Hypertension related to health care – research priorities: report on a WHO consultation, Copenhagen, 2–4 October 1979

EURO Reports and Studies 32 llypertelrsion related to Jlealth CaIe- Hesearch Priorities Report on a WHO Consultation REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN @ EU RO Reports and Studies 32 Hypertelrsion related to Jlealth [ar e - Besea rch Pr ior i t ies Report on a WHO Consultation Copenhagen 2-4 October 1979 REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN 1980 (project ICP/CVD 022) rsBN 92 9020 l7l I @ World Health Organization 1980 Publications of the World Health Organization enjoy copyright pro- tection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2 100 Copenhagen Q, Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in this publication are those of the participants in the Consultation and do not necessarily represent the decisions or the stated policy of the World Health Organization. PRINTED IN DENMARK Reissued under ISBN: 9789289024891 (print) in 2025. Originally published under ISBN-10: 9290201711. ISSN 0250-8710 (print) CONTENTS l. lntroduction. 2. Review ofongoing research on hypertension in relation to health care. 2.1 Present situation 2.2 Examples of ongoing studies. 3. Research 4. Relevance of current and planned research to the needs 5. Future tasks in research 5.1 Prevention and early detection 5.2 Problems in health care delivery. 5.3 Evaltration of drugs and other therapeutic and diagnostic substances. 5.4 Economic aspects of health care 5.5 Standardization of methods, measurements and terminolory 6. The role of WHO 7. Recommendations . 7.1 Action by WHO 7.2 Research to be promoted by WHO Pa$ I 2 2 2 5 6 8 8 10 l4 l7 18 l9 20 2t 2l Annex I Annex Il Annex III Hypertension research related to health care - Dr T. Strasser Guidelines on uniform data presentation. List of participants . 24 55 58 WHO CONSULTATION ON HYPERTENSION RESEARCH RELATED TO HEALTH CARE Copenhogen, 2-4 October I 979 I. INTRODUCTION The Consultation on Hypertension Research related to Health Care was held in the WHO Regional Office for Europe from 2 to 4 October 1979. A list of participants is given in Annex III. Professor F. de Padua was elected Chairman of the meeting and Dr T. Stras- ser acted as Rapporteur. In his keynote address Dr lco A. Kaprio, WHO Regional Director for Europe, stated that the European Advisory Committee for Medical Research had delineated five priority areas for research, namely: standardization of methods, measurements and terminolory; prevention, prophylaxis and early detection; evaluation of drugs and other therapeutic and diagnostic sub- stances; problems in health care delivery; and economic aspects of health care. In view of its great public health importance in the European Region, arterial hypertension was selected as a single topic involving each of the priority areas. The purpose of the present meeting was thus to review the ongoing and especially planned research in the European Region with a view to (a) selecting programmes lor WHO coordinated research; (b) defining priority areas for coordinated research; and (c) drawing up proposals for future activities on the basis of statements received from countries of the Region. It was expected that the meeting would reach general agreement on the proposed lines of research, that it would provide a statement of the main research programmes in this field and, more specifically, that leading (co- ordinating) institutes/research bodies in the priority areas would be selected and that a timetable ol major activities would be established. Professor S. Bergstrtim, Chairnran of the European Advisory Committee for Medical Research, drew attention to the prospective increase of WHO research activities, as promoted by both the global and the regional advisory committees. Professor de Padua emphasized the public health importance of arterial hypertension which, in Portugal, had led to a high incidence of cerebro' vascular disease and other complications. The situation could be improved only by an organized and comprehensive struggle against the condition. Such an objective involved both public health action and further research, and I required endorsenlent by the health profession and by social and political bodies. For that purpose, attention should be drawn to the importance of formulating national policies on the prevention of hypertension and other cardiovascular diseases, including guidelines on public health action and research priorities. A policy statement prepared by the Portuguese Centre for Preventive Cardiology had proved a useful tool in promoting hyper' tension research on the national level, since it contained a clear statement of priorities for such research and provided for support by health authorities in the activities. 2. REVIEW OF ONGOING RESEARCH ON HYPERTENSION IN RELATION TO HEALTII CARE 2.1 Present situation In virtually all countries of the European Region hypertension in relation to health care is under lively investigation, as was amply demonstrated in the replies of Member States to an enquiry initiated by the Regional Office in preparing the Consultation and in the contributions of the participants to the discussions at the meeting. It is evident that numerous research projects have been under way during the past four to five years. They range from studies of prevalence of elevated blood pressure using single blood pressure measurements in population groups or samples, to more sophisticated projects aimed at deter- mining actual morbidity due to complications of hypertension in defined communities, and to wide-scale projects in some countries encompassing the whole national situation. Thus the projects may be small and isolated or form part of national research programmes, or even take the form of international or intercontinental cooperative undertakings. They include retrospective, cross- sectional and prospective investigations. The scope varies from measurement of age- and sex-specific blood pressure values to double-blind drug trials or the study of psychological, social and environmental factors. Hypertension may be studied as a self-contained category or be analysed within the context of primary or overall health care systems. In all the countries represented in the Consultation there is acute awareness of hypertension as a significant individual and public health problem, requiring further research. 2.2 Examples of ongoing studies To obtain a balanced assessment of the current activities in various parts of the European Region, spokesmen were invited to present summaries of selected ongoing studies. 