Table 4.
Some barriers to and policies that could enhance hypertension control.
| Barrier | Policies and programs to address barrier |
|---|---|
| Lack of knowledge, behaviors and skills of people with and at risk for hypertension | Programs that enhance public health literacy, skills and behavior change related to hypertension (e.g., the US national plan to improve health literacy).35 |
| Inequity in access to affordable, high quality, easily accessible care and treatment | Ensure adequate resource allocation to ensure easy access to high quality affordable services for underserved populations and include marginalized populations in the design and implementation of programs. Establish monitoring frameworks that assess and report outcomes on underserved subgroups and modify programs to address inequitable outcomes. |
| Lack of knowledge, behaviors and skills of health care professionals | Restructure training programs for all health care professionals (undergraduate and continuing health care education) to be competency based and emphasize team-based patient-centered public health approaches with quality-of-care monitoring to screening, diagnosis, treatment, and control of non-communicable diseases, including hypertension. PAHO has a standardized and very successful hypertension education program for the primary health care team.36 |
| The health system is designed for acute care and is centered around health care professionals | Evolve the health care system and its infrastructure to deliver high-quality primary care that is easily accessible (e.g., home-based care, worksite, community centers) and affordable (preferably free or low cost).37 Utilize technology to make care more effective and efficient (e.g., smart phones, telemedicine) |
| Lack of screening for and diagnosis of hypertension | Develop a national hypertension screening program to detect the vast majority of people with hypertension. Screening sites should include community resources and examples include old age care homes, dentist offices, blood donation sites, shopping centers, community centers, fire stations, places of worship and barber shops. Resources are available to aid the development of hypertension screening programs.38,39 |
| Suboptimal quality of care | Develop a quality-of-care culture using protocols to report performance to the overall program as well as clinics and clinicians. Develop recognition awards for clinics and clinicians with high performance (e.g., Million Hearts Hypertension Control Champions).40 |
| Lack of program monitoring | Build monitoring and evaluation indicators into the hypertension control program. A PAHO-WHL monitoring, and evaluation framework outlines the key indicators. 33 Regularly report progress to the program and, where appropriate, clinics and clinicians. |
| Lack of adherence to treatment and clinic visits | In training programs emphasize improving adherence to treatments and visits. Some strategies like ensuring treatment regimes in protocols are affordable and straightforward, use of single pill drug combinations, 90-to-120-day prescriptions when targets are met, blister packs, health care professional monitoring of adherence, follow-up of patients who miss appointments, engagement of families in the treatment plan, provision of standardized information on hypertension with individualized written instruction where appropriate, can help to improve adherence.41 |
| Inaccurate BP devices | Develop regulations to only allow the sale of accuracy validated devices for clinical use (including home and ambulatory BP devices)*.26,27 |
| Inaccurate assessment of BP | Ensure those screening for hypertension and those diagnosing hypertension use an accuracy validated automated BP device and have been trained and certified to use the device. There is a standardized PAHO-WHL online training program42,43 and a list of validated automated blood pressure measuring devices44 at the HEARTS in the Americas webpage.17 |
| Lack of identification of people whose blood pressure is high or normal only when outside the clinic setting (e.g., white coat hypertension and masked hypertension)** | Where feasible and affordable, encourage the use of out-of-clinical office BP readings (i.e., community, home or ambulatory) to confirm the diagnosis and monitor BP control.45,46 Ambulatory blood pressure devices are designed to take many blood pressure readings at regular intervals in people who follow their usual daily routines. Home blood pressures are those taken in a home environment, while community blood pressures refer to readings taken outside the home and clinical office (e.g., a pharmacy). |
*an accuracy validated automated BP device has passed accepted national or international accuracy standards testing by an independent group of investigators.26,27
⁎⁎white coat hypertension is a clinical condition where a person only has high blood pressure in the clinical office and normal blood pressure outside the clinical office. Masked hypertension is a clinical condition where a person has high blood pressure outside the clinical office and normal blood pressure in the clinical office.