In the WHO Eastern Mediterranean Region, two out of five adults are estimated to have high blood pressure.^[1] Most of these people remain undiagnosed. However, many of them could be easily treated, which would significantly reduce their risk of death and disability from heart disease and stroke.

Shifting focus from expensive tertiary care of noncommunicable diseases to primary and secondary prevention provided by primary health care and the community would be cost effective and save lives. Prevention requires reaching the individual before the disease takes hold, and that means intervening at earlier stages of life.

Most preventive health care and screening for early disease detection and management takes place in the primary health care setting. Primary health care facilities are on the frontline of health care and are ideally positioned to provide regular contact with patients and to apply the preventive measures and continuum of care that people need to prevent or delay disabilities resulting from chronic health conditions. Primary health care facilities can deliver a defined package of services to prevent and control hypertension consisting of: information, education and communication related to healthy lifestyle and proper nutrition; smoking control services; and regular medical check-ups for adults over 40 years of age. Primary health care facilities should be able to screen for hypertension, map diagnosed cases, set up a community-based follow-up system, treat hypertension and undertake relevant emergency management. Other important activities for primary health care facilities include strengthening collaborative work with various stakeholders and community groups involved in this area and developing initiatives based on best practices by supporting information exchange among care providers.

Situation in the WHO Eastern Mediterranean Region

Most primary health care facilities in the Region still focus on curative care of diagnosed cases with no defined interventions for prevention and screening of the disease within their catchment areas. Screening and early detection programmes are limited. Lack of a registration system for diagnosed patients by primary health care facilities and the absence of follow-up mechanisms are among current challenges related to hypertension at the service delivery level. Lack of availability of essential medicine and simple medical equipment and treatment protocols are among other challenges.

Actions for the health system

• Integrate noncommunicable diseases in the work of primary health care facilities.

• Ensure access to essential medicines and protocols for treatment of hypertension, and set up referral facilities for complicated cases or resistance to medications.

• Develop and test service delivery reforms that combine health promotion, prevention, screening and treatment, as well as providing a continuum of care.

• Strengthen health promotion and prevention services at the primary health care level to ensure access to “healthy options” such as management of lifestyle-related risk factors including obesity, tobacco consumption, physical inactivity and unhealthy diet as part of the primary health care interventions.

• Strengthen the volunteerism approach: involve community health workers and nongovernmental organizations and establish home visit programmes for awareness-raising, counselling, monitoring, follow-up and for linking people with primary health care facilities.

• Strengthen data collection and surveillance related to hypertension and noncommunicable diseases to efficiently capture, analyse and use data.

• Apply continuous in-service training to bring about lasting changes to the role of primary health care providers in prevention of hypertension and to improve staff communication skills.

• Promote partnerships across all sectors (public, private, civil society) to ensure coordinated efforts.

• Empower patients for self-care and educate patients about self-monitoring and compliance with medications.

Actions for health care providers: the “5As” approach

• Ask. Ask all patients over the age of 40 years about their smoking, nutrition, alcohol consumption and physical activity and record this information in household file

• Advise. Provide brief, nonjudgmental advice using education materials and motivational interviewing

• Raise awareness of the catchment population about causes of hypertension, preventive measures and the major signs and symptoms of hypertension, advocate for best buy strategies

• Assess. Map high risk and diagnosed cases within catchment area of the primary health care facility

• Assess behavioural risk factors, socioeconomic status and medical history and record it in household files:

Smoking for every patient over 10 years of age ideally at each consultation [If possible assess level of nicotine dependence for those who are identified as current smokers

Nutrition by asking and recording number of portions of fruit and vegetables eaten per day and types of fat eaten

Overweight and obesity by measuring body mass index (BMI) and adult waist circumference especially for those patients who appear overweight and record it in the family file

Physical activity by asking about the current level and frequency of physical activity per week

Alcohol by asking every person aged 15 years and over about drinking and if yes; the quantity and frequency of alcohol intake. 

Assess readiness to change and substance dependence (smoking and alcohol)

• Assess pre-hypertensive status

• Assist. Provide motivational counselling and a prescription (if indicated)

• Provide culturally appropriate preventive care for disadvantaged groups

• Inform families about importance of management of hypertension and involve them in the treatment process

• Arrange. Refer patients as needed to higher levels of care or hotline support services, group lifestyle programmes or individual providers (e.g. dietician or exercise physiologist)

• Schedule regular check-up visits for patients diagnosed with hypertension.

[1] World Health Statistics 2012