The Assessment of Prevalence of Hypertension as Cardiovascular Risk Factors Among Adult Population

Among the non-communicable diseases, cardiovascular disorders are the leading cause of morbidity and mortality in both the developed and the developing countries. The spectrum of risk factors is wide and their understanding is imperative to prevent the first and recurrent episodes of myocardial infarction, stroke or peripheral vascular disease which may prove fatal or disabling. This book has tried to present an update on risk factors incorporating new research which has thrown more light on the existing knowledge. It has also tried to highlight regional diversity addressing such issues. It will hopefully be resourceful to the cardiologists, general practitioners, family physicians, researchers, graduate students committed to cardiovascular risk prevention.

physical inactivity and psychosocial stress are the leading risk factors for cardiovascular disease, as well as consequential manifestations of such life styles: hypertension, glucose intolerance and hyperlipidemia. These risk factors also reflect major preventable health problems. (5-12)) In the world the issue of cardiovascular disease became very pressing in early 1970s. At that time many health intervention program were planned at the level of the community and their purpose was to promote health and reduce detrimental life style changes. The basic starting premise was that the use of measures to reduce risk factors in population with clinically identified risk factors has only a limited effect on prevention of cardiovascular risk factor at the national level; on the other hand, global public health actions have more effects altogether.
The first implemented program that was based on these ideas was the North Karelia Project carried out in Finland in 1972. This project achieved significant results, in particularly through the hypertension control programs. It started off as a pilot but after significant net reductions in both risk factors and cardiovascular disease-caused mortality rate, the project was rolled out to the national level. Over the next 25 years, smoking prevalence in men was significantly reduced and so was serum cholesterol and blood pressure levels. Over this period, mortality rate caused by cardiovascular disease in men aged 35-64 years dropped by 68%, coronary heart disease mortality rate by 73%, cancer mortality rate by 44%, and mortality rate for all samples effectively dropped by 49%. (13)(14)(15) Building on this success, many projects have been implemented since then in the form of demonstrational projects under different WHO programs: CINDI (WHO/EURO), CARMEN (WHO/AMRO), and INTERHEALTH (WHO/HQ). Apart from clinical trials, all these projects involved different design, intervention approach, method, intensity, goals in reducing the risk factors, evaluation measurements and timeline. Major role of projects implemented in community is to demonstrate and stimulate health policies of noncontagious disease prevention. (16) In their recommendations for 2003, the WHO and the International Society of Hypertension (ISH) defined three sets of risk factors required for monitoring in management of hypertension. (Table 1.) (28) Based on this, a stratification of overall cardiovascular risk factors was provided. Three major risk categories -low, medium and high risk -were calibrated to effectively indicate absolute likelihood of developing a cardiovascular disease in the next 10 years as follows: (1) low risk -less then 15%; (2) medium risk -15-20%; and (3) high risk -over 20%. (Table 2  Even with extensive knowledge about the pathophysiology and the epidemiology of hypertension, simple diagnostics, availability of efficient drugs, hypertension still has high prevalence and as a result introduction of an effective hypertension control represents considerable public health challenge. (18,19) Public health systems worldwide continue to cope with inadequate management of hypertension and there is a need to ensure constant improvement of management by health professionals in order to make sure that at least two thirds of treated patients suffering from hypertension reach adequate control of blood pressure.
In doing so it is necessary to perform control of major risk factors, such as smoking, obesity, increased total serum cholesterol and diabetes mellitus. (18,19) All this creates necessary prerequisites for setting up different methods of controlling hypertension that basically prevent continuation of costly cycle of clinical management of hypertension and the related complications.
Definitions of hypertension, in particular in public health sense, are essentially pragmatic. They can be used and they were also defined to characterize a group of individuals who potentially may benefit from specific treatment regimes -non-pharmacological and pharmacological. Definition of hypertension which is more then 30 years old and which says that "Hypertension should be defined as the level of blood pressure which requires investigation and treatment to improve the condition" indicates that any numerical definition and categorization should be flexible and based on evidenced risk and availability of effective and welltolerated drugs. (20)(21)(22)(23)(24) Also clinically used definitions are rather arbitrary because of the nature of blood pressure distribution in the population. (25-27) Researchers have long discussed about threshold values of high blood pressure in different populations, in particular those threshold values that warrant therapeutic interventions. There is also variability in deciding the threshold values for evaluation of cardiovascular disease risk factor in individuals.
Problem-based approach to hypertension is twofold: (i) it is described as a separate clinical entity/condition and is classified as a prevalent cardiovascular disease. Also hypertension is a very important factor in development of morbidity and mortality that are caused by cardiovascular disease; or (ii) it is described as intermediary (biological) factor in development of cardiovascular disease and conditions of circulatory system. In both cases hypertension is recognized as "an entry point" for the management of cardiovascular disease.   Hospital discharge rate statistics for these diseases is not analyzed at the Federation of Bosnia and Herzegovina level. (32) As the Federation of Bosnia and Herzegovina is currently going through a strong transitional and reform period of its socioeconomic development, its health system should be responsive to health and social needs of its population, especially at times when such needs turbulently change. Health system of the Federation of Bosnia and Herzegovina should be flexible and prompt to provide adequate and timely response to demographical and social changes, changes in epidemiological patterns of diseases, expectations of health care users for quality and their role in decision-making, inequity in health care system, and scientific an technological progress. (32,33) According