2 2.2.1 Reseorch project in Skaraborg, Sweden This control study involves 265 000 people in two separate areas: one for intervention and the other for control. It is being conducted in three stages. Stage I is aimed at improving care for known hypertensive patients, mainly through information and education of physicians, nurses and other health personnel. In stage 2, previously undetected hypertensives are being diagnosed under a special programme. Stage 3 will aim at total control of hypertension in the community. The study should also elucidate the effects of such community activities on quality of life in both the negative and the positive sense. Negative effects affecting the wellbeing of the population might include increases in anxiety and complications of drugs, while the posi- tive effects might include the introduction of regular health checks and the adoption of better lifestyles. An economic evaluation of the project covers the annual cost of all components including the value of the time of health staff and patients, the cost of treatment (drugs and other items) and travel expenses. The effects of the project will be measured in terms of morbidity and mortality and of changes in the quality of life it is expected to elicit. 2.2.2 Finnish tattonal progrumme on heolth care for arterial hypertension The programme was set up after an analysis of health care for hyper- tension in Finland had shown lhat the situation was unsatisfactory. It pro- vides for prevention, early detection, diagnosis, drug treatment and sur- veillance without drug treatment. Prevention involves health education aimed at reducing obesity and at lowering salt intake. Adequate physical activity and cessation of smoking are advised. Although special target goups such as children and young adults have been identified, health education isdirected to the whole population. Surveillance covers both hypertensive patients under drug treatment and subjects with elevated blood pressure not under- going treatment with antihypertensive medicaments. Physicians are res- ponsible for diagrostic evaluation and initiation of treatment and for care and follow-up of patients whose treatment is complicated. Public health nurses are responsible for ensuring continuity of care and surveillance of most patients with slightly raised blood pressure, and for carrying out the greater part of the health education. Special arrangements have been made for train- ing personnel. There is provision as an integrated part of the programme for an inflormation system and continuous evaluation, which should provide the necessary feedback of information for programme management. It should be emphasized that no new mass screening is foreseen. 2.2.3 CMEA cooperative studlt on h_vpertension in children This study, coordinated by the Hungarian Institute of Cardiology on behalf of the Council for Mutual Economic Asistance, is being carried out 3 in Berlin, Budapest, Havana, Kaunas and Moscow. It deals with the distribu- tion of blood pressure and the natural history of hypertension in childhood, including risk factors in its developnlent, in a total of 17130 children. Girls and boys born in 1964 were screened for blood pressure n 1977. Those in the upper part of the blood pressure distribution were then recalled for de- tailed examination, as well as a l0% sample of all the other subjects. Parents were also examined. Since the methods were carefully standardized, the results are comparable internationally. It has been confirmed that sexual maturation has a geat influence in raising blood pressure in this age group and that, because of the rapid changes which occur, age should be considered in months rather than in years. Renal disease, diabetes, hospital admission, and hypertension and diabetes in parents were more frequent for children in the upper lVo of the blood pressure distribution. A follow-up study of 5- l0 years is foreseen. 2-2.4 WHO project on community control of hypertension This cooperative study was launched in 1972, realizing that hypertension, although easy to detect and treat, remained nevertheless a poorly controlled condition in most parts of the world. On the assumption that hypertension car be controlled by organized. community-based programmes in various socio- economic and health care settings, it was proposed to study whether such programmes are feasible, effective and useful, i.e., cost+fficient. Under the study protocol, intervention and matched reference communities were selected in a number of countries and baseline preliminary surveys were made. The intervention measures included training of health personnel, health education of the general public especially on hypertension control, case- finding through screening and other methods and upgrading of health services for hypertension care. All hypertensive subjects identified were put on a register and were followed up at regular intervals and the data were pro- cessed centrally by WHO. Three levels of participation in the cooperative project can be distin- guished. At the level of full cooperation, a number of centres implemented the whole protocol, including the study of a reference community (Havana, Lisbon, Lyons, North Karelia, Padua, Ulan Bator). Some centres only did a feasibility study in an intervention community, without a relerence area (Accra, Barbados, Fukuoka, Ibadan, Paris, Tel-Aviv). Other centres (Beijing, Berlin, Dakar, Moscow, Prague, Reykjavik) and the European Working Party on Hypertension in the Elderly are cooperating through exchange of ex- perience. In addition, hypertension control projects were implemented by seven centres in Latin America under the coordination of the WHO Regional Office for the Americas. A terminal survey is now under way in the project areas and the study is to be evaluated in 1980. Preliminary information shows that programmes for community control of hypertension are feasible, on the 4 condition that a certain minimum of health services exists. The data show that they may also be effective in terms of lowering morbidity and mortality due to complications of hypertension. The question of whether the pro- grammes are cost+fficient is open tbr the time being and certainly merits in-depth study. 