High Blood Pressure: Causes, Global Inequalities, And Initiatives To Reduce It

Causes and impact of high blood pressure worldwide

According to WHO (2018) high blood pressure is the biggest cause for coronary heart diseases and for hemorrhagic strokes. Internationally, it is estimated that high blood pressure has caused 7.5 million deaths and about 12.8% of overall deaths happening in the world. It estimates for 57 million or 3.7% of the overall disability adjusted deaths. Blood pressure levels are the main causes of the risk for strokes and coronary heart diseases. Additionally, it is also the cause of peripheral vascular diseases, heart failures visual impairments, retinal hemorrhage and renal impairment.

As per WHO, the highest blood pressure was recorded in the African region, where it was as high as 46% amongst men and women. On the other hand, the lowest blood pressure was recoded in America which was 35% amongst men and women. In all the regions of WHO, it was noted that men have slightly high blood pressures than women.

According to Cock (2013) the actors of global actors are national public health institutes and public health agencies of the member countries of WHO. Furthermore, the key scientific advancements play a crucial role in the empowerment of specific areas of health systems like workforce skills, laboratory capacity, preparedness and implementation of programs and operational research and evaluation.

According to the opinion of Hong et al., (2013) the goal setting strategies for patients suffering from chronic diseases should be to set realistic goals to guide them throughout their life with the help of chronic disease management . In this regard, the information given to the patient to reach the blood pressure goal initiating from the drug therapy is considered crucial in the processes of setting realistic goals and attaining them.

 As per Mills et al.,  (2016)the global inequalities of health  in the context of high blood pressure are increasing mostly in the lower  and medium income countries whereas it is decreasing or stable in high income areas.

In this regard, a stakeholder analysis was executed in India with the help of government, academia, industry, customers and non-governmental organizations.  It was done with the help of cross –sectional population survey of 1395 people residing in urban, rural and slum areas of urban areas of Northern and Southern regions of India. The sodium intakes and the attitudes, knowledge and behaviors associated with sodium were assessed along with identifying the sources of salt in the Indian diet in the survey. In this regard, a database of branded food composition comprising of the information related to the nutritional content of junk and processed food was also formulated .So, in this article, the initiative to achieve a 30per cent reduction in salt intake by 2025, has been taken by the Government of India will be explained (The George Institute of Global Health, 2012).

Global inequalities and regional differences in high blood pressure

As per Indian Council of Medical Research (2018) due to increased blood pressure, there has been an increase in death rates in India. So, in order to raise awareness about hypertension, the Indian Council of Medical Research along with 50 partner institutions throughout the country have been organizing a campaign which is conceptualized by the International Society of Hypertension to educate the communities to eliminate hypertension. The objective of the campaign is to make the people aware and motivate them to get their blood pressures checked at continuous intervals (Pharmabiz.com, 2016).

In this regard, 4 sets of programs have been published viz. 2006, 2009, 2011 and 2014 comprising of 80 product classes. The targets published in 2014 were to be accomplished in 2017. They assisted in providing guidance to the industry on the salt intakes they aimed to achieve thereby resulting in reducing the salt levels in all the included categories.

As per Ministry of Health and Family Welfare (2017) the Indian Hypertension Management Initiative aims to reduce the disabilities and deaths occurring as a result of cardiovascular diseases through the improvement of the control of high blood pressure, elimination of artificial trans-fat, leading risk factors of cardio vascular diseases and the main reason of death in India. SO, in this regard, the Government of India has executed a national action plan for the elimination and control of high blood pressure and other non-communicable disease with specific goals to be accomplished by the year 2025 which includes a 25% decrease in the death rates arising from non-communicable diseases, a 25% relative reduction in the removal of   high blood pressure and 30% reduction in the intake of salt and sodium.

The Health Check programs in India address the top seven causes to prevent deaths and permanent disability. High Blood pressure is one of them. The program is initiated for the health checkups of the people belonging to the deprived communities. It also has accessibility to the groups facing a higher risk of heart attacks and it provides an opportunity for influencing the health inequalities (Department of Health, 2010).

