Public education on hypertension: a new initiative to improve the prevention, treatment and control of hypertension in Canada

Effects of blood pressure unawareness and poor adherence to antihypertensive drugs on outcomes of cerebrovascular accidents among patients with their first-ever stroke

AIMS

Our main target was to investigate the relationship of blood pressure (BP) unawareness and poor antihypertensive drug adherence with the clinical outcomes of the stroke including hospitalization time, degree of disability, and mortality rate.

METHODS AND RESULTS

In this cross-sectional study, we evaluated 530 eligible patients (male = 313; female = 217), aged 18 years and older who had a proven diagnosis of nontraumatic first-ever stroke and were referred to the Shahid Beheshti Hospital of Hamadan, Iran, during the period from March 2019 to September 2021. The prevalence of BP unawareness was 19.6%, and 31.8% of antihypertensive drug users (14.3% of all studied population) had poor drug adherence, in which, older age, male gender, marriage, rural residence, and smoking were associated with the lack of appropriate drug adherence. There was no significant difference between patients with diverse stroke types (ischemic or hemorrhagic) from the points of BP awareness and adherence to antihypertensive drugs; nevertheless, patients with a positive history of cardiac diseases had a significantly higher awareness of their BP status ( P  = 0.037). BP unawareness was associated with poor clinical prognosis, and could significantly increase stroke mortality ( P  = 0.001) and disability ( P < 0.001) rates as well as the duration of hospitalization ( P  < 0.001). Moreover, those who survived the stroke (modified Rankin Scale < 6) had the highest odds to be aware of their BP status (adjusted odds ratio [AOR] = 2.380 [95% confidence interval [CI] = 1.39-4.07]). Additionally, nonsmokers (AOR = 7.740), urban residents (AOR = 3.314), and literate patients (AOR = 2.092) had the highest odds of having appropriate drug adherence.

CONCLUSION

Stroke mortality and morbidity rates can be significantly modified by persuading people to monitor their BP regularly and maximize antihypertensive medication adherence. In the meantime, increasing the literacy level in society and reducing the smoking rate can play important roles in achieving these goals.

Evaluation of the Community-Based Hypertension Management Programs in China

Purpose

The National Essential Public Health Services Package (NEPHSP), a set of community-based hypertension management programs, was launched by the Chinese government in 2009. However, the data are limited for the comprehensive evaluation of NEPHSP on hypertension management. This study was to estimate the effect of NEPHSP on hypertension control nationwide in China.

Methods

Data were from China Hypertension Survey (CHS). The participants (n = 119,412) aged ≥35 years with hypertension were included in the analysis. Further, a subset of 64,188 diagnosed hypertensive patients were analyzed to evaluate the effect of NEPHSP by comparing the ones covered and not covered by NEPHSP. Blood pressure (BP) was measured by trained staff using a validated digital portable monitor in local communities or clinics.

Results

Among adults aged ≥35 years with hypertension, the coverage of NEPHSP was 25.6% and increased with age. The coverage was significantly higher in women than in men (P < 0.001). Among the 64, 188 diagnosed hypertensive patients, compared to the control group (not covered by NEPHSP), the mean systolic and diastolic BPs were 2 mmHg and 1.6 mmHg lower in NEPHSP group, respectively. The rate of treatment for hypertension was significantly higher in NEPHSP group than the control group (93.0% vs. 81.4%, P < 0.001), and the rate of BP control was also significantly higher in NEPHSP group than the control group (35.9% vs. 29.6%, P < 0.001). Furthermore, similar trends were found in rural and urban, as well as in men and women.

Conclusions

Our results showed that NEPHSP is effective in improving hypertension treatment and control in hypertensive patients in China. However, the coverage of NEPHSP was still low.

A proposed research agenda concerning supervisor training for newcomer organizational socialization

Purpose

The purpose of this paper is to identify extant training needs for preparing supervisors to support newcomers’ organizational socialization and to develop a research agenda concerning aspects that conduce to making supervisors efficacious in the process of organizational socialization.

