Improving blood pressure and dyslipidemia control by increasing health literacy in Croatia-missions 70/26 & Do you know what is your number

Abstract

Purpose

In 2022 hypertensive disease was the second cause of death in Croatia. The crude prevalence of hypertension is increasing and still majority of hypertensive patients did not reach blood pressure and cholesterol goals Low awareness, and small number of treated and controlled patients point on poor adherence and even worse clinical inertia.

Materials and methods

Croatian Hypertension League (CHL) has started the permanent public health action Hunting the Silent Killer aiming to increase health literacy. In 2023 we decided to intensify program with two missions – ‘70/26’, and ‘Do you know what is your number?’ aiming to achieve target values in 70% and in 50% of patients treated for hypertension and dyslipidaemia, respectively, by 2026. For the health care workers, the program will primarily involve digital education, and ‘School of Communication in Hypertension’. In the second arm of the program, we will advise patients and general population to visit our educational website with important and useful information on how to improve bad lifestyle, how to proper measure blood pressure, why is it important to sustain in taking drugs etc. In 2026, the CHL will organise field research to assess the success of programs using the same methodology as we used in previous EH-UH studies.

Conclusion

We will monitor and analyse trends in the management and control of patients treated for hypertension and dyslipidaemia. This will enable us to make an evidence-based conclusion how successful we were in increasing health literacy.

PLAIN LANGUAGE ABSTRACT

Hypertension is the most compelling cause of death in Croatia with increasing prevalence.

Still 50.1% of treated hypertensive patients and more than 70% of patients with dyslipidaemia in Croatia are uncontrolled.

Programs 70/26 and Do you know your number aimed to achieve 70% and 50% control of hypertensive and dyslipidaemia patients, respectively, by 2026.

To accomplish these goals, health literacy of healthcare workers, patients, and general population we will try to improve mostly using digital education and by organising schools of communication.

GRAPHICAL ABSTRACT

Keywords:

• Hypertension
• blood pressure
• dyslipidemia
• health literacy
• adherence
• clinical intertia

Introduction

Cardiovascular and cerebrovascular diseases are leading causes of death in Croatia (39%). According to data collected by the Croatian Public Health Institute, hypertensive disease (I10–I15) was ranked at the second position (9.2%), after ischaemic heart disease (12.2%) [1]. I10–I15 referes to ICD-10 coding of World Health Organisation from 2019 [2]. Hypertensive disease is more frequent cause of death among women than among men (11.6% vs. 6.7%). Interestingly and importantly women are dying five times more of hypertensive disease than of breast cancer (11.6% vs 2.2%). Unfortunately, they are not aware of this treat, and the number of women dying of hypertensive disease has an increasing trend (10.0% in 2020 vs. 11.6% in 2022). According to the results of the nationwide surveys EHUH 1 (2000–2006) and EHUH 2 (2018–2022) (Epidemiology of Hypertension in Croatia) prevalence of hypertension is increasing (50.9% vs. 44.7%) [3,4]. However, i this period, we observed increase of awareness (78.7% vs. 72.6%), higher number of treated hypertensive patients (87.4% vs. 59.6%), and better control of treated hypertensive patients (49.4% vs. 19.4%). These positive trends are results of permanent public health activities and educations Croatian Hypertension Society and Crotian Hyper­tension League have been organising for more than 15 years. Nevertheless, still 50.1% of treated hypertensive patients are uncontrolled. Particularly poor control was found in subjects with diabetes, prediabetes, and those with high salt intake (41%, 33.3%, 44.5%, respectively). The problem is even bigger when we consider the other crucial cardiovascular risk factor – dyslipidaemia. In the EHUH 2 cohort, the crude prevalence of dyslipidaemia defined as LDL cholesterol > 3 mmol/L or taking statins was 64%, with poor awareness (33%), and small number of treated patients (25%) [5]. Less than 30% of very high-risk patients with diabetes, hypertension or chronic kidney disease were treated. These results point on poor adherence and even worse clinical inertia. Being aware of these facts, 5 years ago Croatian Hypertension League has started the permanent public health action named Hunting the Silent Killer aiming to increase health literacy among general population which will hopefully improve lifestyle and increase awareness. In 2023 we decided to intensify our program by initiating two missions – ‘70/26’ devoted to hypertension, and ‘Do you know what is your number?’ dedicated to dyslipidaemia.