The logical model for exploring the inputs, outputs and influence of the initiatives to mitigate the problem of cardio vascular diseases can be explained as under:

1. Description of the program:  Firstly, the governments, NGOs and researchers of the member states of WHO should be updated regarding the developments in the salt reduction plans of WHO at the international levels. They should also track the global targets of the member countries and their action plans for accomplishing them.

So, certain policies should be formulated to track the performance of these countries to accomplish their targets to decrease the salt intake by 30% between 2010 to 2025 (WHO, 2016).

Key actors in addressing high blood pressure and public health agencies’ role

 Evaluation of the program: A stakeholder analysis shall be executed to analyze the key stakeholders in this process and clarification of the aspects of the program which are to be evaluated. Certain aspects such as the dietary habits of the people and the salt content of their diets shall be assessed in this behalf (Gov.UK, 2017).

1. Focus on the evaluation design: The associated personnel should access the study design, methods of data collection and the development of the data collection methods. In this regard, the interventions such as surveillance to measure and regulate the salt consumption patterns, the sodium content of food and the evaluation of the impact of the salt reduction programs shall be administered.

For this the population survey design, shop survey data collection methods and the 24 hour urine collection protocol shall be applied.

1. Collection of data and its analysis: The administration needs to identify the crucial methods of collecting data and the resources required in this behalf. For example in Uzbekistan, the 24 hour urine collection program was successful as a data collection strategy. The analysis can be executed   with the help of development of user friendly portable equipment which provide instant and dependable results for verifying the salt content. Similar methods can be adopted in India as well.
2. Dissemination strategies: Several dissemination strategies can be used such as training programs, communicating to the stakeholders through peer reviewed journals, preparing summary reports targeted for different audiences etc (World Health Organization, 2016).

As per Odusola et al., (2016) the enablers which influence the implementation of the initiatives are :

1. Availability of necessary resources: The accessibility to inexpensive health insurance is one of the crucial means which can provide good quality care to the poor populace .It is the main driver which enables people to access the quality care.
2. The development of quality improvement plans and equipment up gradations by the insurance companies can prove to be an incentive for improving the hyper tension care.
3. The pre requisites for high quality care are continuous diagnosis and screening tests to eliminate or trace the cardiovascular diseases.
4. Furthermore, the constructive dialogues and good relationships amongst the providers of health care services and the patients are essential for the successful implementation of the initiatives.
5. Good quality control systems are crucial for ensuring proper implementation of the initiatives.
6. The insurance companies should abide by the guidelines to supervise that proper care has been given to the patients.
7. Lastly, the availability of protocol to make sure that the supplies of medicines and laboratory consumables have not been expired should also be viewed as important conditions for CVD prevention care (Australian Institute of Health and Welfare, 2017).

The barriers which influence the implementation of the initiatives are:

1. As per Crouse & Kumar (2014) one of the threats to global health initiatives is influenza which is a communicable disease. Research show that people suffering from heart attacks are likely to be inflected by flu. Furthermore, the villa infection can raise the chances the blood pressure of the body.
2. The language barriers with the patients can prove to be limitation during the consultation with the medical practitioners.
3. The dependency of the poor patients on the subsidized health insurance can prove to be barrier in the implementation of the initiatives.
4. There is a need for education and awareness to address the local and cultural understandings regarding the healthy life styles of the patients.
5. Inadequate infrastructure of the important diagnostic machinery and shortage in the supply of the medicines can prove to be a hindrance in the implementation of the initiatives.
6. Poor remuneration and living standards of the rural healthcare workers can hamper the implementation of the initiatives.
7. Poor connections of internet can influence the quality and output of care of the patients in a negative manner (WHO, 2016).