3. RESEARCH For obvious reasons less information is available on planned research than on the current studies. A variety of research proposals in various coun' tries of the European Region have, however, been made known. It has been computed that if the blood pressure distribution of the general population were moved l0mm to the left, as much would be achieved in pro- moting community health as by normalizing the blood pressure of all hyper- tensives. For this reason it has been proposed in Sweden to study measures affecting blood pressure not only of identified patients but also of the total population. Such measures, which underline the importance of primary prevention of high blood pressure, are for the time being concerned only with the moderation of salt intake by the population. Studies on this question, although difficult, may be within the realm of the possible. Research on salt excretion and salt moderation is foreseen in other countries. In Yugoslavia, for instance, a study of differential salt excretion in populationswith a higher and lower prevalence of hypertension are being planned. Further studies on salt intake and salt moderation are envisaged in Portugal and the USSR. Studies of environmental influences on the development of high blood pressure have been proposed in the German Democratic Republic, within the framework of occupational health research, and in Yugoslavia, where an in- depth investigation will be made of the existing differences between rural and urban populations. The different effects of drugs given to populations at large is another question that preoccupies a number of investigators, and studies have been proposed in Sweden and the Federal Republic of Germany. Problerns of direct relevance to national health agencies include the most effective and efficient modes of detecting hypertension, compliance with drug treatment and the economics of hypertension control. The need lor studies on these topics is felt in the Federal Republic of Germany, the United Kingdom and the USSR. among others. A number of hypertension studies are to be undertaken within the pro-ject for disease prevention of the Italian National Research Council. These projects need appropriate coordination and attention is drawn in this respect to the importance of international guidelines to be produced by WHO. 5 Various coordinated programmes for control and care ol hypertension are being planned under the sponsorship of national cardiological societies or national antihypertension leagues, e.g., in the Federal Republic ol Ger- many, Italy and Poland. In the Federal Republic of Germany hypertension research is also carried out within the framework of multifactor community intervention studies, developed as a collaborative effort by several centres. Future plans in Portugal relate to: evaluation of health education through television; evaluation of the benefits of nationwide reduction of salt intake; and the assessment of the effectiveness of a semistandardized regirnen and care by nonmedical personnel. 4. RELEVANCE OF CURRENT AND PLANNED RESEARCH TO THE NEEDS To establish a basis for discussion of further research perspectives, the question of whether the current and planned research in this field satisfies the needs had first to be clarified. A detailed analysis of the research needs is given in Annex I. Six main elements in the delvery of appropriate hypertension care may be distinguished: population; health services; detection; effects of care; possible causal, con- tributing and risk factors; and possible intervention in relation to these factors. Among the factors, a fair amount is known about blood pressure in the popula- tion from earlier epidemiological studies, but much more information should be obtained about the others. For instance, the relative value of various therapeutic procedures (diagnostic work-up, hygienic and dietary treatment, drug therapy) and the different roles of health workers and institutions (general practice, specialists, nurses and allied health personnel, hospitals) should be studied in greater depth and quantitatively assessed. The relative importance of various means of detecting hypertension (routine health care, casual screening, systematical screening, self-measurement) and the effects of health care in terms of cost-benefit also call for more research. There is only rudimentary knowledge of the possible causal, contributing and risk factors in hypertension and primary prevention of the condition, and the study of genuine public health solutions is still a virtually undiscovered field. Table I lists the different areas of research in current studies, as shown by reports from Member States and information from other sources. Information was obtained on a total of 148 studies, i.e.. from Mem- ber States for 82, through other channels for 66 and from both sources for 19. It is assumed that the total number o[ studies in Europcan coun- tries is around 200. 6 Table 1. Scope of research in current studies in the European Begion lnternational cooperation 48 Descriptive epidemiology lntervention Community control Therapy Health care Primary prevention Other 57 35 24 14 14 't1 10 Genetic factors Childhood Psychosocial factors Salt consumption Oral contraceptives Behaviour 1 3r 1t 6 4 8 1 2 t1 l07 Psychological factors Obesity Physical environrnent Chemical environment Nutrition Socioeconomic factors Blood pressure distribution Prevalence of hypertension Uses of screening Overdiagnosis Underdiagnosis Self -measu rement Diagnostic work-up Role of general practice Role of the hospital Role of nurses Allied health personnel Hygienic treatment Physical activity Dietary treatment Hypotensive drugs Patient education Health personnel education Health services utilization Surveillance Compliance lnformation systems 43 43 1t 5 I 5 4 11 2 2 1 3 17 12 7 3 11 4 't4 3 Costs, economics Sideeffects Benef its for the community Complicati ons prevented lmprovement of health Protection of the environment General health education 6 Knowledge of hypertension 1 2 Attitudes to hypertension 4 3 Causal hypotheses testing 7 5 Mild hypertension natural history 6 Tracking 2 lncidence of hypertension 1 l'l Old age 4 A/ote.' Figures refer to the percentages of studies reviewed which belong to the categories listed. Since some studies have been classified under several headings, the sum ol the percentages exceeds 100. 7 It will be noted in Table I that 487o of all studies are being under- taken with sonre kind of international cooperation (not necessarily through WHO). Many are of the descriptive epidemiological type, whi.le only some deal with problems of intervention and community control. A smaller num- ber deal with health care or include research on primary prevention of arterial hypertension. Regarding the items mentioned specifically in the information avail- able on the studies, research on blood pressure and/or hypertension in child- hood was reported in 22% of cases. Other items frequently mentioned in- clude research on blood pressure distributions in populations and on the prevalence ol hypertension. Many items of great relevance are rarely mentioned and it may therefore be assumed that most of the studies are only marginally concerned with them, if at all. Such topics include overdiagnosis and underdiagrosis, the role of various types of health personnel, non-drug treatment, utilization ol health services, hypertension care related to old age, and the economics of hyper- tension care. Clearly, research in these areas should be expanded and intensi- fied if hypertension care is to be optimized or even improved. 