education intervention in the caribbean: a public health appraisal - NCBI

HYPERTENSION AND HEALTH EDUCATION INTERVENTION IN THE CARIBBEAN: A PUBLIC HEALTH APPRAISAL Ivor L. Livingston, PhD, MPH Washington, DC

Epidemiologic data on morbidity and mortality have established hypertension and its related diseases as posing a public health problem for the developing world. In the case of the Caribbean region, the in-

Dr. Livingston is Graduate Assistant Professor of Medical Sociology, Department of Sociology, Howard University, Washington, DC and is currently Postdoctoral Fellow, Department of Behavioral Science and Health Education, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland. Requests for reprints should

be addressed to Dr. Ivor L. Livingston, Department of Sociology, PO Box 987, Howard University, Washington, DC 20059.

creasing magnitude of the hypertension problem is complicated further by the region's fiscal crisis-its low cash availability for health expenditures and the concomitant experience in infectious diseases. Given these problems, it is reasoned that health education as an intervention approach is the only practical method to employ to address the problem of improved control of hypertension. The success of any such health education program will depend on, among other things, the framework used to guide the program, the population targeted on the basis of defined levels of arterial blood pressure and at-risk characteristics, and the specifics (ie, cultural, pharmacological, nonpharmacological, and motivational) of the message to be disseminated.

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HYPERTENSION IN THE CARIBBEAN

As a major health problem, hypertension is increasingly being viewed as a chronic, degenerative disease or affliction of modem society.' Although it is usually viewed within the context of developed countries, as in the United States where the disproportionate rates of blacks vs whites are frequently documented,2 hypertension is fast emerging as a public health problem in developing countries as well.3 Heretofore, developing countries were recognized as having a predominance of infectious diseases, but the increasing incidence of hypertension in the case of predominantly black developing countries, eg, those of the Caribbean and Africa, has prompted reports showing that contrary to widespread belief the pattern of arterial pressure and behavior of hypertension do not differ in any important respect among African, Caribbean, and American blacks.4 In the Caribbean region, essential hypertension is recognized as a major public health problem.5 In addition to presenting documentation of hypertension as a public health problem in the region, hypertension beliefs in that region will be reviewed and how health education can aid in improving the management of hypertension and its related diseases by involving all health care providers and receivers.

destructive sequela of hypertension, cerebrovascular accident, has been reported to be among the ten leading causes of death in the Caribbean region (Table 1). Congestive heart failure and, increasingly, ischemic heart disease are other sequelae that are leading contributors to death in the region.6"4 It has been noted, however, that myocardial infarction is found to be relatively uncommon in the region.5 As can be seen from Table 1, there are other hypertension-related disorders included in the list that contribute to high rates of morbidity and mortality in the Caribbean region. Ashcroft and Stuart'5 reported that diabetes mellitus is associated with hypertension in about 30 percent of Jamaican patients treated at the University Hospital of the West Indies. It was also suggested that the interaction of these two problems significantly increased the risk of coronary artery disease for these patients. In contrast to reports of other studies-the Veterans Administration Cooperative Study,'6 for example-a relatively high degree of renal problems associated with hypertension have been reported in the region. Again using Jamaica as an example, it has been reported that renal decompensation is secondary to the hypertensive process, and it is a primary factor accounting for the need for dialysis not only in Jamaica, but also in Barbados and Trinidad.5 It has been suggested that this renal decompensation phenomenon may be due mainly to the severity of the blood pressure elevation that already existed. '7

HYPERTENSION AS A PUBLIC HEALTH PROBLEM According to Grell,6 the prevalence of blood pressures exceeding the World Health Organization (WHO) criterion of 160/95 mmHg exceeds 20 percent in the English-speaking Caribbean. Countries of the Caribbean where this relatively high prevalence has been reported include the Bahamas,7 Barbados,8 Guyana,9 Jamaica,'0 and St. Kitts."I It has been said5 that hypertension is the most common chronic disease in the West Indies. It poses a serious public health problem in view of the documented morbidity and mortality associated with its various sequelae, eg, coronary heart disease12 and cerebrovascular disease.13 Another 274