The strategies for identifying the barriers to   the implementation of the initiatives to mitigate the problem of high blood pressure can be explained as under:

1. The patient based attitudes about high blood pressure and side effects of medication can be identified by creating well targeting communication plans and informing the population about the potential risk factors.
2. The administration should observe the dietary habits, level of exercise, consumption of alcohol and usage of tobacco amongst the population of the member states. They should also observe the obesity levels of the people residing in the member countries.
3. Since the factors of behavioral risk are responsible for 80% of the severe heart conditions and high blood pressure, so the administration should assess the cardio-metabolic risk assessment and management plans of the target area (WHO, 2013).

The strategies for identifying the enablers to   the implementation of the initiatives to mitigate the problem of high blood pressure can be explained as under:

1. The administration should trace the guidelines and promotional strategies to raise the awareness amongst the people to reduce the salt content in their diets and to eliminate high blood pressure.
2. They should evaluate various community health centers and their working styles on the collection of clinical data on blood pressure, cholesterol and other indicators of risk (Department of Health and Human Services, 2015).

As per Tan et al., (2017) the quantitative methodology of focus group was adapted to study the evaluation of the initiative. It was based on COREQ (Consolidated criteria for reporting the qualitative research). It comprised of a 32 item checklist meant for interviewing the participants and focus groups. For this, phenomenology approach was utilized to understand the views of the patients on medication and hypertension management.

This method comprises of the usage of the live experiences of the patients to analyze the issue. The content of the focus group with questionnaire was based on the literature reviews on the high blood pressure management strategies of the patients and the perceptions of the patients regarding the use of medication. The selection of the patients was done on the basis of living standard, age and blood pressure levels.

The members were asked with the help of semi structured questionnaires and they were told to communicate with each other, share their experiences and exchange ideas. The preparation of the questions was in an open ended format and was tested for face and content validity along with clarity with three pharmacist having vast experiences in the field of pharmacy practice.

Furthermore, discussion topic was forwarded to an experienced moderator who was independent, for further clearance. After his assurance that the topic is up to the level of the patients, the study was executed.

The outcomes used to examine the influence of the initiative on the health priority area can be evaluated with the help of three major themes. They included medication management of high blood pressure, the knowledge of patients regarding high blood pressure and self-management of high blood pressure.

Goal setting strategies for patients with chronic diseases

The medical strategies and adherence to increase the medical adherence are the main features in medication management of high blood pressure. Some of the patients revealed that they forget to take the medicines. The study reveals that these are the barriers to adherence amongst the patients.

With regards to the   knowledge of patients  regarding high blood pressure  , it was analyzed that some of them were less aware of the normal blood pressure levels .Although some of them were aware of the side effects of the medications.  So it has been concluded that the patients are not aware about the real mechanisms action and the side effects of the medication. So it can be viewed as a hindrance in implementing the initiative in the health priority area (Craig et al., 2016).

Regarding the self-management of the high blood pressure which consisted of personal initiatives taken by the patients and their self-awareness on the symptoms of high blood pressure. In some of parts of Africa, Asia and Europe, usage of therapies of herbal and traditional approaches were considered to be the strategies instead of taking medications for controlling high blood pressure.

So it can be viewed as another hindrance and appropriate measures should be taken to spread awareness amongst the patients about the different aspects of high blood pressure (Liao et al., 2016).

The study explored the perceptions of the patients suffering from high blood pressure and on the use of medications by them in the context of India. It also highlighted the issue and concerns regarding high blood pressure management. The misapprehensions about the side effects of the medications have resulted in poor adherence amongst the participants.

Furthermore, absence of knowledge and awareness towards the targeted blood pressure levels was noted amongst the members. The results lead to the low level of self-monitoring amongst the patients. To resolve the issues, certain strategies have to adopt by the government of India to raise the awareness amongst the patients.

The health education talks and execution of the screening programs by the health care workers in coordination with the non-governmental organizations shall be initiated at the community level for mitigating the issues.  

