A community-based intervention program to effectively treat hypertension in developing countries

This issue of the Journal of Hypertension contains a report on a community-based randomized trial carried out in hypertensive patients [1]. The results are interesting for two main reasons: the trial was performed in an African developing country where it is still difficult to detect hypertension and implement healthcare programs and an excellent blood pressure (BP) control was achieved owing to a pragmatic strategy aimed to facilitate the medication adherence among hypertensive patients. Two approaches were compared during a 6-month follow-up: a nurse-led clinic-based care strategy with physician back-up and a similar program complemented by home visits, which was also managed by nurses. The overall BP normalization rate (BP <140/90 mmHg) was excellent, reaching approximately 66%. This is particularly impressive considering the fact that black patients tend to have more severe forms of hypertension than white patients [2]. Hypertension is a leading cause of cardiovascular mortality worldwide, both in industrialized and in low-income developing countries [3,4]. The present guidelines insist on targeting a strict BP control during antihypertensive therapy [5–7]. This is, however, far from easy [8] despite the availability of different classes of BP-lowering drugs and the possibility to combine them whenever required [9,10]. Different barriers may contribute to the unsatisfactory BP control in patients on antihypertensive therapy. For instance, poor understanding of illness may lead to a poor acceptance of treatment. Also, the clinicians may not be committed enough to normalize their patient's BP [11]. Finally, poor socioeconomic conditions and access to healthcare services and medications might also impact adversely on the quality of BP control [12]. Factors related to patients, physicians, and healthcare organization are all expected to play a major role in treating hypertension successfully worldwide but especially in countries where funding is limited. This study by Adeyemo et al.[1] deserves credit for having monitored adherence to the prescribed antihypertensive medications. This was done by pill count and by checking for riboflavin fluorescence in urine under ultraviolet light. Treatment compliance was very high, as almost 80% of participants took nearly all prescribed pills, which most likely accounted for the fact that BP control was achieved in more than half of the patients. Several particularities related to the study design have probably facilitated this good medication-taking behavior [13–15]. Extensive interviews were conducted with study participants during an initial phase. This might have promoted a better understanding of illness and acceptance of the treatment. The intervention program involved trained nurses, which is expected to have influenced positively the self-management of participants during the course of the study. The drug regimen was very simple, comprising a thiazide diuretic as first-line, with the adjunct of a β-blocker as second step, if needed. A key point was that these medications were provided free of charge. Of note, the patients were reimbursed for transportation costs for clinic visits. The 6-month compliance to medication among newly diagnosed hypertensive patients obtained in the present study contrasts with the observations made several years ago in the Seychelles islands [16]. In this latter study, compliance to a single daily pill (thiazide or β-blocker, or fixed combination of the two) was monitored for 1 year using an electronic pill container. After 1 month, only 46% of patients took the medication on 6 or 7 days a week, and this proportion fell to 26% after 12 months. A major determinant of compliance in this study was the regularity of attendance to follow-up visits. In the study of Adeyemo et al. [1], no information is given on the attendance to clinic visits and its impact on compliance to treatment. One can only note that, among patients who started the trial, 81% completed the 6-month follow-up. This percentage, together with the excellent observance of treatment observed over the same period, contrasts with the rather poor persistence on thiazide and β-blocker therapy reported repeatedly in industrialized countries [17]. Notably, both the quality of BP control and the degree of compliance to therapy were very similar in patients randomized to the clinic management only and in those allocated to the clinic management associated with home visits. At first glance, this may appear surprising as home BP monitoring by the patients themselves is known to improve medication adherence and, as a result, to increase the fraction of patients normalizing their BP [18]. There is, however, one possible explanation for the lack of difference between the two treatment strategies, that is, the excellent compliance maintained in the two treatment groups, which gives practically no room for improvement. Taken together, we believe that the present study offers convincing evidence that high BP can be successfully controlled in most hypertensive patients even in developing world settings, provided that efforts are directed at educating patients, supporting their medication-taking behavior, and giving them access to effective and well tolerated BP-lowering drugs. Hopefully, the same kind of studies will be repeated in other poor-income countries assessing BP not only with clinic measurements, but also using ambulatory BP monitoring. ACKNOWLEDGEMENTS Conflicts of interest B.W. and F.F. have no conflicts of interest to disclose regarding the content of this manuscript.