Opinion

Boonsub Sakboonyarat, MD is an MPH student at Harvard T.H. Chan School of Public Health, and Assistant Professor of Community Medicine at Phramngkutklao College of Medicine, Thailand

The prevalence of uncontrolled blood pressure (BP) among hypertensive patients in Thai rural community¹ was two times higher than those in nationwide². Uncontrolled BP leads to further complications such as heart failure and stroke^3,4. To alleviate uncontrolled hypertension (HT) in the Thai rural area, health literacy, treatment adherence and BP awareness should be improved through multimodality approach with community participation.

According to a recent study from the National University of Singapore⁵, “Community participation is a fundamental element of an equitable and rights-based approach to health that is proven effective in optimizing health interventions for positive public health impact.” In Thai rural area, the community assets are available; for instance, health care services and human resources including healthcare personnel, community leaders, and adolescents. Hence, the participation of potential stakeholders and the multimodality interventions are the key methods to improve BP controlled among hypertensive patients in a Thai rural community.

The team-based care is one of the effective multimodality approaches improving BP controlled. For instance, the team-based care approach for hypertensive patients in rural Alabama⁶ demonstrated that the proportion of controlled BP rise from 12.5% to 91.7% in 12 months. The team-based care⁷ consists of primary care providers, nurses, community health workers and patients, affording and facilitating responsibilities of HT care to enhance the primary care worker’s activities. As can be seen, all physicians and community members participate in care to improve health.

In Thailand, primary care services in the community are accountable to the healthcare workers in the primary care unit (PCU); however, the healthcare workers are limited compared with the responsibility of care for a large number of patients in the area. For my first-hand experience in 2019, I had a chance to develop the model of primary care services for hypertensive patients using an innovative network of homecare providers (WinCare)⁸ in northern, Thailand. Under this model, the proportion of uncontrolled BP among hypertensive patients significantly dropped from 52% to 16% in 6 months.

We can apply the multimodality approach using the WinCare model to handle behavioral risk factors and enhance the treatment adherence including taking medication and meeting a physician. Firstly, the community leaders should launch the campaign to encourage the villagers recognizing uncontrolled HT as well as complications. The adolescents in the community will facilitate the appropriate health behaviors for hypertensive patients in their households. Besides health literacy improvement, the well-trained health volunteers visit the patients at home to measure BP and record in the mobile application as well as reminding the patients to take their medication. Recently, the American Heart Association⁹ launched the campaign that “Know Your Numbers”. If the BP is not at the target level, coordinate with health care team to develop a plan to achieve goal. At the PCU, the longitudinal data of BP will be available; therefore, the physician will use the information to decide treatment appropriately.

To initiate the multimodality approach, the expenses may be prepared for the automated BP machines, and resources for the interventions. The cost-effectiveness of real-world interventions should be evaluated and compared to another approach. The incentive for additional providers working in the community may be considered and supported by the third party such as the universal health coverage scheme¹⁰ under the National Health Security Office.

As a public health educator, I firmly believe that multimodality approach with the participatory potential stakeholders in the community will be able to facilitate hypertensive patients residing in a rural area to improve BP controlled and alleviate complications.