Design/methodology/approach

A review of the literature on the development of socialization agents for organizational socialization generally indicates that relatively minimal research has been undertaken on this topic. Most articles have focused on the effects of organizational socialization on other variables – such as newcomers’ work outcomes, turnover intention and organizational commitment. The review was conducted in light of this phenomenon. It is based on the structured literature review method, per Rocco, Stein and Lee (2003).

Findings

Supervisor training is suggested as a means for enhancing organizational socialization. However, supervisor training is not often studied in organizational socialization research. Therefore, the verification of the impact of supervisor training on organizational socialization is required. Given the proposed research agenda, identifying the impact of supervisor training on different areas of organizational socialization domains and inspiring increased interest on supervisor training as an effective program for organizational socialization are logical outcomes.

Research limitations/implications

The concept of socialization is used in broad areas of research, such as education, military and engineering. However, it was reviewed here vis-à-vis human resource development (HRD). Therefore, the focus was on the notion of organizational socialization, which is appropriate for employee training development. The concept of organizational socialization in this paper, therefore, was delimited, as it failed to include all meanings of socialization. This paper sought to review all studies related to organizational socialization. However, some research was not considered and, thus, not discussed in this paper. This was because of time and resource constraints. The author sorted previous studies by personal standards and, thus, may have inadvertently included non-germane or excluded relevant citations.

Practical implications

Supervisory training for organizational socialization can be proposed as a potential area for leading to an effective organizational socialization program. So HRD professionals should study further about the topic and develop such programs. Increased attention on supervisor training for organizational socialization may increase the number and quality of supervisor training programs. Such studies would augment HRD professionals’ knowledge about organizational socialization and eventually enhance performance in organizations.

Social implications

This paper can expand the area in which social learning theory can be applied. According to Bandura and Walters (1977), the social learning theory posits that learning new behaviors can usually be acquired by observing and imitating others. This implies that newcomers emulate other organizational members to adapt to the organization and their assigned roles. In this process, supervisors can play a key role through showing them the appropriate behaviors, supporting their learning and providing appropriate feedback. Presumably, then, new employees may perform better if supervisors receive training on crucial socialization efforts.

Originality/value

Significantly, socialization agents are uniquely situated to greatly impact the organizational socialization process of newcomers. Among the socialization agents, supervisors garner enormous influence on newcomers’ organizational socialization. However, relatively few studies investigated the training of supervisors for organizational socialization.

Adherence to Antihypertensive Treatment and Associated Factors in Central Ethiopia

Background

Adherence to treatment is a primary determinant of treatment success. Nonadherence attenuates clinical benefits to the recipients of the treatment. However, monitoring adherence to long treatment regimens is not given due emphasis in low-income contexts. This study aimed to assess adherence to antihypertensive treatment and factors associated with it in Central Ethiopia.

Method

This is an institution-based cross-sectional study conducted in 4 public hospitals in Central Ethiopia from December 4, 2016, to September 25, 2017. The Morisky Medication Adherence Scale (MMAS-8) was used to assess the level of adherence. The Revised Illness Perception Questionnaire (IPQ-R) was used to assess illness perception. The MMAS-8 score ranges from 0 to 8, a score of 8 reflects high adherence, 6 to 7 medium adherence, and <6 low adherence.

Results

A total of 989 hypertensive patients participated in the study, of which 36.0% were assessed to have high adherence, 31.7% medium adherence, and 32.3% low adherence. We found that treatment adherence was significantly and positively associated with having family support (AOR: 1.65; 95% CI = 1.23, 2.22), high perception about consequences of hypertension (AOR: 1.51; 95% CI = 1.17, 1.95), and high perception about the severity of the disease (AOR: 1.42; 95% CI = 1.09, 1.86).

Conclusion

The treatment adherence to antihypertensive medications is low in Central Ethiopia. Engaging family members in the treatment plan and improving patients' understanding of the illness are critical in achieving high adherence to medication in this context.

A Gap in Post-Stroke Blood Pressure Target Attainment at Entry to Cardiac Rehabilitation

BACKGROUND

Recurrent events account for approximately one-third of all strokes and are associated with greater disability and mortality than first-time strokes. Blood pressure (BP) is the most important modifiable risk factor. Objectives were to determine the proportion of post-stroke patients enrolled in cardiac rehabilitation (CR) meeting systolic and diastolic BP (SBP/DBP) targets and to determine correlates of meeting these targets.

