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Invited Commentary
Public Health
December 8, 2021

Understanding Barriers to Adherence to Optimal Treatment of Elevated Blood Pressure and Hypertension—Insights From Primary Care

Author Affiliations
  • 1School of Public Health, Sun Yat-Sen University, Guangzhou, China
  • 2Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-Sen University, Guangzhou, China
  • 3Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, Scotland, United Kingdom
JAMA Netw Open. 2021;4(12):e2138651. doi:10.1001/jamanetworkopen.2021.38651

Lifestyle modifications, including the restriction of dietary sodium intake, have been recommended worldwide as first-line treatment for people with elevated blood pressure.1 Recent evidence has further confirmed the benefits of salt substitutes in terms of reduced rates of stroke, major cardiovascular events, and death.2 The study by Liu et al3 explores the acceptability of, and adherence to, a salt substitute as well as the barriers to sodium reduction. In this mixed-methods investigation conducted in rural China, participants from the Salt Substitute and Stroke Study were used.2 A total of 1025 participants completed the knowledge, attitude, and practice questionnaire regarding salt intake, while 30 participants receiving salt substitutes completed qualitative interviews. Despite finding that the overall acceptability of the use of salt substitutes in daily life among rural participants was high, an inadequate awareness of the recommended daily salt intake was reported. In addition, participants commonly reported being unaware of the health benefits of consuming salt substitutes and reported still favoring the use of regular salt when preparing pickled foods. Barriers to sustainable adoption of salt substitutes included insufficient health education, self-perceived high costs, and contextual factors (such as preference for habitual flavors of food). The authors suggested that these barriers should be taken into account in formulating sodium reduction strategies in rural areas.

This study is of critical interest because more than 80% of the global salt-related disease burden occurs in developing countries.4 However, the barriers identified in this study should not be treated as unique determinants of achieving sustainable salt reduction because adherence to the core components of lifestyle modification in a sustainable manner shares common pathways and risk factors with barriers. Alongside various biomedical innovations conducted to address the question of which treatment (including lifestyle) is most effective in reducing morbidity and mortality, a further important yet largely unresolved question regarding how to achieve long-term adherence to recommended treatment regimens might be of greater relevance to frontline physicians. Although long-term lifestyle management and health behavior change have been placed as core and fundamental components in chronic disease prevention programs, nonadherence is commonly reported, with barriers that include, but are not limited to, a lack of social support, inadequate knowledge, fearful emotions, negative health beliefs, resource constraints, underestimation of risks, and unfavorable cultural preferences. Adherence to treatment (including lifestyle recommendations) over time remains insufficient worldwide and, in particular, in low- and middle-income countries (LMICs) where the rural population accounts for a substantial proportion of the whole.

In contrast to high-income countries, where the food industry and salt-labeling legislation have played a significant role in achieving a population-level reduction in salt consumption, most of the salt consumed in LMICs is added by consumers during food preparation at home.4 A public health campaign to raise awareness of the harmful effects of excessive salt intake is therefore of crucial importance. Because primary care clinicians are well placed to understand people’s health care needs in the care continuum, it is widely recognized that the integration of public health approaches and primary care could be a very effective method of disease prevention in local communities, with the potential for improving the health of the entire population.5 Primary care is being strengthened in China, and also in other LMICs, as the backbone of the health care system. Community-based general practice physicians serve as the primary point of contact with patients, thereby exerting a potentially sustainable impact on the health of individuals, families, and communities. The key attributes of primary care (ie, first contact, continuity, coordination, comprehensiveness, community orientation, and family centeredness) make for a high-value service delivery that can help to address the wider determinants of health through public health activities, including health education. However, the delivery of health education alone may not suffice because the influence of health education may not always be sustained in the real-world setting in which patients with coexisting hypertension have more difficulties in long-term self-management.6 This situation further calls for the development of a multidisciplinary, integrated primary care team approach that involves physicians, nurses, public health practitioners, nutritionists, pharmacists, and social workers. A wide variety of different yet complementary expertises and skills should be aligned to tackle the increasing complexities of disease prevention and control. This approach also carries the potential to enable a combination of strategies on health education, behavior counseling, skill building, and community advocacy while taking into account patients’ health literacy, individual preferences, personal beliefs and intrinsic values, and other long-standing contextual barriers to optimal treatment adherence.