As per Hallberg et al., (2016) the patients should be motivated for a better lifestyle. They should be encouraged to quit unhealthy habits such as smoking and weight management.  They should be encouraged for self-monitoring their progress in this case. It should be viewed as a source of assistance for observing that how the wellbeing, symptoms and life style have changed over a period of time.  

Initiatives in India to reduce salt intake and hypertension

Using the self-management system, the awareness can be increased about the factors affecting the blood pressure. The relation between the blood pressure, physical activity and stress can be considered in this regard. For this, the influence of the lifestyle, daily life situation and medication can be considered to affect and motivate the tendency of the patients to self-adherence.

For mitigating the problem of high blood pressure from the masses, then the public organizations are well suited for this purpose. They can spread awareness in the form of executing educational activities regarding the potential threats, changes in the lifestyle and better adherence to mediation for meeting the challenges of behavioral adaptations.

The horizon must be expanded to include pre patent advocacy and education which requires funding by the governments of member countries on a modest scale. A system of public sector certification and eligibility for   monetary contributions from public sources should be formulated to accelerate the effective prevention of high blood pressure. It would also fill the communication gap between doctors and patients (Go et al., 2014).  

In this regard, the consumption of medicines can be influenced by government regulation of pricing and reimbursement to the patients which can promote the ration access to the medicines especially for costly and creative products.

Another effective strategy to mitigate the issue can be by removing the inequality between the prevention and effective treatment by contributing to the cost of programs which will mitigate the clinical, financial and social burdens from the patients as well as clinics. The private sector should also be motivated to contribute in this regard.

The public policy should assist in bridging up the communication gap amongst the doctors and patients. It should lay stress on top down campaigns which would recognize the patients and act as principles of control in the process of controlling high blood pressure (Centre for Disease Control and Prevention, 2018).

Conclusion 

Hence to conclude, it can be said that to mitigate the problem of high blood pressure  in India ,there is a need for the doctors  to remain upgraded pertaining to  the improvements  in the use of medications , processes and diagnosis is crucial in this regard. Furthermore, they must provide training and assistance, education for healthy lifestyles and prevention and management of chronic diseases to the patients.  The public institutions must endeavor to raise the heath literacy levels of the patients and serve as promoters for the family and friends of the patients and for providing social support for improving the health of the patients.

Efforts in India to raise awareness about hypertension

References 

Australian Institute of Health and Welfare (2017). Risk factors to health. Retrieved May 24th , 2018 from https://www.aihw.gov.au/reports/biomedical-risk-factors/risk-factors-to-health/contents/high-blood-pressure 

Centre for Disease Control and Prevention (2018). Evidence Summary: Control High Blood Pressure. Retrieved May 24^th  , 2018 from https://www.cdc.gov/sixeighteen/bloodpressure/index.htm 

Cock,K.M.D., Simone, , P.M., Davison,V. & Slutsker, L.(2013). The New Global Health. Emerging Infectious Diseases,19(8),1192-1197.

Craig, L.E., McInnes, E., Taylor, N., Grimley, R., Cadilhac, D.A., Considine, J. & Middleton, S.(2016).  Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF). Implementation Science, 11(157),1-18.

Crouse, S. & Kumar, S.(2014). Health Inequalities and Infectious Disease Epidemics: A Challenge for Global Health Security. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science,12(5), 263-273.

Department of Health (2010). Evaluation framework for health promotion and disease prevention programs . Victoria: Prevention and Population Health Branch, Victorian Government Department of Health.

Department of Health and Human Services (2015). Heart Disease and Stroke Strategic Plan. Retrieved May 24^th  , 2018 from https://dpbh.nv.gov/uploadedFiles/dpbhnvgov/content/Programs/Heart/Docs/Heart%20and%20Stroke%20Strategic%20Plan.pdf 

Go, A.S., Bauman, M.A., King, S.M.C., Fonarow, G.C., Lawrence, W., Williams, K.A. &  Sanchez,E.(2014). An Effective Approach to High Blood Pressure Control A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension .DOI: 10.1161/HYP.0000000000000003.