METHODS

A retrospective study of 1,804 consecutively enrolled post-stroke patients in a CR program was conducted. Baseline data (database records 2006-2017) included demographics, anthropometrics, clinical/medication history, and resting BP. Multivariate analyses determined predictors of achieving BP targets.

RESULTS

Mean age was 64.1 ± 12.7 years, median days from stroke 210 (IQR 392), with most patients being male (70.6%; n = 1273), overweight (66.8%; n = 1196), and 64.2% diagnosed with hypertension (n = 1159), and 11.8% (n = 213) with sleep apnea. A mean of 1.69 ± 1.2 antihypertensives were prescribed, with 26% (n = 469) of patients prescribed 3-4 antihypertensives. SBP target was met by 71% (n = 1281) of patients, 83.3% (n = 1502) met DBP target, and 64.3% (n = 1160) met both targets. Correlates of meeting SBP target were not having diabetes, younger age, fewer prescribed antihypertensives, and more recent program entry. Correlates of meeting DBP target were not having diabetes, older age, fewer prescribed antihypertensives, and more recent stroke.

CONCLUSIONS

Up to one-third of patients were not meeting BP targets. Patients with diabetes, and those prescribed multiple antihypertensives are at greater risk for poorly controlled SBP and DBP. Reasons for poor BP control such as untreated sleep apnea and medication non-adherence need to be investigated.

Knowledge, attitude and practice regarding hypertension among residents in a housing area in Selangor, Malaysia

Background and aims

Hypertension is becoming a global epidemic and threat to the world population. This cross-sectional study was carried out at a housing area in Selangor, Malaysia to study the knowledge, attitude and practice (KAP) regarding hypertension among the residents.

Methods

A total of 110 respondents aged 18 years old and above were selected by convenience sampling. Data was collected using a structured interviewer-guided questionnaire with Likert-scale choices of answers.

Results

All respondents were Malay with the mean age of 41 years [Standard Deviation (SD)=11.828]. The total mean and SD of knowledge, attitude and practice scores were 74.33 (SD=6.25), 44.22 (SD=5.05) and 27.55 (SD=2.86), respectively. There were significant positive correlations between knowledge with attitude (r=+0.393; p<0.001) and practice (r=+0.378; p<0.001). However, there was no significant correlation between attitude and practice (r=+0.120; p=0.212). There were significant fair positive correlations between age with knowledge (r=+0.402; p<0.001), attitude (r=+0.265; p=0.005) and practice (r=+0.337; p<0.001) regarding hypertension. Meanwhile, gender, educational level, employment status and family history had no significant association with knowledge, attitude and practice regarding hypertension.

Conclusion

This study revealed that KAP regarding hypertension were associated with age, but not with other socio-demographic characteristics studied. The awareness, prevention and control programs of hypertension in their community should be increased, so that the residents could enjoy and maintain the healthy lifestyle.

The Determinants of and Barriers to Awareness and Treatment of Hypertension in the Korean Population

This study investigated whether sociodemographic, health behavioral, biomedical, and health status factors are associated with the awareness and treatment status of hypertension. Data were analyzed from 13 180 adults with hypertension in a nationally representative sample collected from 2007 to 2015 through the Korean National Health and Nutrition Examination Survey. Among hypertensive Korean adults, only 65.2% were aware of their condition and being treated with antihypertensive medications. Younger age was identified as an important barrier to diagnosis and treatment of hypertension. Although there were slight differences between participants aged <65 and ≥65 years, higher risks of being untreated or being unaware of having hypertension were also associated with male gender, lower education levels, unhealthy behaviors, and a better health conditions. We suggest that aggressive interventions to improve the awareness, treatment, and/or control of hypertension should be applied to young and middle-aged people who are vulnerable to hypertension management.