The Croatian Hypertension League, Crotian Society for Hypertension and Croatian Atherosclerotic Society has initiated these missions together with the Croatian Cardiac Society, the Croatian Renal Association, all societies of family medicine physicians, the Croatian Stroke Association, the Association of Medical Nurses and Technicians for Hypertension, the Croatian Association of Cardiology Nurses, the Croatian Chamber of Pharmacists, and, of course, the Croatian Institute of Public Health. Croatian Academy of Science and Arts endorsed these programs, and Croatian Ministry of Health included these programs in the general national action plan for primary prevention of chronic non-communicable diseases and national action plan for increasing the health literacy.

Methodology

Aims

The goal of these missions is achieving target values of blood pressure in 70% of patients treated for hypertension by 2026. The second aim is to increase awareness, treatment and control of patients with dyslipidaemia to at least 50% by 2026. While our goals may seem overly ambitious, setting an aspirational target that are not inherently unachievable will motivate us to work harder, leading to considerable progress.

Participants

This program will involve physicians, nurses, and pharmacists – essentially, all healthcare workers – having in mind the fact that hypertension is the main public health problem in Croatia, as well as a strong, and in most patients with cardio-kidney-metabolic diseases the main risk factor that can be both prevented and successfully controlled with the right approach. Dyslipidaemia is a special problem because of even lower awareness and poorer control. To join this project, one simply need to fill out a straightforward form, either on a dedicated place of the 70/26 program on the Croatian Hypertension League’s website (https://www.70-26.hr), using QR code placed at our educational posters, or using an iPad during a visit from an associate from Servier.

Patients and general population will be invited to participate via various media, social networks, educational posters placed in public places, and during public health events.

Methods

We plan to achieve the goal of this programs by reducing clinical inertia and by increasing adherence, which are key steps wherever physicians have all currently available medications at disposal, as is fortunately the case in Croatia. Missions have two arms – one for healthcare workers and the other one for patients and general population.

Healthcare workers

For healthcare workers, the program will primarily involve digital education, sharing various interesting, important, and useful materials and tips. These resources aim to enhance health literacy, making it easier for health care workers to transfer this knowledge to patients. Participants in the program will regularly receive email notifications (weekly newsletters) about available new educational materials (webinars, guidelines, interesting papers, journal clubs…) which could be found at the educational platform of the Croatian Hypertension League, HealthMed (www.healthmed.hr). Each project participant just needs to consistently keep track of the information they will receive by digital media and incorporate the new knowledge in their daily work. They will also need to share updates about this program and the importance of achieving its intended goal among their colleagues and, of course, among their patients. We hope that these educational activities will advance clinical work, thereby improving the management of patients treated for hypertension and dyslipidaemia. Overall, tasks and responsibilities within the program will not impede the daily work of physicians, nurses, technicians, or pharmacists. Education, for both patients and healthcare workers, is an integral part of our professional duties. Nevertheless, to stimulate health care workers to participate and to be active, physicians’, nurses’ and pharmacist’s chambers will award participants with point according to their rules.

The incredibly special and important part is ‘School of Communication in Hypertension’ where all health care workers will have a chance to learn how to improve communication with patients, families, media, and between each other. The programs also will be presented and discussed at conferences of societies included in the Croatian Hypertension League.