The case study
In order to effectively evaluate the prevalence of cardiovascular risk factors (overweight and obesity, smoking, history of hypercholesterolemia and diabetes mellitus) and also blood pressure values, a cross-sectional population study was carried out in the Federation of Bosnia and Herzegovina on a sample of adult population (aged 25-64 years), which was representative for the Federation of Bosnia and Herzegovina. (30) The households were selected using the random sample method, following the survey conducted in the field. From each household one individual aged 25 to 64 years was selected. Stratified sampling allowed inclusion of both urban and rural areas within the selected municipalities.
Original size of the sample was 3,020 households/respondents, which is effectively the internationally recommended sample size for evaluation of noncommunicable diseases risk factors in adult population. The survey was carried out in the autumn of 2002. Compared to the original sample (3,020 people), response rate was very high (91.5 %). Female respondents made 59 % of the total sample.
Methodology of the survey fully complied with the international recommendations for survey protocol. (36)(37)(38)(39) The survey involved interviews with and physicals measurements of individual respondents in their homes. The physicals measurements actually included blood pressure measurements.
Hypertension awareness in the respondents was evaluated through a question listed on the survey questionnaire about whether the respondents being informed on high blood pressure by health professionals.
Drug treatment of hypertension was evaluated by another question listed on the survey questionnaire. The term "treated" included the respondents who at that point were using antihypertensive drugs.
Control of hypertension was evaluated by the question on awareness of their hypertension, use of antihypertensive drugs and measured value of blood pressure.
The survey used a criterion for evaluation of hypertension prevalence which is normally used in population research studies. This criterion was based on the blood pressure threshold values and values of actual treatment by antihypertensive drugs. The respondents were hypertensive if they were using antihypertensive drugs and/or if their systolic blood pressure (SBP) was ≥ 140 mmHg and/or diastolic blood pressure (DBP) was ≥ 90 mmHg.
In addition to the above definitions, the research study also used the WHO/ISH definitions which categorize hypertension into three grades: mild, medium and severe. Following these definitions, mild hypertension included respondents who reported SBP of 140-159 mmHg and/or DBP of 90-99 mmHg; medim hypertension included respondents who reported SBP of 160-179 mmHg and/or DBP of 100-109 mmHg; and severe hypertension included respondents who reported SBP of > 180 mmHg and/or DBP of > 110mmHg. (see Table 3) Limitation of the survey is reflected in the categorization of hypertensive respondents based on one off blood pressure measurement, which in fact may lead to overrated hypertension levels, especially in patients who reported threshold values of SBP of 140mmHg and/or DBP of 90mmHg.
Although cross-sectional research studies are not ideal tools for evaluation, they are necessary to obtain information about individuals who have no contact with health professionals in health care institution, individuals who are not aware of their hypertension, level of treatment and control of hypertension in different countries. Description of blood pressure patterns in the population and the underlying trends classified by age, sex, education and other socioeconomic variables, actually allows development of strategies for reduction of morbidity and mortality caused by high blood pressure.