MANAGEMENT OF HYPERTENSION The costs to developed and developing societies from hypertension and its destructive sequelae continue to rise steadily and the attendant medical costs also continue to escalate.'8 In the case of developing countries, the situation is relatively acute given their restricted and deteriorating fiscal conditions. It stands to reason, therefore, that more effective management techniques, ie, prevention and control, will serve to reduce the medi-



TABLE 1. PRINCIPAL CAUSES OF DEATH* (RATES PER 100,000 POPULATION) Trinidad and Tobago (1976) Diseases of the heart Cerebrovascular disease Malignant neoplasms Diabetes mellitus Accidents Influenza, pneumonia Enteritis and other diarrheal diseases Perinatal morbidity Bronchitis, emphysema, and asthma Cirrhosis of the liver

St. Lucia (1976) Cerebrovascular diseases Heart diseases (excluding ischemic heart) Pneumonia (excluding viral) Senility Ill-defined conditions Enteritis and other diarrheal diseases Ischemia heart Perinatal mortality Bronchitis, emphysema, and asthma Cirrhosis of the liver Hypertensive disease Barbados (1975) Heart disease Cerebrovascular diseases Malignant neoplasms Other circulatory diseases Hypertensive diseases Pneumonia Diabetes mellitus Perinatal mortality Motor vehicle accidents All other accidents

St. Kitts and Nevis (1977) Cerebrovascular diseases Heart diseases Malignant neoplasms Avitaminosis and nutritional deficiences Hypertensive diseases Enteritis and diarrheal diseases Diabetes mellitus Pneumonia Genito-urinary system Diseases of arteries, arterioles, and capillaries

169.0 85.9 58.8 55.6 36.8 32.9 27.9 23.6 15.8 11.4

91.0 66.0 51.0

51.0 40.0 27.0 26.0 14.0 12.0 11.0 10.0 170 130 130 60 50 40 40 35 20 10 155 125 87 55 53 45 41 29 25 16

*Table reprinted from Grell,5 from Chief Medical Officier's and Ministry of Health Official Reports

cal care costs associated with chronic diseases such as hypertension, as well as improve the health status of the public.'9 For essential hypertension, the most frequently occurring form in the Caribbean20 as well as in the United States, the economic benefits associated with effective therapy control have been adequately demonstrated.'6'2' It has been said22 that six drugs are satisfactorily being used in the Caribbean. These include thiazide diuretics, reserpine, the beta-blocking agents, oral hydralazine, guanethidine, and methyldopa. In the United States it has been reported'9 that effective hypertension control can prevent or postpone 35 percent or more of strokes (one of the leading causes of death in the Caribbean5) at a cost of about $200 a year per person affected as compared with the current costs of $20,000 and up per year. The implications for greater hypertension control through cost-effective methods are particularly important in developing countries where per capita expenditures for health are stringently calculated. Effective control of hypertension using a combination of prevention strategies,23 whether in the Caribbean or elsewhere, is hindered by various factors. Such factors include the unknown etiology and multidimensional nature of hypertension,24 its insidious or asymptomatic nature,25 and the inability of the dominant biomedical model. The dominant biomedical model is said to be too simplistic with its emphasis on the diagnosis and treatment of diseases using mainly drugs and/or surgery.26 Given the developmental nature of chronic hypertension, more effective management of the disease and its related disorders can be realized in the Caribbean if the philosophy of the holistic medical model is accepted. Essentially, the holistic model27 recognizes that health and disease result from the interaction of several factors, ie, physical, mental, and environmental. A knowledge of these factors will promote health and help prevent disease. What is implied in this model, and what is of foremost importance to the position expressed in this paper, is that health education directives embodying "holism" can be very effective public health intervention tools to further address the problem of improved management of hypertension in the Caribbean.


