and the great impulse to telemedicine: the basis of the WONCA Europe Statement on Telemedicine at the WHO Europe 70th Regional Meeting September 2020

Telemedicine is the use of telecommunication and information technologies to support the delivery of healthcare at a distance, guaranteeing patients healthcare by facilitating access where barriers exist; the COVID-19 pandemic has attracted worldwide interest in this field.

The purpose of this paper is to highlight the main pros and cons of telemedicine, which serve as the basis of the WONCA Europe Statement at the WHO Europe 70th Regional Meeting on 14 September 2020.

Pros of telemedicine include virtual healthcare at home, where patients receive support in certain conditions without leaving their houses. During a pandemic, it can be adopted to limit physical human interaction. Unfortunately, it can negatively affect the quality of the doctor–patient relationship, the quality of the physical examination, and the quality of care. Telemedicine requires effective infrastructure and robust investments to be feasible and effective.

Our Whole Lives for Hypertension and Cardiac Risk Factors (OWL-H)—Combining a Teaching Kitchen Group Visit with an Online Platform: A Feasibility Trial (Preprint)

Background

Hypertension (HTN) affects millions of Americans. Our Whole Lives: an eHealth toolkit for Hypertension and Cardiac Risk Factors (OWL-H) is an eHealth platform that teaches evidence-based lifestyle strategies, such mindfulness and cooking skills, to improve self-management of HTN.

Objective

The primary goal of this pilot study was to evaluate the feasibility of OWL-H combined with teaching kitchen medical group visits (TKMGVs) in a low-income population of participants with HTN.

Methods

We conducted a pre-post 8-week study to assess the feasibility of a hybrid program (a web-based 9-module self-management program, which includes mindfulness and Mediterranean and Dietary Approaches to Stop Hypertension diet) accompanied by 3 in-person TKMGVs among patients with HTN. Data including demographics, platform use, and satisfaction after using OWL-H were examined. Outcome data collected at baseline and 8 weeks included the Mediterranean Diet Questionnaire, Hypertension Self-Care Profile Self-Efficacy Instrument, Blood Pressure Knowledge Questionnaire, and the number of self-reported blood pressure readings. For the statistical analysis, we used descriptive statistics, paired sample t tests (1-tailed), and qualitative methods.

Results

Of the 25 enrolled participants, 22 (88%) participants completed the study. Participants’ average age was 57 (SD 12.1) years, and 46% (11/24) of them reported a household income <US $30,000 per year. Among the 22 participants who logged in to OWL-H, the average number of mindfulness practices completed was 7 and the average number of module sessions accessed was 4. In all, 73% (16/22) of participants reported that they were “very satisfied” with using OWL-H to help manage their HTN. Participants’ blood pressure knowledge significantly increased from baseline (mean 5.58, SD 1.44) to follow-up (mean 6.13, SD 1.23; P=.03). Participants significantly increased their adherence to a Mediterranean diet from baseline (mean 7.65, SD 2.19) to follow-up (mean 9, SD 1.68; P=.004). Participants’ self-efficacy in applying heart-healthy habits, as measured by the Hypertension Self-Care Profile Self-Efficacy Instrument, increased from baseline (mean 63.67, SD 9.06) to follow-up (mean 65.54, SD 7.56; P=.14). At the 8-week follow-up, 82% (18/22) of the participants had self-reported their blood pressure on the OWL-H platform at least once during the 8 weeks.

Conclusions

The eHealth platform for HTN self-management, OWL-H, and accompanying in-person TKMGVs have the potential to effectively improve lifestyle management of HTN.

Trial Registration

ClinicalTrials.gov NCT03974334; https://clinicaltrials.gov/ct2/show/NCT03974334

Hypertension in Low- and Middle-Income Countries

In recent decades low- and middle-income countries (LMICs) have been witnessing a significant shift toward raised blood pressure; yet in LMICs, only 1 in 3 are aware of their hypertension status, and ≈8% have their blood pressure controlled. This rising burden widens the inequality gap, contributes to massive economic hardships of patients and carers, and increases costs to the health system, facing challenges such as low physician-to-patient ratios and lack of access to medicines. Established risk factors include unhealthy diet (high salt and low fruit and vegetable intake), physical inactivity, tobacco and alcohol use, and obesity. Emerging risk factors include pollution (air, water, noise, and light), urbanization, and a loss of green space. Risk factors that require further in-depth research are low birth weight and social and commercial determinants of health. Global actions include the HEARTS technical package and the push for universal health care. Promising research efforts highlight that successful interventions are feasible in LMICs. These include creation of health-promoting environments by introducing salt-reduction policies and sugar and alcohol tax; implementing cost-effective screening and simplified treatment protocols to mitigate treatment inertia; pooled procurement of low-cost single-pill combination therapy to improve adherence; increasing access to telehealth and mHealth (mobile health); and training health care staff, including community health workers, to strengthen team-based care. As the blood pressure trajectory continues creeping upward in LMICs, contextual research on effective, safe, and cost-effective interventions is urgent. New emergent risk factors require novel solutions. Lowering blood pressure in LMICs requires urgent global political and scientific priority and action.

Allocation of the "Already" Limited Medical Resources Amid the COVID-19 Pandemic, an Iterative Ethical Encounter Including Suggested Solutions From a Real Life Encounter

The shortage of healthcare providers is well-documented in low-income countries (LIC) prior to COVID-19, due to various causes including the migration to developed countries, scarcity of supplies, poor healthcare infrastructure, limited ICU facilities, and lack of access to guidelines and protocols. One of the important hitches in LIC is the insufficient testing capacity that precluded accurate assessment of disease burden and subsequently resource allocations. Trying to adhere to the principles of bioethics including respect to others, beneficence, and justice should be applied on the ground in the particular setting of the LIC. Solutions should be tailored to the tangible needs and possibility of implementation in real life in the face of the “already” limited resources by making use of simple, yet plausible, measures. Implementing guidelines and frameworks that were set to work in the better-resourced nations is a call for futility. The adoption of novel solutions to overcome the unique challenges in the LIC is exigent. These include the use of automated screening algorithms and virtual video clinics. Moreover, integrating electronic intensive care unit (e-ICU) software may allow for remote monitoring of multiple patients simultaneously. Telemedicine could help in getting consultations worldwide. It can also enhance healthcare workers' knowledge and introduce new skills through teleconferences, e-workshops, and free webinars. Healthcare workers can be remotely trained to enhance their skills. Agencies, such as the WHO, should develop comprehensive programs to tackle different health issues in LIC in collaboration with major institutions and experts around the world.