Gov.UK (2017). Health Matters: Combating high blood pressure with the NHS Health Check. Retrieved May 24^th  , 2018 from https://publichealthmatters.blog.gov.uk/2017/01/24/health-matters-combating-high-blood-pressure-with-the-nhs-health-check/ 

Hallberg, I., Ranerup,A. & Kjellgren, K.( 2016). Supporting the self-management of hypertension: Patients’ experiences of using a mobile phone-based system. Journal of Human Hypertension,2016 (30), 141-146.

Hong , S.H., Wang , J. & Tak , S.(2013). A Patient-Centric Goal in Time to Blood Pressure Control from Drug Therapy Initiation. Clinical and Translational Science, 6(1), 7-12.

Indian Council of Medical Research(2018). Hypertension: The Silent Killer. Retrieved May 24^th  , 2018 from https://icmr.nic.in/media/2018/Press%20Release%20Hypertension.pdf 

Liao, Y., SiegeI, P.Z., White, S., Dulin, R. & Taylor, A.(2016).  Improving actions to control high blood pressure in Hispanic communities — Racial and Ethnic Approaches to Community Health Across the U.S. Project, 2009–2012. Preventive Medicine ,2016(83),11–15.

Mills, K.T. , Bundy, J. D., Kelly, T.N., Reed, , J.E., Kearney, P.M., Reynolds, K., Chen, J. & He, J.(2016).Global Disparities of Hypertension Prevalence and Control: A Systematic Analysis of Population-based Studies from 90 Countries. Circulation, 134(6),1-19.

Ministry of Health and Family Welfare (2017). Health Ministry and ICMR launch India Hypertension Management Initiative (IHMI). Retrieved May 24^th  , 2018 from https://pib.nic.in/newsite/PrintRelease.aspx?relid=173938 

Odusola, A.O., Stronks, K., Hendriks, M.E., Schultsz, C., Akande, T., Osibogun, A., Weert, H.V. & Haafkens, J.A.(2016). Enablers and barriers for implementing high-quality hypertension care in a rural primary care setting in Nigeria: perspectives of primary care staff and health insurance managers. Global Health Action,2016(9), 1-16.

Pharmabiz.com (2016). Health Ministry launches IHMI to reduce disability and death related to cardiovascular diseases. Retrieved June 1^st , 2018 from https://www.pharmabiz.com/NewsDetails.aspx?aid=105778&sid=2 

Tan, C.S., Hassali, M.A., Neoh , C.F. & Saleem,F.(2017) . A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level. Pharmacy Practice 2017,15(4), 1-11.

The George Institute of Global Health (2012). Developing a national salt reduction program for India. Retrieved May 24^th  , 2018 from https://www.georgeinstitute.org/projects/developing-a-national-salt-reduction-program-for-india 

WHO (2013). High blood pressure – country experiences and effective interventions utilized across the European Region. Retrieved May 24^th  , 2018 from https://www.euro.who.int/__data/assets/pdf_file/0008/185903/e96816.pdf 

WHO (2018). Global Health Observatory (GHO) data. Retrieved May 23^rd , 2018 from https://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/ 

WHO(2016) .SHAKE the salt habit: The SHAKE technical package for salt reduction. Retrieved May 24^th  , 2018 from https://www.who.int/dietphysicalactivity/publications/shake-salt-habit/en/ 

WHO(2016) .SHAKE the salt habit: The SHAKE technical package for salt reduction. Retrieved May 24^th  , 2018 from https://apps.who.int/iris/bitstream/handle/10665/250135/9789241511346-eng.pdf?sequence=1 

World Health Organization (2016) .Meeting of the WHO Action Network on Salt Reduction in the Population in the European Region (ESAN). Retrieved May 24^th  , 2018 from https://www.euro.who.int/__data/assets/pdf_file/0009/325737/Salt-action-network-ESAN-Lisbon-meeting-report.pdf