5. FLNURE TASKS IN RESEARCH The future tasks in research, facing both the scientific community and national health authorities in the European Region, were considered under the following headings: prevention and early det ect ion ; problems in health care de- livery; evaluation of drugs and other therapeutic and diagnostic substances, economic aspects of health care; standardization of methods, measurements and terminology. This corresponds to the five priority areas for research delineated by the European Advisory Committee for Medical Research. 5.1 Prevention and early detection The ternr "prevention" refers to the prevention of both elevated blood pressure and complications of hypertension. Since the meeting was concerned mainly with epidemiological and cornrnunity approaches, it endeavoured to propose research relevant to the whole population. The main issues considered under this heading were: (l) detection and management of subjects prone to the development of elevated blood pressure (including children); 8 (2) detection and management ol subjects at high risk of complications; (3) prevention of complications of hypertension in view of the fact that they occur mainly in people with relatively low blood pressure (in com- bination with other risk factors); (4) determination of the proper place of early detection, screening and case-finding. The present knowledge suggests that both genetic and environmental factors influence the distribution of blood pressure and the prevalence of hypertension. At the moment several possible genetic markers have been identified, such as the abnormal retention of sodium by the red blood cell membrane, and other factors which seem relevant to early identification of individuals prone to hypertension. Considering the present impossibility of influencing genetic patterns and the impracticability of genetic counselling, the only solution to the problems described above, if it were possible, would be to move the whole blood pressure distribution curve to the left. 5.1 .l Sodium restiction Apart from genetic factors, a major determinant of blood pressure distribution and elevated blood pressure prevalence in populations may be sodium intake, although some doubts and uncertainties were expressed by participants in that respect. This does not imply that the neurogenic mech- anisms conditioning individual reactions to external stresses and other factors are not of importance. It was felt that research on sodium restriction in the diet should have first priority and that the following steps could usefully be undertaken by interested groups with the help and under the coordination of the Regional Office: (l) dissemination of detailed information about ongoing studies on salt and hypertension; (2) design of a protocol f,or a pilot study to be conducted in family groups to determine (a) whether salt reduction in populations is feasible, and (D) whether such a reduction is in fact associated with a reduction of blood pressure values in the population (this would involve the moni- toring of changes in blood pressure in the whole range of its distribution, i.e., in hypertension, borderline elevations and the so*alled normotensive conditions); (3) in the case of a successful outcome, transfer of the experience to large communities, with follow-up oI complications. 9 In the same field, studies should be envisaged on a method for moni- toring the effect of natural experiments which apparently are occurring in some countries with decreased consumption of salt. Studies on salt intake and restriction should not neglect the ratio of sodium to potassium which may be more critical than salt alone. Other possible dietary factors should be considered for further metabolic, clinical and epidemiological studies. The problem of variations in body weight should be studied carefully to avoid confusion with changes in salt intake. 5.1 .2 Genetic studies In view of the importance of genetic factors and of individual reaction to external and environmental factors, it is recommended to introduce measurement of biochemical markers in population studies. Optional com- ponents may be added, such as tissue typing and investigation of genetic links between juvenile diabetes and juvenile hypertension. Increased knowledge of genetic mechanisms in the development of hypertension may soon provide a sounder basis for studies aimed at bet- ter identification of hypertension-prone individuals in families with a gen- etic predisposition. 5.1 .3 Multifuctor prediction and prevention The problem of factors contributing to the development of elevated blood pressure requires more research on the effects of body weight, physical activity, reaction to physical and mental stresses, salt consumption and other factors, including both observational and intervention studies. The same approaches can be usefully applied to the hygienic treatment of mild hyper- tension. One of the most important issues to be studied is the identification of biochemical and other variables which might allow individual prediction of complications, since they may or may not develop in people with the same blood pressure and similar levels of other risk factors. 5.1 .4 Psychosoctul factors It is recognized that psychosocial factors in blood pressure and hyperten- sion require more basic research as well as large-scale population studies. 5.2 Problems in health care delivery 5.2.1 Behavbur Some examples of behavioural research were suggested in the discus- sion. There was general agreement that it would be useful if psychologists l0 formed a part of the team in a hospital clinic. ln this respect two particu lar needs were identified: (l) the need to consider the social and psychological characteristics of the patient and his response to therapy; (2) the need to develop methods to assess the course of treatment in individual patients (this might include study of compliance with differ- ent therapeutic regimens and attitudes of patients and physicians to different forms of treatment and to the control of blood pressure). One problem in such behavioural studies is the development of para- meters to express changes and values in the techniques under investigation. Such parameters should be identified and evaluated, to allow workers in the {leld to use them for comparative studies. It is particularly important that all research should allow international comparisons, and techniques should therefore be standardized in order to yield repeatable, reliable and com- parable information. 