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Health Education in the Caribbean According to De Haes,28 the effectiveness of health education as an intervention strategy is, in part, evident from its basic objectives, ie, to influence behavior that may affect both health and disease, including behaviors necessary to prevent illness and promote health, as well as those necessary to enhance recovery and to help persons live with disabilities or chronic disorders. In the Caribbean, the dominant question about hypertension and its sequelae is the following: How educated or aware are patients and the wider public, especially those at risk? It has been said6 that major educational and treatment programs for patients and the public should be initiated in the Caribbean. The urgency of this statement is evident from reports of several surveys and community studies conducted in the region. From studies conducted in Jamaica,29 it was reported that a lack of awareness of hypertension was evident when a significant excess mortality over a 13-year period occurred only in untreated hypertensives with blood pressures above 180/100 mmHg. In a study of Jamaican hypertensives at the time of pre-immigration screening, it was reported that only 56 percent had been previously aware of their hypertension. When the known hypertensives were compared with the newly discovered hypertensives, 85 percent of both groups were aware that an elevated blood pressure could cause stroke; 55 percent of the known hypertensives and 32 percent of the newly discovered hypertensives believed that it was a cause of cardiac failure; 21 percent and 9 percent, respectively, that it was associated with heart attacks; and 13 percent and 6 percent, respectively, that it caused renal failure.30 Other studies underscore the need for health education, particularly in the area of hypertension. For example, in a community blood pressure survey conducted in rural Barbados,8 it was reported that of the 4,322 participating adults only 40 percent identified as hypertensive were previously aware of the diagnosis and, of these, only 13 percent were on medication. Bearing in mind the apparent need to institute educational programs to increase awareness of hypertension,6 it is now necessary to examine misconceptions about hypertension and their effects on adherence to antihypertensive medication. 276

Effects of Common Misconceptions on Adherence to Antihypertensive Medication Several reports have suggested that individuals' health beliefs can positively influence the preventive illness-related behaviors they adopt.25'31'32 In the case of hypertension control, one such illnessrelated behavior is adherence to antihypertensive medication. Notwithstanding the wide range of drug therapies available and the empirical evidence of their proven efficacy in controlling hypertension (ie, reducing related morbidity and mortality),16'21 research shows that a major constraint to improved control of hypertension is patient adherence and patient-practitioner relationship. 3334 Patients' beliefs regarding hypertension can greatly influence, among other things, the extent to which they adhere to prescribed hypertension medication. As with their black American counterparts,35 black West Indians, the largest racial group in the Caribbean, have retained folk medical beliefs from their African ancestry.36 Given these realities, empirical studies, particularly of an ethnomethodological variety, are needed to address more effectively the problem of improved hypertension control. One recent such ethnomethodological study was conducted in St. Lucia.37 Dressler37 reported that the health beliefs of St. Lucians were influenced to a great extent by two important belief systems-the personalistic (ie, disease is believed to be the result of purposeful intervention of a human, nonhuman or supernatural agent) and the naturalistic (ie, disease is believed to be the outcome of natural forces). For example, 52 percent of respondents believed that eating cucumber was good for hypertension and 82 percent felt that eating papau was also effective. The persistence of such misconceptions will certainly hinder efforts to improve the control of hypertension. With specific reference to adherence to antihypertensive medication, Dressler reported that only 47 percent of respondents had taken 70 percent or more of their prescribed hypertension medication. Fifty-five percent of respondents reported having used bush-tea for their high blood pressure. According to Watkins,38 what is important to educational interventions to increase

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adherence to medications is not the usage of bush-tea per se, but the beliefs and attitudes that the use of bush-tea implies.

