Editorial Comment

A community-based intervention program to

effectively treat hypertension in developing countries
Bernard Waeber and Francois 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 [57]. 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 patients 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, 31:4748
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 31:4748 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 [1315].
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
www.jhypertension.com

47

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Waeber and Feihl

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.

REFERENCES
1. Adeyemo A, Tayo BO, Luke A, Ogedegbe O, Durazo-Arvizu R, Cooper
RS. The Nigerian antihypertensive adherence trial: a community-based
randomized trial. J Hypertens 2013; 31:201207.
2. Cooper R, Rotimi C. Hypertension in blacks. Am J Hypertens 1997;
10:804812.
3. Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ,
et al. National, regional, and global trends in systolic blood pressure
since 1980: systematic analysis of health examination surveys
and epidemiological studies with 786 country-years and 5.4 million
participants. Lancet 2011; 377:568577.
4. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and
regional burden of disease and risk factors, 2001: systematic analysis
of population health data. Lancet 2006; 367:17471757.

48

www.jhypertension.com

5. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL
Jr, et al. Seventh report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure.
Hypertension 2003; 42:12061252.
6. Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano
G, et al. 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). J Hypertens 2007; 25:11051187.
7. National Institute for Health and Clinical Excellence. Hypertension:
clinical management of primary hypertension in adults. http://
guidance.nice.org.uk/CG127/Guidance/pdf/English; 2011. [Accessed
22 November 2012].
8. Wang YR, Alexander GC, Stafford RS. Outpatient hypertension treatment, treatment intensification, and control in western Europe and
the United States. Arch Intern Med 2007; 167:141147.
9. Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ. Combination therapy
versus monotherapy in reducing blood pressure: meta-analysis on
11 000 participants from 42 trials. Am J Med 2009; 122:290300.
10. Struijker-Boudier HA, Ambrosioni E, Holzgreve H, Laurent S, Mancia G,
Ruilope LM, et al. 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; 61:1592
1602.
11. Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL,
et al. Clinical inertia. Ann Intern Med 2001; 135:825834.
12. Douglas JG, Bakris GL, Epstein M, Ferdinand KC, Ferrario C, Flack JM,
et al. 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.
Arch Intern Med 2003; 163:525541.
13. Burnier M. Medication adherence and persistence as the cornerstone of
effective antihypertensive therapy. Am J Hypertens 2006; 19:1190
1196.
14. Waeber B, Brunner HR, Metry JM. Compliance to antihypertensive
treatment: potential implications in practice. Blood Pressure 2007;
6:332342.
15. Harmon G, Lefante J, Krousel-Wood M. Overcoming barriers: the
role of providers in improving patient adherence to antihypertensive
medications. Curr Opin Cardiol 2006; 21:310315.
16. Bovet P, Burnier M, Madeleine G, Waeber B, Paccaud F. Monitoring
one-year compliance to antihypertension medication in the Seychelles.
Bull World Health Organ 2002; 80:3339.
17. Waeber B, Feihl F. The relevance of long-term adherence to nonpharmacological and pharmacological treatment of hypertension.
Curr Hypertens Rev 2007; 3:203207.
18. Ogedegbe G, Schoenthaler A. A systematic review of the effects
of home blood pressure monitoring on medication adherence. J Clin
Hypertens 2006; 8:174180.

Volume 31  Number 1  January 2013

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.