Blood pressure
Mean value of SBP was under 140 mmHg, while the DBP mean value was above 80 mmHg in both male and female respondents. Reported values were higher in female respondents.
Age and gender structure showed that the lowest percentage of the respondents was from the youngest age group 25-34 years, males in particular. The highest number of respondents was from the age group 35-44 years, which proportionally included the highest number of females and males. Mean value of SBP in male respondents was 132 mmHg and in female respondents it was 135 mmHg. The difference was statistically significant (p < 0.001) (See Table 4.). Mean value of DBP was 84 mmHg in both genders. As with the SBP, mean value of DBP also increased with the age of the respondents.

Prevalence of hypertension
Following the definition of hypertension whereby the respondents were hypertensive if they were using antihypertensive drugs and/or if their SBP was ≥ 140 mmHg and/or DBP was ≥ 90 mmHg. Total of 41% respondents were hypertensive ( Table 5.) Prevalence of hypertension was 36% in male and 45% in female respondents. Proportion of the respondents with hypertension statistically increased to a significant degree in both female and male respondents (p < 0.0001), but slightly higher in female respondents in elderly age group (aged 45 to 64 years). (See Table 6.).
In addition to the above definitions, as already mentioned, the research study also used the WHO/ISH definitions which categorize hypertension into three grades: mild, medium and severe. Following these definitions, mild hypertension included respondents who reported

Awareness of hypertension, treatment and control of hypertension
Almost 54% of hypertensive respondents were not aware of their hypertension. Very high 79% of the hypertensive respondents who are aware of their hypertension were pharmacologically treated, which indicates relatively good availability of antihypertensive drugs. Of the total number of respondents who were pharmacologically treated, the condition was adequately controlled in only 13%. Generally female respondents were more aware of their hypertension and they were more regularly treated and controlled then male respondents.
In the hypertensive respondents there was a statistically significant difference between the genders with respect to the degree of awareness, treatment and control of hypertension. There were 63% of hypertensive male respondents who were not aware of their hypertension as opposed to 50% of females in this particular category of respondents. Hypertension treated but not controlled respondents included 24% male and 34% female respondents. Percentage of the hypertensive respondents who were both treated and controlled was relatively low -5% in male and 6% in female respondents. In genders there was a statistically significant difference among the age groups with regards the degree of awareness of hypertension, treatment and control of hypertension. The degree of awareness of hypertension in both genders significantly increases with the age of the respondents. There were more hypertensive, treated, and non-controlled respondents in older age groups (45 to 64 years) and the portion significantly increased with the age of the respondents. Percentage of hypertensive, treated, and controlled respondents was low at males 5% and females 6%). (Table 8.) The low rate of detection and control of hypertension in hypertensive respondents can be attributed to the lack of standardized integrated programs for reduction of hypertension or at least developed screening programs at the Primary health care (PHC) level. The degree of detection, treatment and control of hypertension increased with the age of the respondents as prevalence of hypertension increased.