Other Factors Affecting Adherence to Antihypertensive Medication Because the issue of adherence to antihypertensive medication is a complex phenomenon, there are various nonbelief factors of a sociopsychological (eg, patient-practitioner relationship), a structural (eg, clinic/office atmosphere), and a communicative (eg, content/mode of disseminating health information) variety that have to be addressed in any comprehensive high blood pressure education program. For example, in a four-year follow-up study conducted in Barbados, it was reported that the major reasons given for noncompliance with antihypertensive medication included lack of awareness regarding blood pressure control, dissatisfaction with clinic facilities, and inability to obtain time off from work.8 In another clinical study conducted in Jamaica,39 it was reported that the success achieved in high clinic attendance and blood pressure control was attributable to a relaxed clinic atmosphere, short waiting times, minimal staff changes, and the availability of drugs.5 Other major sources affecting patients' adherence to their hypertension regimen, and ones that would have to be included in any comprehensive health education directive, are physicians' attitudes and beliefs regarding antihypertensive drug therapies, their "holistic" medical practices, and the joint effect these have on physician-patient interaction and, for that matter, the physician-public interaction. It has been reported that physician adherence to blood pressure management is suboptimal40 and physicians sometimes neglect to measure blood pressure during routine office visits.41 Grell22 said that physicians too often change medications at each visit rather than adjusting tablet dosage to achieve optimum blood pressure control (ie, less than 160/90 mmHg under age 60 and less than 170/95 mmHg for those over 60). According to Wilber and Barrow,42 physicians

are sometimes reluctant to initiate patient education because they are discouraged with the outcomes of care. Others have reported that some physicians are unaware of adherence problems.43 Some do not consider patient education a necessary component of high blood pressure management,44 while others do not consistently heed the consensus of authorities on hypertension control.45

HEALTH EDUCATION INTERVENTION IN THE CARIBBEAN As hypertension is essentially a mass public health disease of modem society,' efforts directed at preventing and controlling its occurrence will have to include, among other activities, health education intervention programs. Because of economic, logistic, and practical considerations, any such health education programs should be incorporated within the Caribbean countries' existing Primary Health Care (PHC) programs. This point was underscored at a recent meeting of the World Health Organization (WHO) on new approaches to health education in primary health care.46 In the Caribbean, as in other developing re-

gions, tPHC includes promotive, preventive, and rehabilitative services in such areas as proper nutrition, maternal and child care, and immunization against major infectious and endemic diseases. Therefore, given the already existing PHC infrastructure, it would be efficacious if educational directives concerning hypertension were also included. Also, given the relatively low gross national product of the Caribbean and, therefore, the region's relatively low dollar availability and expenditure on health,47 the utility of having hypertension-related health education programs under the rubric of PHC activities becomes obvious.

The success of any health education intervention, especially with a multifaceted phenomenon (hypertension), requires that certain important factors be addressed. One such factor includes having, if at all possible, linkages with an already established


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PHC infrastructure, which would enhance the running of the health education program. According to a WHO Expert Committee,46 another factor that is crucial to the success of health education programs is both an appreciation and promotion of a dynamic interaction between health care providers and the general community in which the program is to be directed. Additional factors that are both interdependent and necessary for the success of any health education program include a framework to effect the intervention, a targeted audience, and establishment of the specifics of the health education message that need to be disseminated. An approach that is increasingly being used to address health education interventions, and one that would be most applicable to high blood pressure education, is the PRECEDE (Predisposing, Reinforcing and Enabling Causes in Educational Diagnosis and Evaluation) framework. Essentially, the model provides a framework, which suggests that at all levels of involvement (ie, individual, community, and institutional) certain factors predispose, enable, and reinforce the initiation and continuation of behaviors conducive to blood pressure control.48 As in the PRECEDE framework, defined targeted audiences are crucial to the success of high blood pressure intervention. Following the lead of established sources in the area of high blood pressure health education (eg, National High Blood Pressure Education Program49), audiences fall into two basic segments-primary and secondary. Although available epidemiologic evidence should serve as a major guide as to classifying people into either group, primary audiences could include the following: (1) defined hypertensives and (2) those segments of the population who have or are prone to be at risk sociodemographically (eg, low socioeconomic class position50); socio-psychobehavioral attributes (eg, stress,5' susceptibility to anger,52 low social support53); nutritional factors (eg, excessive sodium consumption54); physiological (excessive body weight55); and genetic56 factors for hypertension. In secondary audiences, the following could be included: family, friends, peers of primary audiences who could serve as important sources of support for the primary group. The entire spectrum of health care providers could be also in278