5.2.2 Education Education needs were not precisely identified. It was, however, con- sidered that the patient should learn about measures which improve his general health status, and that the general practitioner'sknowledge ofmethods of handling essential hypertension should be periodically updated. Phys- icians in hospitals also need to update and exchange information so that the general standard of care throughout the community can be maintained at the highest level. 5.2.3 Team approach During the discussion the role of the general practitioner and of ancillary staff was scrutinized from several points of view. In particular, the functionof the general practitioner was considered to be vital, as he is the person who should be responsible for the coordination of patient care. He should liaise with the hospital physician and monitor patient progress during the various stages of treatment, whether drug therapy or general health measures. Nurses should play an important part in the team looking after the patient, in par- ticular to provide the psycho-hygienic aspects ofhypertension care. 5.2.4 Multidiscip lilwry approach The need for a multidisciplinary approach was strongly emphasized, and it was felt that the potential contribution of each discipline should be ll evaluated. It was noted particularly that epidemiologists and social psy chologists should be members of the teams. 5.2.5 hiorities It was lound difficult to identify priority areas for research. Neverthe- less, it was felt that the topic of nraintenance of patients under care should have highest priority. Other priority items should be the choice of individual therapy, the relerral of patients, and finally detection. Each item was con- sidered from the viewpoint of existing approaches, promotion of such schemes, and the development of new methodolory. A scheme for setting priorities in the research is illustrated in Fig. I . 5.2.6 hopovls It was proposed that further research on hypertension in relation to health care should include the following items. (1) Beluviour Assessment of the impact (if any) of patients' social and psychological characteristics on regimen compliance and response to therapy. (2'1 Education (a) Assessment of the clinical effectiveness and cost-efficiency of ap- proaches to training health professionals in patient education methods. (D) Assessment of the clinical effectiveness and cost+fficiency of alternative modes of patient education aimed at increasing regimen ad- herence. (c) Assessment of the clinical effectiveness and cost-efficiency of alter- native approaches to continuing education of health professionals on hyper- tension management and on modern industrial management methods for improving health care delivery. (3) Team opproach (a) Comparative or independent assessment of waysof preparingortrain ing health professionals to interact with others of different specialties. (b) Assessment of alternative modes of patient referral among health professionals with the aim of improving professional interaction. 12 -c(, (E 6' d) o oo oG-P(l) .co5 .EEE!oAO6= E:-o c b:OPv 'E'; o)s6E o-o >lLud rs s o 8frE* ogo3 o5b_ o.= o.P=6 *oc .EE E E-E o E,(,(! o o. o.o; o,z 6 oC() '-c 3.eoo .rt 6 o o- o () o o)o o :o OO -oEorL> ol o(l, E G OE -ootr EE a- o oacFE6i .=o(oo o oo o c .9 co o o- E .a o .I o o- EDc o o q) Eq)E(, aJ) - .d, LL lio o o o o 1C o o oE G oEIoo o o,o ioc ! cG o! ao o o c 3 o C I E o co G l3 (c) Assessrnent ol the clinical eflectiveness and cost-elficiency ol dilfering teanls or cornbinations of health professionals in delivering hyper- tension cont rol services. (4) Evaluation ol'core (a) Developrnent ol new or improved methods lor evaluating hyper- tension control eflbrts, and especially means to assess changes in the incidence of hypertension and its major complications (stroke, coronary heart lailure, myocardial inlarction, renal tactors). (b) Assessment ol the cost+fficiency and educational effectiveness of various techniques to communicate information and/or skills to a community. (c) Means lor assessing regimen compliance, such as the current method of adding fluorescing compounds to drugs for detection in urine. 5.3 Evaluation of drugs and other therapeutic and diagrostic substances Introduction Following the demonstration that systolic and diastolic hypertension is a major risk factor in cardiovascular disease for both sexes at all ages, research has been undertaken on the potential benefits of lowering blood pressure. Controlled therapeutic trials carried out to date have raised a number of questions which must still be resolved, namely: 5.3.1 Within whot ranges of blood presilre, at what ages and in what specific areos have the beneftts of lowering pressure by the use of antihyper- tensive drugs been demonstrated? The results obtained to date relate essentially to: - permanent elevation of blood pressure in several successive examina- tions, with recording of diastolic pressure values (phase 5); - lessening of cardiac, cerebral and renal complications of hypertension in patients with diastolic pressure values above 105 mmHg belore active treatment, at an average age of 50, in populationswith a major- ity of males. Insufficient data are available on: - diastolic hypertension between 90 and 105 mmHg; - systolic hypertension in isolation or associated with diastolic hyper- tension; t4 - systolic and diastolic hypertension in subjects aged over 60; -- borderline hypertension, especially in children and adolescents, two groups for which pressure value distributions are being determined in many countries. 5.3.1 /s there a non4rug teotment lbr h.t'pertension? Two aspects ol this problem must be considered Are there any non-drug measures available, which have a significant and lasting cff'ect in lowering blood pressure? What are the benefits ol the nreasures for the cardiovascular system, their side-effects if any, and their cost? Apart lronr the use of cstrogen and progesterone contraceptives, liqu<lr- ice and drugs such as phenacetin, corticosteroids or vasoconstrictors in con- nexion with secondary hypertension, attention has been paid to the following factors: - weight reduction - reduction of sodium in the diet - regular physical exercise - elimination of high alcohol intake - attenuation of psychosocial and sensory constraints - other cardiovascular risk tactors. (a) tleight reduction Scveral studies among overweight hypertensives have shown that a I kg decrease in body weight lowers blood pressure by an average of 3l2mmHg. These studies were of short duration. (b) Reduction of sodium in the diet Several studies among hypertensives have shown thal a reduction ol sodium in the diet from 200 to 100 milliequivalent per day (12 to 6golso- dium chloride) lowers blood pressure by an average of ll/l0mmHg. These studies involved small numbers of patients. (c) Regulor physical exercise None ol the current lindings justily proposing physical exercise as a definite rneans ol lowering blood pressure. l5 (d) Elimination of htsh alcohol intake This measure does not at present appear to have a specifically anti- hypertensive eflect. Nevertheless the effect ofalcohol consunrption in raising blood pressure values has been demonstrated as well as its adverse influence in lessening compliance by patients in long-term drug treatment. (e) Attentuation of psychosocial and sensory constroints Even when this measure is leasible, it has not been shown specilically to have a lasting antihypertensive effect. Treatment based on the practice of yoga, relaxation or transcendental meditation has been effective in lowering blood pressure for only short periods of time and in very small numbers of selected subjects. A long-term effect has not been demonstrated and widescale application of such measures would be difficult. $) Other cardiovascular risk factors Measures in respect ol factors such as smoking, level of polyunsaturated fat consumption, etc., are not considered here since they do not directly affect blood pressure. 