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


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 &

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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et al. Hypertension 2003. Outpatient hypertension treatment. et al. Ambrosioni E. Volume 31  Number 1  January 2013 Copyright © Lippincott Williams & Wilkins. this may appear surprising as home BP monitoring by the patients themselves is known to improve medication adherence and. 2001: systematic analysis of population health data. Management of high blood pressure in African Americans: consensus statement of the Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks. Detection. et al. Flack JM. A systematic review of the effects of home blood pressure monitoring on medication adherence. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11 000 participants from 42 trials. The Nigerian antihypertensive adherence trial: a community-based randomized trial. Doyle JP. 2011. 122:290–300. 31:201–207. Lefante J. Overcoming barriers: the role of providers in improving patient adherence to antihypertensive medications. De Backer G. Danaei G. Singh GM. 8. Compliance to antihypertensive treatment: potential implications in practice. 3:203–207. Jamison DT. treatment intensification. Izzo JL Jr. 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. 167:141–147. Cowan MJ. Burnier M. supporting their medication-taking behavior. et al. Madeleine G. provided that efforts are directed at educating patients. [Accessed 22 November 2012]. 3. Bovet P.uk/CG127/Guidance/pdf/English. but also using ambulatory BP monitoring. Mancia G. Hypertension: clinical management of primary hypertension in adults. 6:332–342. Blood Pressure 2007. Mathers CD. the excellent compliance maintained in the two treatment groups. 8:174–180. 17. 4. and giving them access to effective and well tolerated BP-lowering drugs. 80:33–39. The relevance of long-term adherence to nonpharmacological and pharmacological treatment of hypertension. et al. 2. Lancet 2011. National. Am J Hypertens 1997. National Institute for Health and Clinical Excellence. Black HR. Laurent S. and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5. Cifkova R. Law M. and Treatment of High Blood Pressure. Ann Intern Med 2001. Epstein M. Douglas JG.jhypertension. Stafford RS. Ogedegbe G. Feihl F. regional. Alexander GC. Lancet 2006. to increase the fraction of patients normalizing their BP [18]. 18. et al. Dominiczak A. El-Kebbi IM. Ferdinand KC. Struijker-Boudier HA. Chobanian AV. Taken together. Rotimi C. 13. Luke A. Morris JK. which gives practically no room for improvement. Tayo BO. and F. Mancia G. Lin JK. Am J Med 2009. REFERENCES 1. Cook CB. 10:804–812. Branch WT. ACKNOWLEDGEMENTS Conflicts of interest B. Hopefully.com 5. Monitoring one-year compliance to antihypertension medication in the Seychelles. Gallina DL. Harmon G. Bull World Health Organ 2002. Wang YR. 367:1747–1757. 135:825–834. 25:1105–1187. Seventh report of the Joint National Committee on Prevention. that is. 42:1206–1252. Medication adherence and persistence as the cornerstone of effective antihypertensive therapy. Cushman WC. Paccaud F. 48 www. and control in western Europe and the United States. Finucane MM. Global and regional burden of disease and risk factors. http:// guidance. J Hypertens 2013. Waeber B.4 million participants. Brunner HR. Fagard R. Cooper R. Schoenthaler A. Phillips LS. Cooper RS. Evaluation. 15. 14. Germano G. Ferrario C.nice. Bakris GL. 16. 19:1190– 1196. 7. however. Me´try JM. Green LA. have no conflicts of interest to disclose regarding the content of this manuscript. Ezzati M. J Hypertens 2007. Paciorek CJ. Krousel-Wood M. as a result. Curr Hypertens Rev 2007. Lopez AD. At first glance. 12. Unauthorized reproduction of this article is prohibited. 2007 Guidelines for the Management of Arterial Hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Arch Intern Med 2003. The need for combination antihypertensive therapy to reach target blood pressures: what has been learned from clinical practice and morbidity-mortality trials? Int J Clin Pract 2007. Bakris GL. Adeyemo A. 6. 61:1592– 1602. 11. Waeber B. Durazo-Arvizu R. 9. 163:525–541. Clinical inertia.Waeber and Feihl randomized to the clinic management only and in those allocated to the clinic management associated with home visits. Arch Intern Med 2007. Ruilope LM. Hypertension in blacks. the same kind of studies will be repeated in other poor-income countries assessing BP not only with clinic measurements. Curr Opin Cardiol 2006.W. Murray CJ.org. one possible explanation for the lack of difference between the two treatment strategies. 377:568–577. . Wald NJ.F. Bestwick JP. Ogedegbe O. Burnier M. 10. 21:310–315. Am J Hypertens 2006. There is. J Clin Hypertens 2006. Wald DS. Holzgreve H. Waeber B.