The World Hypertension League Challenges Hypertension and Cardiovascular Organizations to Develop Strategic Plans for the Prevention and Control of Hypertension

Increased blood pressure (BP), the leading risk for death and disability globally, is estimated to be responsible for almost one in five deaths and an estimated 7% of disability globally.1 In many economically developing regions, the prevalence of hypertension is both high and increasing.2 Globally, it is estimated that approximately one half of people with hypertension are not aware they have it and that fewer than 20% have controlled BP.2, 3, 4 The epidemic of noncommunicable diseases (NCDs) that are driven by hypertension, tobacco, unhealthy diets, physical inactivity, excess alcohol, obesity, and diabetes is viewed as a threat to the world's development and economies apart from the widespread social and personal distress that NCDs cause.5

It is dismaying to realize that, with the current knowledge, these NCD risks, specifically with respect to hypertension, are largely preventable and treatable. The World Health Organization (WHO) has outlined a series of public health policies to promote healthy diets, physical activity, lower alcohol consumption, and a tobacco‐free environment that would largely prevent blood pressure‐related disease burden and most NCDs if fully implemented.6 Specifically, dietary sodium is highly relevant to the hypertension community as the primary adverse effect of excess dietary salt is mediated through increased BP and attributed to nearly one third of hypertension cases.7 Clinically, controlling hypertension can also prevent its adverse health consequences (although it will not impact patients with suboptimal but normal BP wherein half of BP‐related risk resides).8 From a clinical perspective, the issue put simply is to screen BP at all encounters, diagnose patients with high BP, and treat patients to control.

Underlying the simplicity of the above is the high complexity of influencing, developing, and implementing public health policy; changing community structure, values, and resources; enhancing public self‐efficacy; providing comprehensive primary health care service delivery; ensuring health care providers have the information they need; and surveillance, monitoring, and evaluation to determine what is working and what is not.9 This speaks to the need for comprehensive systematic plans for the prevention and control of hypertension. Several high‐resource countries have developed or are in the process of developing systematic plans for hypertension control.7, 9, 10 Notably, it is the United States and Canada that have long histories of developing and updating such strategies that have the highest rates of hypertension control.9, 11 From these “Best Practices” and lessons learned, strides can be made in translating hypertension prevention and control to all populations.

Strategic planning can be developed by either governments or nongovernmental organizations such as national hypertension societies or preferably through partnership of government and nongovernmental organizations. Strategies focusing on hypertension are perhaps the most feasible and impactful starting point to prevent and control NCDs (arguably competing with tobacco for most impactful health intervention). Several countries have cardiovascular programs that incorporate hypertension prevention and control, while the WHO advocates hypertension integration into NCD prevention and control strategies for low‐resource settings.12 Since the most appropriate strategy is likely to depend on the specific national situation, hypertension organizations have a social responsibility to ensure that hypertension prevention and control is prominent and specifically featured in national NCD or cardiovascular strategies. In this regard, the need for focused hypertension strategies is advocated by the World Hypertension League (WHL). Specifically, that in both low‐ to middle‐resource settings and many high‐resource settings, the most appropriate approach is to incorporate the hypertension strategy into a more comprehensive approach. Further, if a hypertension strategy is the primary starting focus, the ultimate plan should be eventual integration with other risks and diseases. With this framework, the WHL specifically challenges all national hypertension and cardiovascular organizations to develop focused hypertension strategies that can stand alone or are a part of a more comprehensive approach to prevent NCDs.

In developing a strategy, the first step is to consider the context. Is the strategy for the organization's internal use, to use for advocacy to outside organizations, to improve hypertension prevention and control in the population, or even broader to prevent and control NCDs? Is it limited in scope, focusing on clinical control, or is it intended to also address prevention? What are the baseline hypertension data for the population, perhaps using data from the Global Burden of Disease Survey? The scope of the strategy will dictate the different partner organizations that are required for implementation. In general, organizations (ie, primary care) that are impacted by a strategy are much more likely to be supportive if they were involved in the development. Involving governmental organizations is likely critical if the strategy is to involve changes in health policy and the health care system or require substantive governmental resources.

The strategy should set targets for achieving improvements in prevention and control, outline the actions that will allow achievement of those targets, and outline the available indicators that will track progress toward the targets.

There are several hypertension strategies that hypertension organizations can use as templates.7, 9, 10, 12, 13, 14 All strategies require adaptation to the national or regional circumstances based on cultures, values, health literacy, health care systems, and available resources. A commonly used framework in high‐ and low‐resource settings is the Wagner Expanded Chronic Care Model, which the WHL used in developing a hypertension strategy template.15 The WHL has a Powerpoint slide set (www.whleague.org) to support strategic planning that can be adopted to meet the needs of the setting. Some examples of the interventions national organizations can include in their strategic plans under each category in the Wagner model are provided in the Table. Hypertension organizations may find it is most feasible by initially focusing on the health systems or information systems components of the strategy. Simple guidance aimed at primary care settings and utilizing care algorithms are key components and can be adapted from those of the WHO.12 It is paramount that those in low‐resource settings be cognizant of the need to target scarce health care system resources to those at highest risk.12 Strategies that are clinically focused can still indicate the importance of public health policies to prevent hypertension.

Table 1.

Examples of Actions That Could Be Advocated for Hypertension Prevention and Control Using the Wagner Expanded Chronic Care Model as a Framework15

Parameter	Examples of Actions
Build Healthy Public Policy	National policy to have targets and timelines for reducing salt additives to foods	Consideration of health in all government polices
Create supportive environments	Healthy low‐salt foods readily available and affordable to the full population	Fresh fruits and vegetables readily available and affordable to the full population
Strengthen community actions	Safe accessible places to be physically active	High capacity to regularly screen blood pressure in the full population
Self‐management/develop personal skills	Education about healthy eating, cooking, physical activity, healthy body weight, and smoking and alcohol consumption in schools	Personalized information about hypertension management and training to gain skills for all people diagnosed with hypertension
Delivery system design/reorient health services	Available, affordable, high‐quality antihypertensive medications for the full population	Strong interdisciplinary primary care teams with capacity to manage noncommunicable diseases and their risks
Decision support	Simple care algorithm spanning screening, diagnosis, treatment, and control	Health records that incorporate care algorithm and track key hypertension indicators at the clinic level
Information systems	Regular population health surveys that track hypertension prevalence, awareness, treatment, and control in key populations	Standardized analysis for key hypertension indicators with broad dissemination of the findings to decision makers in public and clinical health

Summary

Random, unplanned actions and interventions along with extensive speciality‐focused clinical guidelines have not substantively impacted hypertension prevalence and control. The WHL strongly advocates strategic planning exercises for national and regional organizations that have hypertension as a major focus. Set aspirational targets for prevention and control and, at a minimum, plan to achieve the United Nations targets of a 25% reduction in uncontrolled hypertension and a 30% reduction in dietary salt by 2025 (Table).6, 16

Statement of Financial Disclosure

Dr M. Niebylski and K. Redburn are paid contractors for the World Hypertension League but have no other conflicts. All other authors have no disclosures or other conflicts to declare.