Facebook recruitment of Chinese-speaking participants for hypertension education

Effective dissemination of health information to a desired population can be a challenging and expensive process, particularly to Chinese-Americans. Print and radio advertisements are limited by geographic, language, cost, and demographic barriers. The expense and efforts necessary to overcome these challenges can delay the distribution of knowledge and make it more expensive than necessary. The advent of web-based advertisements through media platforms such as Facebook offers a new method of reaching target audiences who can be both cost-effective and specific. A Facebook advertisement was displayed for 48 hours and consisted of a 26-character Chinese text body. The advertisement linked to an external informational video on hypertension prevention. Demographic information including age and gender were recorded. Descriptive statistics were used to compare reach and number of ad clicks between age groups. The 48-hour campaign reached a total of 508 people. Of those reached, 289 participants (56.9%) were between the ages of 55-64 years, and 170 participants (33.5%) were 65 years or older. The campaign also generated 52 link clicks. The results show that Facebook is a promising method of engaging Chinese-Americans. It is particularly effective in reaching the older female population and is a cost-effective alternative to print-based advertisements.

Evaluating a train-the-trainer approach for improving capacity for evidence-based decision making in public health

Background

Evidence-based public health gives public health practitioners the tools they need to make choices based on the best and most current evidence. An evidence-based public health training course developed in 1997 by the Prevention Research Center in St. Louis has been taught by a transdisciplinary team multiple times with positive results. In order to scale up evidence-based practices, a train-the-trainer initiative was launched in 2010.

Methods

This study examines the outcomes achieved among participants of courses led by trained state-level faculty. Participants from trainee-led courses in four states (Indiana, Colorado, Nebraska, and Kansas) over three years were asked to complete an online survey. Attempts were made to contact 317 past participants. One-hundred forty-four (50.9 %) reachable participants were included in analysis. Outcomes measured include frequency of use of materials, resources, and other skills or tools from the course; reasons for not using the materials and resources; and benefits from attending the course. Survey responses were tabulated and compared using Chi-square tests.

Results

Among the most commonly reported benefits, 88 % of respondents agreed that they acquired knowledge about a new subject, 85 % saw applications for the knowledge to their work, and 78 % agreed the course also improved abilities to make scientifically informed decisions at work. The most commonly reported reasons for not using course content as much as intended included not having enough time to implement evidence-based approaches (42 %); other staff/peers lack training (34 %); and not enough funding for continued training (34 %). The study findings suggest that utilization of course materials and teachings remains relatively high across practitioner groups, whether they were taught by the original trainers or by state-based trainers.

Conclusions

The findings of this study suggest that train-the-trainer is an effective method for broadly disseminating evidence-based public health principles. Train-the-trainer is less costly than the traditional method and allows for courses to be tailored to local issues, thus making it a viable approach to dissemination and scale up of new public health practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1224-2) contains supplementary material, which is available to authorized users.

Hypertension management initiative prospective cohort study: comparison between immediate and delayed intervention groups

The Heart and Stroke Foundation of Ontario's Hypertension Management Initiative (HMI) was a pragmatic implementation of clinical practice guidelines for hypertension management in primary care clinics. The HMI was a prospective delayed phase cohort study of 11 sites enrolling patients in two blocks starting 9 months apart in 2007. The intervention was an evidence-informed chronic disease management program consisting of an interprofessional educational intervention with practice tools to implement the Canadian Hypertension Education Program's clinical practice guidelines. This study compares the change in blood pressure (BP) from baseline to 9 months after the intervention between groups. In the immediate intervention group, the mean BP at baseline was 134.6/79.1 mm Hg (18.2/11.5) and in the delayed intervention group 134.2/77.1 mm Hg (18.9/11.8). The fall in BP in the immediate intervention group from baseline to 9 months after the intervention was 7.3/3.6 mm Hg (95% confidence interval (CI): 5.9-8.7/2.6-4.5) and in the delayed group 8.1/3.3 mm Hg (95% CI: 7.0-9.3/2.5-4.1) (all P<0.0001 were compared from baseline to the end of 9 months of the program in both groups). This study is the first to demonstrate that implementation of an interprofessional knowledge integration initiative for the control of hypertension can rapidly lead to lower BP levels.

The Know Your Numbers (KYN) program 2008 to 2010: impact on knowledge and health promotion behavior among participants

BACKGROUND

Since 2007, the National Stroke Foundation in Australia has undertaken a community-based 'Know Your Numbers' program on blood pressure and other stroke risk factors.