Beyond the individual-level barriers reported in the study by Liu et al,3 the clinician-level and system-level barriers from the perspective of health inequalities, albeit unexamined in this study, are equally important in understanding suboptimal adherence to treatment. The inverse care law persists in most health systems whereby patients in poorer areas who have more complex and multifactorial problems are less likely to have their unmet needs addressed because of the maldistribution of the health workforce and other resources.7 Patients who live in rural or remote areas may have lower expectations and may be less able to adhere to treatment, while encountering greater clinician-level barriers (eg, suboptimal physician capacity, incompetent health care workforce, and greater stress among health care professionals) and system-level barriers (eg, poor accessibility of integrated services and lack of coordination of care) than patients who live in urban areas. These barriers may act together, rather than in isolation, to hinder the personalization and prioritization of care to deliver what really matters to individual patients, resulting in suboptimal health care in rural areas of high socioeconomic deprivation with exacerbated health and social disparities. A stronger primary care system, characterized by the cohesive provision of highly cost-effective services for all people across their whole life course, is believed to contribute substantially to improved health equity and equality.5 Further primary care–oriented, longitudinal research on how socioeconomic, cultural, and environmental factors, as well as individual behaviors, are associated with changes in treatment adherence may be of vital importance to shed light on the possibilities to promote facilitators and overcome such barriers.

Achieving and improving a sustainable concordance with treatment regimens among a rural population is inevitably challenging but promising. For this to occur, strategies that incorporate population-wide, evidence-based approaches tor reduce health inequalities on the basis of a strong primary care system are needed.

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Article Information

Published: December 8, 2021. doi:10.1001/jamanetworkopen.2021.38651

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Wang HHX et al. JAMA Network Open.

Corresponding Author: Stewart W. Mercer, PhD, Advanced Care Research Centre, Usher Institute, Old Medical School, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom (stewart.mercer@ed.ac.uk).

Conflict of Interest Disclosures: None reported.

Unger  T, Borghi  C, Charchar  F,  et al.  2020 International Society of Hypertension global hypertension practice guidelines.   Hypertension. 2020;75(6):1334-1357. doi:10.1161/HYPERTENSIONAHA.120.15026 PubMedGoogle ScholarCrossref
Neal  B, Wu  Y, Feng  X,  et al.  Effect of salt substitution on cardiovascular events and death.   N Engl J Med. 2021;385(12):1067-1077. doi:10.1056/NEJMoa2105675 PubMedGoogle ScholarCrossref
Liu  Y, Chu  H, Peng  K,  et al.  Factors associated with the use of a salt substitute in rural China.   JAMA Netw Open. 2021;4(12):e2137745. doi:10.1001/jamanetworkopen.2021.37745Google Scholar
He  FJ, MacGregor  GA.  Role of salt intake in prevention of cardiovascular disease: controversies and challenges.   Nat Rev Cardiol. 2018;15(6):371-377. doi:10.1038/s41569-018-0004-1 PubMedGoogle ScholarCrossref
World Health Organization.  Primary Health Care: Closing the Gap Between Public Health and Primary Care Through Integration. World Health Organization; 2018.
Hu  XJ, Wu  HF, Li  YT,  et al.  Influence of health education on clinical parameters in type 2 diabetic subjects with and without hypertension: a longitudinal, comparative analysis in routine primary care settings.   Diabetes Res Clin Pract. 2020;170:108539. doi:10.1016/j.diabres.2020.108539 PubMedGoogle Scholar
Mercer  SW, Patterson  J, Robson  JP, Smith  SM, Walton  E, Watt  G.  The inverse care law and the potential of primary care in deprived areas.   Lancet. 2021;397(10276):775-776. doi:10.1016/S0140-6736(21)00317-2 PubMedGoogle ScholarCrossref