Editorial Comment

A community-based intervention program to
effectively treat hypertension in developing countries
Bernard Waeber and Franc¸ois Feihl

See original paper on page 201

T

his 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 lowincome 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
Journal of Hypertension 2013, 31:47–48
Division of Clinical Pathophysiology, Centre Hospitalier Universitaire Vaudois and
University of Lausanne, Lausanne, Switzerland
Correspondence to Bernard Waeber, Division of Clinical Pathophysiology, Centre
Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
E-mail: Bernard.Waeber@chuv.ch
J Hypertens 31:47–48 ß 2012 Wolters Kluwer Health | Lippincott Williams &
Wilkins.
DOI:10.1097/HJH.0b013e32835c7ca0

Journal of 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 b-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 b-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 b-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
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