AIMS

The aims of this study are to assess, in a sample of registrants participating in a three-month follow-up survey, retention of knowledge of risk factors and health conditions associated with hypertension, and whether those who were advised to see their doctor sought treatment or performed other health promotion actions.

METHODS

Various organizations (mainly pharmacies) were recruited to offer a 'free' standardized blood pressure check and educational resources for one-week/year between 2008 and 2010. Data collection was done thru registration log and detailed questionnaires for a sample of registrants at baseline and three-months. Descriptive statistics were used for comparison of baseline and three-month data.

RESULTS

There were 59 817 registrants over three-years. A total of 2044/2283 (90%) registrants completed a baseline survey (66% female, 50% aged >55 years); 43% had blood pressure ≥140/90 mmHg whereby 32% were unaware of their blood pressure status. Follow-up surveys were obtained from 510/805 (63%) baseline participants who provided consent. At three-months, improved knowledge was found for 9 of 11 risk factors for hypertension (e.g. lack of exercise baseline 73%; three-months 85%, P < 0·001). Knowledge for all the health conditions assessed that are associated with hypertension improved (e.g. stroke baseline 72%; three-months 87%, P < 0·001, heart attack baseline 69%; three-months 84%, P < 0·001). All respondents reported at least one health promotion action. Among 141/510 advised to visit their doctor, 114 (81%) did.

CONCLUSION

Know Your Numbers is a successful health promotion program and encourages people to be reviewed by their doctor.

[Effectiveness of an educational intervention on hypertension directed at elderly hypertensive patients]

INTRODUCTION

Hypertension is the most prevalent cardiovascular risk factor among people over the age 60. The aim of this study is to assess the effectiveness of an educational intervention tool, and its reliability.

MATERIAL AND METHODS

Experimental study, prospective, randomised, parallel-group in a sample of 120 patients, 62 in the intervention group and 58 in the control group. The intervention group received a written and oral educational program on hypertension and cardiovascular risk; the control group did not receive any intervention.

RESULTS

At the end of the intervention there was an increase in the percentage of correct responses, with statistically significant differences compared to the control group, as regards knowledge of hypertension, risk factors associated with the risks of having high blood pressure and control medication.

CONCLUSION

The implementation of an educational intervention on hypertension and cardiovascular risk associated with the same care activity is capable of increasing the level of knowledge by elderly hypertensive patients admitted to hospital.

Building blocks for peer success: lessons learned from a train-the-trainer program

The National HIV/AIDS Strategy (NHAS) calls for a reduction in health disparities, a reduction in new HIV infections, and improved retention in HIV care and treatment. It acknowledges that HIV-positive peers can play an important role in supporting these aims. However, peer training must be comprehensive enough to equip peers with the knowledge and skills needed for this work. This article describes the development of a national train the trainer (TTT) model for HIV peer educators, and the results of its implementation and replication. A mixed methods evaluation identified who was trained locally as a result of TTT implementation, what aspects of the TTT were most useful to trainers in implementing local training sessions, and areas for improvement. Over the course of 1 year, 91 individuals were trained at 1 of 6 TTT sessions. These individuals then conducted 26 local training sessions for 272 peers. Factors that facilitated local replication training included the teach-back/feedback model, faculty modeling of facilitation styles, financial support for training logistics, and faculty support in designing and implementing the training. The model could be improved by providing instruction on how to incorporate peers as part of the training team. TTT programs that are easily replicable in the community will be an important asset in developing a peer workforce that can help implement the National AIDS Strategy.

Do recommendations for the management of hypertension improve cardiovascular outcome? The canadian experience

The Canadian Hypertension Education Program (CHEP) was established in 1999 as a response to the result of a national survey that showed that a high percentage of Canadians were unaware of having hypertension with only 13% of those treated for hypertension having their blood pressure controlled. The CHEP formulates yearly recommendations based on published evidence. A repeat survey in 2006 showed that the percentage of treated hypertensive patients with the blood pressure controlled had risen to 65.7%. Over the first decade of the existence of the CHEP, the number of prescriptions for antihypertensive medications had increased by 84.4% associated with a significant greater decline in the yearly mortality from stroke, heart failure and myocardial infarction and a significant decrease in the hospitalization for stroke and heart failure. Therefore, the introduction of the CHEP and the yearly issue of updated recommendations resulted in a significant increase in the awareness, diagnosis and treatment of hypertension and in a significant reduction in stroke and cardiovascular morbidity and mortality. The CHEP model could serve as a template for its adoption to other regions or countries.