Control of hypertension
Experiences of good practice exercised in various countries have showed that significant progress in health can be made through a well organized and focused approach to prevention, treatment and control of the disease, which should be a part of any health system. This is possible to achieve in social environments which support intervention programs in community. In order to make this happen, major changes need to be made in the areas of health policies, organization of health, training/academic education of health professional who also need to be properly equipped. Ultimately, such approaches do not require considerable resources compared to highly complex clinical interventions. (2,3,4) Following the general managerial approach, the World Health Organization introduced in mid 1980s a number of integrated programs for prevention and control of disease that were defined as "programs that combine resources and approaches to prevention and control of selected diseases and related conditions and programs that will allow managerial unification of activities that will lead to prevention and control of diseases and promotion of health in overall community." (4) Integrated management of disease and risk factors is particularly recommended in countries with limited financial resources for health care. Mechanisms of such integrated approach can be used to evaluate actual health needs, develop manuals to be used at all levels of management, supervision, adequate treatment and mobilization of community in support of the population's health.
One of well-founded approaches and an example of good practice is Integrated Management of Childhood Illness (IMCI) which is very efficient and applicable in developing countries as more than 80 developing countries has adopted the IMCI as their national policy aimed at improving children's health. This approach allows provision of children's health care in an efficient and effective way. (2) Since non-communicable diseases, in particular cardiovascular disease, are leading cause of global morbidity and mortality, defining an integrated management of cardiovascular disease, including risk factor management, represents a major challenge for the national health systems worldwide. The modeling of an integrated management of noncommunicable diseases means improved supervision and monitoring, development and implementation of intervention prevention programs for different target population groups, implementation of intervention programs in the community and advocacy in public policies with considerable support for health care services. The model of integrated management should promote rational allocation of resources, evidence-based treatment, costeffectiveness and self-management strategies aimed at achieving improved health outcomes through full involvement of the entire community. (44,45) The integrated approach to control of hypertension is innovative in shifting the paradigm from "treatment of hypertension" to "management of hypertension" as an integrative program in control of risk factors such as high cholesterol, obesity and diabetes mellitus. This movement to an innovative approach is supported by evidence of cost-effectiveness of managerial approaches to the integrative control of hypertension in the population. Therefore the developing of an integrated hypertension management model at the level of the community should be supported in the country as the original, flexible approach and comprehensive package that combines different sustainable activities that will produce a synergic effect in fight against selected risk factors. (46)(47)(48) Population approaches in dealing with the health needs of the population are the bigger challenge with the long-term results. Epidemiological theories confirmed by research studies have indicated that intensive treatment of individuals who are under a threat of high risk of developing a disease have actually yielded limited progress in reducing general risk in the population as opposed to the population approaches. (49)(50)(51) This effectively corroborate the fundamental axiom of preventive medicine which says that a large number of people exposed to small risk can result in much bigger number of cases that the small number of people exposed to high risk. (2) However, effective and efficient control of blood pressure in the population requires two approaches: population approach and individual approach to high risk individuals. Both approaches are necessary and complementary for effective control and management of hypertension in the community. It is important to specifically note that balanced combination of population preventive strategy and preventive strategy in dealing with the high risk individuals is vital for effective control of epidemic and growing burden of noncommunicable in the community in general, in particular hypertension and cardiovascular disease. (See Figure 3) (2,4)