5.3.3 What is the present status of drug treatment for hypertension? Blood pressure can be lowered in most hypertensives, using the cu;rent drugs. It is important, however, to determine and prescribe the minimum effective treatments so as to encourage patient compliance. At the same time new drugs must be developed, since none of those now available are wholly free of side-effects, and they are not effective for a small proportion of hypertensives. A comparative evaluation must be made of the action and side-effects of the drugs, in the short and long term. The relative advantages of the different therapies should not be evaluated only in terms of lowering blood pressure but also of preventing the cardiovascular complications of hypertension. The value of computerized methods in improving data collection and ensuring long-term follow-up of hypertensives has recently been demonstrated in a number of European countries. 5.3.4 llhat factors influence the attitudes of physicians and patients to treatment of hypert ension? Food habits and drug prescribing practices vary considerably in coun- tries. The effect of these differences in controlling hypertension and pre- venting cardiovascular complications is not known. t6 Paticnt conrpliance in following health and dietary advice antl observing drug t reatnrent depends on many fhctors, which greatly influence t he results ob- tained, at individual and cornmunity level. Hypertension control associations have been established in several European countries to inlorm medical and allied health workers, educate patients and the public and promote research. 5.4 Economic aspects of health care The wide-ranging discussions on this matter t-ell under the tbllowing broad headings. 5.4.1 General utmments (a) lt was lelt in the discussion that econonric/cost elenrents are in- corporated in more national studies than was evident lronr the information provided to WHO (Table I ). (b) It proved difficult to give more than superficial consideration to this wide-ranging and important topic in the brief time allocated to the meeting. 5.4.2 Role of ecornmists The role of economists in examining a rnedical problem from the stand- point of a different discipline was discused under a number of headings, including: (a) identification and cost+lficiency exanrination of options within health care delivery systenls; (D) more precise definition ol diseases (e.g., is hypertension a disease or a sign?); (c) cost irnplications of setting different standards for intervention (e.g., levels of blood pressure for the provision ol treatrnent and/or prevention); (d) consequences, positive or negative, of treatr.nent and nontreat- ment (e.g., "labelling effect" in hypertension in relation to sickness absence tiom work). 5.4.3 Economic factors in rcsearch Economists should not concentrate on cost containment in health service research (which tends to have an adverse effect upon researchers). Econontic tl advice is necessary in understanding health service organization, structure, nlethods of payment, policies and relationstrips with regard to the drug indus- try, prescribing practice, etc. Such understanding is essential in analysing and in- terpreting the outcome of most health service studies involving intervention. Screening models must not be concerned only with case-finding, but also with the full implications of screening. At the same time, the evaluation of health services involves considerable problems lor which simulation models may be more appropriate than controlled trials, and economists have an im- portant role to play in designing such models. In the design of studies economists should also take into account the "programme impact on the economy", e.g., if instrumentation is widely provided in the community, self-measurement oI blood pressure will have an impact on services; health education may also have an impact on ser- vices; community interventions may affect local economiesi and on a wider scale there may be correlations between economic and health factors. 5.4.4 Conclusions It was concluded that in most instances there should be an economic component in the design of health service studies. It would be concerned with elfectiveness and efficiency, i.e., with outcome and the cost of achieving this. Only rarely would there be justification for separate economic studies and it was felt unlikely that such studies could be mounted on a multina- tional comparative basis. The usefulnessof providinga checklist of economic factors to be taken into account in planning health service studies should be considered by WHO. 5.5 Standardization of methods, measurements and terminology The meeting recognized the extensive work carried out by WHO, both at its headquarters and at the Regional Office for Europe, in the field of stan- dardization for studies on chronic ischaemic heart disease, acute myocardial infarction and community control of hypertension. There was general agreement that WHO should continue its efforts in these directions, as already outlined by working groups and expert commit- tees on arterial hypertension. The group considered the following items of importance for the future research to be promoted and coordinated by WHO: (a) design of basic standard protocols, including: - measurement of blood pressure - conditions, techniques, number of measurements, etc. -- diagrostic work-up in hypertensive patients l8 - standards for reporting results in hypertension research in order to compare and pool findings of different studies, e.g., for cross- tabulation of systolic and diastolic blood pressure and blood pressure distribution curves (as this subject was discussed at the recent WHO Working Group on Pilot Projects lor the Study and Control of Atherosclerosis Precursors in Childhood, it was sug- gested that the guidelines established at that meetingbe adopted - see Annex II); (D) setting of minimum technical standards for blood pressure measure- ment devices, including automatic and semi-automatic machines; (.) review and selection of existing standards for research, e.9., outcome variables, measurable psychosocial and behavioural indicators; (d) asessment of acceptability of proposed standards and compliance with protocols (feasibility, motivation, costs, etc.); (e) assessment of the contribution by existing WHO reference labora- tories (e.g., measurement of serum lipids, coding of ECGs) and of the needs for their expansion in other fields of standardization. In view of the universal use of the millimetre of mercury (mmHg) for measurement of blood pressure in clinical practice and epidemiolory, the par- ticipants were of the opinion that it should not be replaced by the kilo-pascal for this purpose. 