Tackling health literacy: adaptation of public hypertension educational materials for an Indo-Asian population in Canada

Background

Indo-Asians in Canada are at increased risk for cardiovascular diseases. There is a need for cultural and language specific educational materials relating to this risk. During this project we developed and field tested the acceptability of a hypertension public education pamphlet tailored to fit the needs of an at risk local Indo-Asian population, in Calgary, Alberta, Canada.

Methods

A community health board representing Calgary's Indo-Asian communities identified the culturally specific educational needs and language preferences of the local population. An adaptation of an existing English language Canadian Public Hypertension Recommendations pamphlet was created considering the literacy and translation challenges. The adapted pamphlet was translated into four Indo-Asian languages. The adapted pamphlets were disseminated as part of the initial educational component of a community-based culturally and language-sensitive cardiovascular risk factor screening and management program. Field testing of the materials was undertaken when participants returned for program follow-up seven to 12 months later.

Results

Fifty-nine English-speaking participants evaluated and confirmed the concept validity of the English adapted version. 28 non-English speaking participants evaluated the Gujarati (N = 13) and Punjabi (N = 15) translated versions of the adapted pamphlets. All participants found the pamphlets acceptable and felt they had improved their understanding of hypertension.

Conclusions

Involving the target community to identify health issues as well as help to create culturally, language and literacy sensitive health education materials ensures resources are highly acceptable to that community. Minor changes to the materials will be needed prior to formal testing of hypertension knowledge and health decision-making on a larger scale within this at risk community.

Canadian efforts to prevent and control hypertension

Suboptimum blood pressure is estimated to be the leading risk factor for death worldwide and is associated with 13.5% of deaths globally. The clinical diagnosis of hypertension affects one in four adults globally and is expected to increase by 60% between 2000 and 2025. Clearly, global efforts to prevent and control hypertension are important health issues. While Canada had a prevalence of hypertension similar to that of the United States in the early 1990 s, the treatment and control rate was only 13% compared with 25% in the United States. A national strategic plan was developed, and a coalition of organizations and health care professional and scientist volunteers actively implemented parts of the strategy. Specific initiatives that have evolved include the development of hypertension knowledge translation programs for health professionals, the public and people with hypertension, an outcomes research program to assess the impact of hypertension and guide national-, regional- and community-based knowledge translation interventions, and a program to reduce the prevalence of hypertension by decreasing sodium additives in food. These initiatives have relied on the active involvement of health care professional volunteers, health care professional and scientific organizations and various government departments. There have been large increases in the diagnosis and treatment of hypertension, with corresponding reductions in cardiovascular disease and total mortality associated with the start of the hypertension initiatives. As a result, Canada is becoming recognized as a world leader in the prevention, treatment and control of hypertension.

The effect of a patient education booklet and BP 'tracker' on knowledge about hypertension. A randomized controlled trial

PURPOSE

Home blood pressure (BP) monitoring is increasingly prevalent. The Canadian Hypertension Education Program (CHEP) developed a Family Practice BP tracking diary for home readings with an educational booklet. We evaluated the effectiveness of these tools compared with the standard approach of a hypertension information leaflet on BP-related knowledge, attitudes and behaviours of hypertensive family practice patients.

METHOD

Single-blind randomized control trial on patients with raised BP.

RESULTS

Three practices in Ontario, Quebec and Nova Scotia recruited a total of 109 eligible patients. The average age was 66.1 (SD 9.3) years and 58 (54.7%) were male. There was a statistically significant increase in the mean number of correct responses to 20 hypertension knowledge questions of 1.14 from 15.3 (SD 2.2) at baseline to 16.4 (SD 2.2) at 3 months in both groups (n=72, P<0.001). Patients frequently did not realize that usually more than one drug plus lifestyles changes were necessary to reduce BP to target or that it might take 6 weeks for some drugs to achieve their full effect. The BP tracking diary and the booklet had positive evaluation from the patients.