Patients and general population

Patients and general population will be advised to regularly visit the permanent educational website of the Croatian Hypertension League prepared for the general population, ‘The Hunt for the Silent Killer’, where they will find important and useful information on how to improve bad life-style, how to proper measure blood pressure, why is it important to sustain in taking drugs etc. (https://tihiubojica.hr/). We will use various social media (Facebook, Instagram, LinkedIn, You-tube www.facebook.com/lov.na.tihog.ubojicu;www.instagram.com/lov.na.tihog.ubojicu/ www.youtube.com/channel/UC78vBUNsfRyb9bdYIDa5BOQ). In addition to education about reduction of salt intake and balanced nutrition, our main aim for general population is to increase physical activity. With Run Croatia company we developed application adopted for our population which will measure daily physical activity. To stimulate our citizens to be more active we prepared awarding system. For determined number of points which one will earn for physical activity, subject could win special award prepared for various age groups. The key point is that awards will also improve lifestyle (discounts for buying sports’ shoes or sportswear, for buying healthy food, for eating healthy dishes in restaurants, for participation in sports recreation …). Furthermore, we are planning to organise a series of public health events where we will further educate our population, but also offer blood pressure measurements, measurements with metabolic scale, determination of blood glucose, cholesterol, uric acid… During these events we will organise also with Run Croatia races for all age groups starting with children (running, cycling, climbing…).

We anticipate support from various media outlets. Importantly, Večernji list, the main daily newspaper in Croatia is media partner of the Croatian Hypertension League. Both arms of the programs are presented in Figure 1.

Figure 1. Plan for 70/26 and “what is your number” with two arms (one for healthcare workers and the other for general population and patients) each consisting of digital and on-site education.

How will we assess the success of programs?

As the program approaches its conclusion in 2026, the Croatian Hypertension League will organise a series of field examinations to assess its performance throughout Croatia. The field examination will follow the pattern and algorithm used in the EHUH studies. This way, by utilising the same methodology, we will be able to monitor trends in the management and control of patients treated for hypertension and dyslipidaemia. At the end of the program, family medicine physicians, who are participating in these programs, will need to invite approximatively thirty patients from their patient database through a randomisation procedure. They will inform these patients about the program by phone and invite them for an examination, including measurements, and communicate the time and location of the examination. The assessment process, which will ensure double anonymity (neither the patient’s name nor the name of the physician who randomised patients will be known), will be conducted by the Croatian Hypertension League’s team to avoid any bias.

Conclusion

Based on the firm evidence we will be able to make a conclusion on how successful we were, and furthermore we could suggest these programs as a model for increasing health literacy and as a model for improvement in prevention, treatment and control all other non-communicable chronic diseases.

Acknowledgments

We are thankful Servier not only for financial support, but also for logistic help. This company helps us in several educative activities for last decades. We are thankful d8solutions company, our digital partner for help and support, particularly Katarina Grgurić, Marija Abramović Sušnić and Marko Gašparić. We are grateful to all members of the editorial board of the HealthMed, the educational web platform of the Croatian Hypertension League for preparation of educational materials: Jerko Barbić, Nikolina Bašić Jukić, Maja Baretić, Lovorka Bilajac, Hrvoje Budinčević, Sanja Ćurković, Vida Demarin, Vesna Herceg Čavrak, Josipa Josipović, Juraj Jug, Hrvoje Jurin, Daniel Lovrić, Branko Malojčić, Mirjana Mihalić, Petra Mijić, Ana Ljubas, Eva Pavić, Vedran Premužić, Tatjana Plaščar Pećin, Dario Rahelić, Valentina Rahelić, Željko Reiner, Dragan Soldo, Ana Stupin, Marko Stupin, Bernardica Valent Morić, Vanja Vasiljev, Ivana Vuković Brinar.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors reported there is no funding associated with the work featured in this article. The program 70/26 is supported by a grant from Servier and grants from Croatian Hypertension League, Croatian Society for Hypertension, and Croatian Atherosclerotic Society.