Strategies for reducing high blood pressure
Despite many efforts to diagnose and effectively treat hypertension, this condition is still the leading cause of cardiovascular morbidity and mortality. This is why it is very important to improve unsatisfactorily treatment and control of hypertension globally. Leading non-communicable diseases, including hypertension, are associated with common preventable risk factors -obesity, smoking and increased levels of fats in the blood. Better understanding of these risk factors and their determinants means better opportunities for prevention and control of the associated non-communicable diseases. Early detection and understanding of extent of this health issue, early warning and early response altogether allow timely prevention of future epidemic and "explosion" of risk factors. (60,61) High rate of undetected hypertension and unsatisfactorily control of hypertension indicate that hypertension today is insufficiently and inadequately treated. This results in far reaching consequences in development of heart-, brains-and kidney-related conditions and eventually fatal outcomes. At this point the health system of the Federation of Bosnia and Herzegovina is treating adverse health outcome and the sequels. Number of complicated cardiac surgeries is on the rise and this in fact puts additional strain on already limited health sector budget allocations.
Lessons from many countries which developed the comprehensive policies showed that there is a significant reduction in mortality caused by cardiovascular disease. In Finland, for example, the comprehensive strategy that effectively combined prevention, promotion in the community and the approach to the treatment resulted in decrease of mortality rate by staggering 60%.
Two preventive strategies are described in the scientific literature: population and individual strategy.
Population strategy in reducing high blood pressure in countries throughout the world is very cost-effective -it is especially suitable for countries with limited resources such as Bosnia and Herzegovina. Population strategy allows potential control of incidence of disease in the population. With respect to hypertension, this approach includes reduction of www.intechopen.com  Population approach supports identification and modification of risk factors associated with different behaviors such as, for example, dietary habits, smoking and physical inactivity. Multiple interventions with regards the risk factors are possible by setting up health policies in the country through the multisectorial approaches in the community. Managerial approach to the population/community requires active involvement of large number of stakeholders from all three levels of management (strategic, tactical and operational) in health sector which is the primary public sector for the starting of such initiative.
It is described in the scientific literature that interventions aimed at changing the unhealthy lifestyles are very successful in reducing the absolute risk of development of hypertension in the population. (52,63,64) Preventive strategies implemented in young population, or rather in early stages of life, allow long-term potential for prevention of conditions which lead to development of hypertension and high blood pressure, as well as for reduction of overall morbidity and complications associated with conditions caused by high blood pressure. (53) On the other hand, individual approach in prevention of disease does not provide a big picture of causes of diseases in the environment and projections of potential trends of the disease. However, it requires continuous and considerable screening of new highly risk individuals. Individual approach to high risk individuals with respect to hypertension includes detection, treatment and effective control of high blood pressure. Such approach requires effective treatment and both modification of lifestyle and pharmacological treatment.
It is necessary to create prerequisites necessary to study the approach to high-risk individuals which in fact primarily includes detection, early diagnosis and start of a treatment of hypertension. Changes to attitudes of health professionals in terms of the integrated hypertension management can be achieved through formal education of health professionals.
Based on the international recommendations, tables of cardiovascular risk stratification are recommended for management of hypertension at the level of an individual. Cardiovascular risk assessment systems have been for the most part developed on the findings of the Framingham Risk Score study. (65,66) Recent SCORE project developed the risk assessment tables to estimate the probability of developing fatal cardiovascular disease within the next 10 years, in particular for high-risk countries in the north of Europe and low-risk countries in the south of Europe. (67)) These categories can be used as indicators for assessment of relative risk in the population. It is recommended that the countries adapt the risk stratification tables and to introduce them in daily practice. The SCORE tables are based on risk assessment relative to values of cholesterol and blood pressure and age and gender.

Model of integrated hypertension management in community
Based on the survey results, it has become necessary to introduce a model of integrated management of hypertension in the Federation of Bosnia and Herzegovina at this point because of the relatively high prevalence of hypertension and leading cardiovascular risk factors.
In the countries with limited budgetary allocations for health, such as the Federation of Bosnia and Herzegovina, population prevention strategies are the most cost-effective solution. (2, 68) These strategies control incidence of risk factors in the population, their goal is to change health behavior and reduce exposure to risk factors and also to reduce risk in the entire population. Potential benefits are high but there are challenges as well because the community largely benefits from preventive measures while it seems that such measures produce limited benefits for an individual. This, on the other hand, may cause a negative motivation in the population and this is described as "preventive paradox." Therefore it is necessary to use the both approaches complementary. The key challenge is to find a suitable balance between the population approach and the approach to high-risk individuals. (69) Managerial approach to the community (to the population) requires active involvement of large number of stakeholders from all three levels of management (strategic, tactical and operational) in health sector which is the primary public sector for the starting of such initiative.
Role of strategic management in the health sector (a country's government) in reduction of risk is significant. The government should act as an advisor in the initiative to reduce the risk factors -selected, highly prevalent in the population and widely distributed risks. One of potential instruments include the passing of legislation, which is more cost-effective as it is assumed that the legal regulations will more readily lead to changes in agreements rather than www.intechopen.com professional recommendations alone. Both approaches require consultations with a large number of active stakeholders and the multisectorial approach. (See Table 9.,) Unfortunately transition countries, such as the Federation of Bosnia and Herzegovina, have a poor regulatory structure and they are more dependable on the non-controlled market. Against such backdrop, it is necessary to select sustainable and implementable measures, including, for example, higher taxes on tobacco products, legislation on reduced salt content in industrially produced food products, use of mandatory content labeling of products, support for production of healthy food or subsidization of price of food produced by local producers. Role of tactical management in health sector, such as public health institutes, medical associations, professional physician associations, is reflected in designing, introducing and implementing intervention programs in the community through a series of mapped activities including preparation of culturally-sensitive promotional and preventive education messages, services aimed at supporting the changed lifestyles, introduction of risk screenings, development of diagnostic and therapeutic protocols, training for of health professionals and development of reference programs.