cluded in secondary audiences. For example, nurse practitioners and pharmacists are currently playing an important role in the health delivery/education system in the Caribbean region5'8 and the importance of their inclusion cannot be overemphasized. Given the early onset of hypertension and factors that are thought to precipitate the disease, eg, obesity and excessive salt intake, which largely originate in childhood,57 the focus on early school-age children as a secondary audience could amount to a very cost-effective and progressive, primary-prevention effort. The content of the health education message is at the core of any successful program.46 It has also been said38 that success is dependent on the motivation accompanying the messages that will relate to positive behavior changes. long after the messages are delivered. As hypertension is a multifaceted disease,24 both the core and collective beliefs associated with this disease will have to be accepted by the public32 for any improvement in its control to be realized. The style and emphases placed on these messages should be "tailored" to the sociodemographic, anthropologic, and epidemiologic realities of the Caribbean. For example, given the pervasive and oftentimes contradictory cultural/health beliefs of the region37 alongside modem acceptable medical practices and the apparent dominant and region-specific occurrences of certain sequelae of hypertension (eg, renal failure, stroke, and congestive heart failure5), the content of the health education message should carefully and specifically address these issues. Another important context-related issue concerning the increasing incidence of hypertension is the rising cost associated with controlling the disease solely by pharmacological therapy. Notwithstanding the limitations on health care expenditures within the region, pharmacological means of controlling hypertension, though relatively effective,'6'21 are costly58 and have negative side effects.59 In addition, there is the real problem of nonadherence to medication.60 Given these realities, the content of health education messages should, in addition to pharmacological therapy, address the issue of nonpharmacologic therapeutic approaches to hypertension control. Although there are various nonpharmacological approaches and perspectives involved in hypertension con-

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trol,6' some factors that have important significance include the emphasis placed on diet (eg, excessive salt consumption55), being overweight,56 and stress52'62 in elevating arterial blood pressure.

education intervention are incorporated within the ethos of the Caribbean region, the expected rewards associated with improved management of the disease, reduced morbidity and mortality, will be forthcoming.

CONCLUSIONS From the issues presented, it is clear that hypertension and its related diseases pose a serious public health problem for the English-speaking countries of the Caribbean. The urgent need for effective public health intervention strategies and programs to prevent and control hypertensionrelated morbidity and mortality is further exaggerated by the regions' concomitant experience of various infectious diseases. Given this unfortunate "double-jeopardy" public health situation, ie, infectious and chronic diseases, it has been concluded that health education is the most practical and potentially effective intervention approach to address the problem of hypertension. It has also been concluded that given the pressing economic conditions and the relatively high rate of infectious diseases in the region, such health intervention strategies would be more successful if they were incorporated under the "umbrella" of each country's primary health care program, thereby utilizing the already existing infrastructure associated with these PHC programs. Notwithstanding the obvious advantages of the linkage between high blood pressure education programs and PHC programs within this region, the ultimate success of education programs will depend on an approach. tailored to the region. This would involve identifying a conducive model (eg, PRECEDE) on which the program can be directed; establishing targeted or priority audiences to receive selected messages; and choosing the mode and content of the health education messages consistent with sociodemographic/cultural backgrounds of the region, the core and collective beliefs that are intended to be disseminated, and the pharmacologic as well as nonpharmacologic therapeutic approaches to hypertension control. If these suggestions for high blood pressure, health

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