CONCLUSIONS

Most patients have a good baseline of knowledge about hypertension but there are still important areas that need to be addressed. The booklet and tracker were well received by patients but the simple leaflet was as effective at improving knowledge.

Hypertension: are you and your patients up to date?

While there have been substantive efforts to improve treatment and control of hypertension in Canada, many individuals with hypertension remain unaware of their condition and many health care professionals are unaware of key hypertension management recommendations. The present article reviews the new Canadian strategic direction for increased knowledge translation and dissemination of information to patients and health care professionals by providing new, innovative and easily accessible resources for hypertension education in Canada. A multitude of resources that address the diverse learning needs of health care professionals and the general public are highlighted.

The 2008 Canadian Hypertension Education Program recommendations: the scientific summary -- an annual update

The present paper summarizes and highlights key messages of the 2008 Canadian Hypertension Education Program recommendations for the diagnosis and management of hypertension. The 2008 recommendations emphasize proper self-measurement of blood pressure as a step toward greater patient involvement in hypertension management. Home measurement is a better predictor of cardiovascular events than office measures; it can also confirm the diagnosis of hypertension, improve blood pressure control, reduce the need for medications in some patients, screen for white coat and masked hypertension, and improve medication adherence in nonadherent patients. The recommendations continue to emphasize the importance of reducing dietary sodium and implementing other lifestyle changes to prevent and control hypertension. Furthermore, regular assessment of blood pressure at all appropriate visits and identification and management of all cardiovascular risk factures continue to be the cornerstone of the Canadian Hypertension Education Program. Most of the new evidence in 2008 confirmed previous Canadian Hypertension Education Program recommendations. A notable new recommendation is the option to initiate pharmacotherapy with two first therapies if blood pressure is higher than 20/10 mmHg above target. Recently, the Ontario Blood Pressure survey found the treatment and control rate of hypertension in Ontario to be far higher than anywhere else in the world. This speaks to the success of primary care and the Canadian health system in diagnosing, treating and controlling hypertension.

The 2007 Canadian Hypertension Education Program recommendations: the scientific summary - an annual update

The present paper summarizes and highlights key messages of the 2007 Canadian Hypertension Education Program recommendations for the management and diagnosis of hypertension. This is the eighth annual update. Important new messages in the 2007 Canadian Hypertension Education Program recommendations emphasize the need for assessing adults with high normal blood pressure on an annual basis and reducing sodium in the diet of Canadians to less than 100 mmol/day. These new recommendations still need to be incorporated into the older but still important considerations for the diagnosis, management and treatment of patients with hypertension, namely, assessing blood pressure in all adults at all appropriate visits, expediting the diagnosis of hypertension, assessing and managing global cardiovascular risk, emphasizing that lifestyle modifications are the cornerstone of antihypertensive therapy, treating to target to achieve optimum cardiovascular risk reduction, using combinations of antihypertensive medications and lifestyle to achieve recommended targets and focusing on adherence to therapy. Minor changes in pharmacological therapies and some new recommendations on routine laboratory tests are discussed.

Antihypertensive medication use by recently diagnosed hypertensive Canadians

PURPOSE

The Canadian Hypertension Education Program (CHEP) was initiated in 1999 to improve hypertension management in Canada. The objective of the present study was to compare antihypertensive pharmacotherapy in Canada before and after the CHEP.

METHODS

Data were obtained from the longitudinal National Population Health Surveys, which consisted of five cycles at two-year intervals from 1994 to 2002. Recent hypertensive respondents 20 years of age and older were identified the first time hypertension was reported or treated, and were included in a study population of 1453 newly diagnosed hypertensive patients. Persistence with medication use was assessed in the cycle after the first report of hypertension.