Levels
Role of operational management in the health sector, such as primary, secondary and tertiary health care levels (hospitals, clinics and health resorts) and non-governmental sector is reflected in the active implementation of recommendations, design and dissemination of written materials and active participation in the health training/education.
These interventions could be used as strategies in creation of population approach in management of hypertension.
Findings of this research study showed that prevalence of detection and prevalence of control of hypertension were relatively low, which further supports the importance of introducing the integrated management of hypertension.
Based on evaluation of prevalence of hypertension and distribution of major cardiovascular factors in the population research study, the managerial approach was assumed, through all developmental stages of the process (input, process and output) for for hypertension. (See Figure 5. )

Input included input variables (income) and resources (actual input).
Input variables (income) included:  Table 10. Activities proposed in managerial process of intervention programs in the community -population approach These interventions could be used as strategies in creation of population approach in management of hypertension. Findings of this research study showed that prevalence of detection and prevalence of control of hypertension were relatively low, which further supports the importance of introducing the integrated management of hypertension. The individual approach is better suited for high prevalence of hypertension. Compounded by the high prevalence of major cardiovascular factors, detection, adequate treatment and control are placed at (70) www.intechopen.com

Recommendations
1. Ensure support to healthy policies in the country by introducing a number of multisectorial approaches in the community that will allow multiple interventions in reducing the risk factors. The community is a significant partner and the vital point in achieving the goals that have been set. 2. It is necessary to develop a model of integrated management of hypertension and major cardiovascular risk factors as a comprehensive model introduced in the community that should be primarily directed towards modification of a detrimental lifestyle.
3. Health care should be restructured in order to effectively provide integrated health care through changed attitudes of health professionals, availability of technologies used for diagnostics and treatment of hypertension and improved quality of the referral system that will reduce inequities in the health. 4. With regards to the findings of the research study, purpose of the integrated hypertension program should be reduction of high blood pressure in adult population, with the following specific objectives -• Raise awareness of hypertension in hypertensive individuals through efficient detection of hypertensive individuals by health professionals through improved monitoring, in particular at the level of Primary health care; • Introduce standardized and suitable diagnostic and therapeutic protocols to be used by health professionals -efficient monitoring and treatment of hypertension; • Improve control of hypertension in hypertensive individuals; • Allow effective collection of data on epidemiology of hypertension. 5. Strong support to development of population approach in the managerial process of implementation of intervention programs of blood pressure control that will promote reduction of mean value of blood pressure in the population (distributional transition) in order to improve and advance cardiovascular health of the population.
In the light of the above recommendations, these activities should be focused on clear identification of health needs. Carefully planned, well designed and well implemented programs of disease control, either population or individual, represent a strong sole instruments to effectively deal with the problem of morbidity through the use of preventive measures. (71,72) Prevention of disease is crucial to human development. Through such approach, it will be possible to reach different groups of the population, which will in turn facilitate equity in health. ( Among the non-communicable diseases, cardiovascular disorders are the leading cause of morbidity and mortality in both the developed and the developing countries. The spectrum of risk factors is wide and their understanding is imperative to prevent the first and recurrent episodes of myocardial infarction, stroke or peripheral vascular disease which may prove fatal or disabling. This book has tried to present an update on risk factors incorporating new research which has thrown more light on the existing knowledge. It has also tried to highlight regional diversity addressing such issues. It will hopefully be resourceful to the cardiologists, general practitioners, family physicians, researchers, graduate students committed to cardiovascular risk prevention.

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