6. THE ROLE OF WHO As stated repeatedly, hypertension is a major public health problem throughout the world, but is of particular importance in European coun- tries. For that reason the European Advisory Committee for Medical Re- search suggested that the Organization discuss in depth the problems of health care in relation to the condition. The role of WHO, however, should extend far beyond mere discussion. It was strongly lelt by the participants that WHO should play an active role in furthering research. It was stated that important research projects are under way or have been planned in various countries using national or local funds and expertise available in the countries. While there does not seem to be any particular need for WHO involvement in projects carried out by scientists working in settings with long-standing traditions in epidemiology and health care, research l9 in countries with less expertise in this domain may benefit l'rom experience of studies at a nlore advanced stage. Moreover, any study even the nrost advanced - may benefit from experience gained in other countries, even if it is based on different approaches because ol' the specific features ol their sociopolitical, economic and health care systems. It was there[ore felt that WHO should servc as a clearing-house lor the research. Informa- tion should be exchanged in a systematic way with WHO ensuring a centri- petal distribution of data obtained from research centres and institutes scattered throughout Europe. The modalities of the inflow of inlbrmation would havc to be defined. The benefits of WHO assuming this clearing-house function would be multiple. The launching of redundant research projects, i.e., investiga- tions duplicating those performed earlier or in other countries, might be prevented and the resources used instead [or the elucidation of priority questions. Standardization of methods, protocols and reporting forms would greatly facilitate the comparison ol results from different studies. This might be achieved by providing consultants who would assist in the design of proto- cols, the evaluation of methodology and the management of community programmes or research projects. As in other fields, WHO could promote research by desigrating col- laborating centres with specific scientific assignments. In general, WHO should reinforce the existing trends in international cooperation. This could be achieved by convening seminars, working groups or task forces to look at new ideas and stimulate research based on information not yet available from the literature. It was noted that, although there is considerable research activitiy, it is insufficiently monitored. It was felt that WHO could play a useful role in stimulating national research in the area of the "white spots", inadequately covered at present. All the objectives outlined above need further consideration and the technical details will have to be worked out, prelerably by task forces and groups of selected experts. 7. RECOMMENDATIONS In view of the complexity of research on hypertension in relation to health care, which elicited discussion on many different items, it is indis- pensable to establish certain priorities if action is to be initiated. As a first step, the citeria lbr such priorities were delined. lt was realized that two types ol priorities have to be outlined: those for direct action by WHO, and those lbr research to be promoted by WHO. 20 The leading criteria for establishing research priorities strould be the urgency and scope of the practical needs, in direct action by WHO, and the existence of reasonably justifiable hypotheses for proposals, in research to be promoted by WHO. 7.1 Action by WHO It ernerged from the discussion that WHO could make a pragrrtatic con- tribution by: (a) collation and dissemhation of inlormation on ongoing and planned research projects; (b) standardization oI rnethods, protocols and reporting forms Both itenrs are considered to have equal importance and the activities should be initiated simultaneously. 7.2 Research to be promoted by WHO The activities of WHO are based on those of Member States and the suc- cess of the Organization's coordination function is dependent on the con- tribution made by individual countries. Priorities for research to be promoted by WHO are as follows. (a) There is a need to identify the natural history of essential hyper tension in dilferent geographical areas and ethnic groups. (D) Studies of lifestyles and of attitudes to measures designed to modify them are required and the socioeconomic factors related to hypertension should be considered. Measures designed to change these factors should be evaluated. (c) Methods to evaluate the efficacy of home care should be designed and comparative studies undertaken. (d) The attitudes of patients and health personnel to different thera- peutic regimens should be elucidated. (e) The place of the general practitioner and nurse in the detection of hypertension and the maintenance ol control need to be examined. Ques- tions of education and cost-beneflt in patient care also have to be con- sidered. 2l Since health care in relation to hypertension. as repeatedly ernphasized, is a very complex lleld, the many important items necessitating research may be divided into four subgroups: (l ) epidemiological research; (2 ) primary prevention: (3) upgrading of treatment; (4) organization and provision of health services The priority areas lor research in these four categories are listed as follows. (l ) Ep itlemio logical research (a) Blood pressure levels in children and adolescents. (b) Blood pressure levels and their variations in ethnic and social groups (c) Epidemiology of psychosocial factors contributing to hypertension (e.g., lifestyle). (d) Role of salt and other dietary components and the eflect that modification of their intake has in reducing the mean level of blood pressure in the community. (2) Primary prevention (a) Effects olmoderation of dietary sodium. (b) Biochemical markers of early hypertension and genetic studies. (c) Measures designed to change lifestyles lor the prevention of' high blood pressure. (3 ) Up4rodinq of treatnrcnt (a) Monitoring of the eflects of very long-term drug treatnrent of hyper- tension in large numbers of people. (D) Optimum ways of treating hypertension lrom the standpoint of preventing coronary heart disease. 