RESULTS

Antihypertensive medication use within two years of hypertension diagnosis increased with age, from 35% in patients 20 to 39 years of age, to 72.1% in those 80 years of age and older. Antihypertensive medication use increased after the CHEP (from 49.2% to 53.8% of the population), as did the use of multiple antihypertensive medications (from 7.5% to 10.6%). The most commonly used antihypertensive medication for men was angiotensin-converting enzyme inhibitors (beta-blockers were second), but the most common medication for women was diuretics. The overall persistence rate for antihypertensive medication use was 73.2% over two years, which had increased after the CHEP (from 70.4% to 75.4%).

CONCLUSIONS

The implementation of the CHEP was followed by increased antihypertensive medication use, increased use of multiple antihypertensive medications and improved persistence with medication use. Although causality cannot be established with the design of the present study, improved hypertension management in Canada is heartening. Sex-related differences were observed in prescribed medications, even though clinical guidelines do not differentiate between sexes.

Impact of World Hypertension Day

It is estimated that nearly one billion people are affected by hypertension worldwide, and this figure is predicted to increase to 1.5 billion by 2025. Nearly one-half of this population are unaware of their condition. Hypertension is the primary risk factor for heart disease and stroke. World Hypertension Day (WHD) has been an initiative of the World Hypertension League to raise hypertension awareness. In the past two years, many countries have taken an active part in promoting awareness through a number of initiatives in their respective countries. In Canada, WHD was a resounding success in 2005 and 2006, and major plans are underway for WHD 2007. The success of the Canadian WHD depends mainly on the partnership and shared values of all stakeholders, including professional societies, nongovernment organizations, government agencies and industry. Although it is too early to assess the impact of hypertension, it is evident that the countries involved are taking hypertension in the population seriously and are moving in the right direction. If the momentum continues, a drastic reduction in the prevalence of worldwide hypertension can be anticipated.

Worldwide epidemic of hypertension

The World Health Report 2002 identified hypertension, or high blood pressure, as the third ranked factor for disability-adjusted life years. Hypertension is one of the primary risk factors for heart disease and stroke, the leading causes of death worldwide. Recent analyses have shown that as of the year 2000, there were 972 million people living with hypertension worldwide, and it is estimated that this number will escalate to more than 1.56 billion by the year 2025. Nearly two-thirds of hypertensives live in low- and middle-income countries, resulting in a huge economic burden. Awareness, prevention, treatment and control of hypertension is a significant public health measure. The World Hypertension League, through its national member societies, launched World Hypertension Day in 2005 and, due to its success throughout the world, it has been made an annual event. The 2006 World Hypertension Day was held on May 13; the theme of the day was "Treat to Goal", with a clear intent to ensure patient adherence and control of hypertension worldwide. In Canada, all stakeholders--professional societies, government, nongovernment organizations and industry--are working together to promote awareness of hypertension and to control it.

Implementation of recommendations on hypertension: the Canadian Hypertension Education Program

The diffusion of research evidence or practice guidelines does not, by itself, lead to changes in practice behaviour or patient outcomes. The Canadian Hypertension Education Program (CHEP) was specifically structured to have an explicit process to improve the ability of primary care professionals to use CHEP recommendations. The key features of this process are reviewed in the present report. The responsibility for implementation of recommendations is divided between the executive committee of CHEP and the Implementation Task Force (ITF). The executive develops an extensive array of summaries and implementation tools for the recommendations, and encourages and facilitates other organizations to develop educational materials and programs. The ITF creates further implementation tools, tailors the tools to specific health care disciplines and creates discipline-specific dissemination strategies. Currently, CHEP recommendations are disseminated through updated full scientific manuscripts, short scientific and clinical summaries, one-page handouts, wall posters, pocket cards, advertisements, extensive slide kits, textbooks, didactic lectures and workshops. A Web site with the recommendations in different formats is maintained to allow easy access. More recently, media releases have been used to alert the public and health care professionals to important recommendations. The transparent and interactive annual process of developing the recommendations by most of Canada's clinical hypertension experts is also viewed as critical to providing uniform educational messages to health care professionals from national and local opinion leaders. The CHEP ITF includes primary care disciplines and specialties important to blood pressure control. The CHEP process for the implementation of recommendations is very extensive and continues to evolve. There is early evidence for improvement in the management of hypertension in Canada that coincides with the initiation of CHEP, suggesting that CHEP could serve as a model for disease management recommendations.