Dhungana, Raja Ram ORCID: 0000-0002-9610-6306 (2021) Hypertension treatment and control in Nepal: health care challenges and the potential of nonpharmacological interventions in the management of high blood pressure. PhD thesis, Victoria University.

Abstract

Hypertension is among the leading preventable causes of cardiovascular diseases and deaths globally. Accumulating evidence suggested that the burden of hypertension is growing, particularly in low-and middle-income countries. Hypertension treatment and control remain challenging due to barriers associated with health system, healthcare providers, and patients. There is a lack of country-specific information on factors influencing hypertension treatment and control in Nepal, a South-Asian lower-middle-income country. Besides, in Nepalese primary care practice, the uptake of guidelines to use non-pharmacological interventions alongside the anti-hypertensive medications for optimum control of blood pressure is low. The aims of this thesis were: (1) to assess the gaps and associated barriers and enablers of hypertension treatment and control in Nepal; (2) synthesize the available evidence on non-pharmacological interventions for hypertension, including alcohol reduction, physical activity, salt reduction, potassium supplementation, weight control, and heart-healthy diet; and (3) explore the potential of yoga intervention, as one of promising non-pharmacological interventions, in the primary care setting in Nepal. This thesis includes five studies. The first study was a secondary analysis of data from two national surveys in Nepal which assessed the prevalence and associated factors of screening, awareness, treatment, and control of hypertension. The second study was a systematic review conducted to assess barriers, enablers, and strategies for hypertension treatment and control in Nepal. The third study narratively synthesised the evidence on nonpharmacological interventions for hypertension in primary care. The fourth study was a randomised control trial, testing the effectiveness of yoga, as a non-pharmacological intervention in primary care, on reducing blood pressure in patients with hypertension. The fifth study was a mixed-methods study exploring the implementation potential of the yoga intervention for hypertension control in the primary care setting. The findings of Study 1 suggested that the gap in cascade of hypertension care is prominent in Nepal, where the poor, the participants from remotely located provinces, those who received treatment from in primary health care centres and public hospitals, those who did not have health insurance coverage, and those under the age of 30 years were at a higher risk of inadequate hypertension care. Furthermore, Study 2 found several barriers to hypertension treatment and control associated with health governance, health service delivery, health financing, medication, technologies, human resources, individual health care providers, and patients, which are the major challenges for improving hypertension management in Nepal. The narrative review (Study 3) showed that previous evidence supports the use of alcohol reduction, sodium intake reduction, physical activity, and weight reduction as non-pharmacological interventions for blood pressure reduction in primary care, but more research is needed on other types of promising interventions, such as yoga. The intervention trial (Study 4) found that a health-worker led yoga intervention is effective for blood pressure reduction among patients with hypertension, while Study 5 showed that it is feasible to implement such an intervention in the primary care setting in Nepal. Overall, the thesis sheds light on imminent health care challenges related to hypertension treatment and control in Nepal. The findings may inform general practitioners, health administrators, and policymakers about the effectiveness, barriers, and facilitators of non-pharmacology interventions, including yoga. This may facilitate the implementation of such interventions in the standard primary care practice, and consequently improve the outcomes of hypertension treatment and control in Nepal.

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