22 (c) Effectiveness of hygienic treatment (including reference to psycho- logical factors) as shown in trials involving limited numbers of subjects but conducted according to strictly designed protocols. (4) Organizatbn arut provisbn of health services (a) Expansion and improvement of comntunity programmes lor the control of hypertension and monitoring oI their long-term effects. (D) Methods to evaluate the efficacy of home care should be designed and cornparative studies undertaken. (c) The attitudes of patients and health personnel to different thera- peutic regimens should be elucidated. (d) The place of the general practitioner and nurse in the detection of hypertension and the maintenance of control need to be examined. Questions ofeducation and cost-benefit in patient care also have to be considered. It is important to note with regard to the various priorities that economic considerations should be integrated into all the research projects outlined. Economists should therefore participate in their design and evaluation. 23 Annex I Hypertension research related to health care Dr T. Strassera Abstract The development of research in hypertension related to health care is examined in two ways. First, an analytical approach is used,whereby hyper- tension and the care and prevention of this condition are viewed as a system with several interrelated subsystems and many components. Then a review is made of the inlormation available on 135 hypertension research studies in the WHO European Region. The two approaches are then combined by ap- plying the theoretical considerations to the actual situation and by consider- ing priority needs from the societal point of view. It is concluded that there is an imbalance in the range of topics now studied. On the other hand, there is an encouraging trend towards international cooperation and the study of blood pressure in childhood. In the immediate future, it is advocated that the ongoing research be brought to completion. For this purpose a systenl lor exchange ol'informa- tion on the studies could be established, as well as standardized procedures for reporting the findings. International monitoring of the research would provide useful leedback to those involved in the work. Practical suggestions are made for enhancing the impact of the current research. It is considered that the next stage ol research should locus on means to optimize the control of hypertension, analysing the overall system of care and its many components lor this purpose. Ultimately, however. research must be directed to the primary prevention ol hypertension. Finally, it is suggested that WHO could play a useful role in coordi- nating the research eflorts, in collaboration with the international scienti- fic community. Background The situation of arterial hypertension in the early 1970s was reviewed in the 1972 Annual Report of the WHO Director-General (1). As shown 24 a Medical Officer, ('ardiovascular Diseases, WHO, Goneva in Fig. l-A, sorne 12-15% of all adults in a nutnber ol populations were found to be hypertensivc. This surprisingly high figure revealed by popula- tion surveys w<-ruld probably never have been uncovered using conventional statistics. Furthermore. it was lound that about half ol' the persons with high blood pressure were unaware of their hypertension. Only hall of those aware cll'the disease received some kind of treatntent, and among these the lreatment was appropriate in only half of'the cases. Fig. 1. The hypertension situation in the community: (A) before starting a community control programme; and (B) after 5 years of programme operation A : total population;8: undetected hypertensives; C: untreated hypertensives black circle: treated hypertensive patients Source: Strasser (2) This "rule ol the halves", found to be true for many countries, expresses numerically the "triple paradox" (3) of hypertension care. according to which: - a condition easy to diagnose often rentains undetected; - although a condi(ion may be sintple to treat, it very olien renrains unt reated ; BA 25 - despite the availability of potent medicaments, treatment is all too often ineffective. lt is easy to understand the causes of this phenomenon. Hypertension is a symptomless condition, unperceived by the population as a health hazard. Even if detected, compliance of patients with the suggested therapeutic regi- mens is usually poor. Since the benefits of effectively reducing severe and mod- erate elevations ol blood pressure were demonstrated fairly recently, the medi- cal profession may not havc absorbed this information sufficiently in theearly 1970s; besides, no clear guidelines were available on therapeutic approaches. e.g., in mild hypertension or in old age, and these are in fact still lacking. As it was known from epidemiological studies that hypertensive patients are at high risk from cerebrovascular disease, ischaemic heart disease, hyper- tensive heart disease and other complications, and a therapeutic trial in 1969-71 had shown that the incidence of complications czrn be reduced by effective hypertensive therapy, it was felt that research should be under- taken to provide a basis lor public health action. WHO therefore instituted a cooperative, multicentre health care trial to determine whether, in various social, economic and health care conditions, public health oriented pro- grammes for the community control of hypertension were feasible, effective and efficient (4,5). This study will be evaluated in 1980-81. Preliminary results from some centres indicate that programmes are feasible. They are also effective in the project areas in so far as they increase awareness of hypertension, help to improve its treatment, and lead to a reduction of the in- cidence of stroke and myocardial infarction. The effect on the health situation of a successful programme for com- munity control of hypertension is shown in Fig. I -B. Compared with the initial situation - still typical throughout the world - the number o[ un- diagnosed and untreated hypertensive persons has substantially decreased in some project areas. The total number of hypertensives has not changed, but the number of those receiving hypotensive medication has risen. There is no doubt that the resulting decrease of stroke and ischaemic heart disease morbidity is a unique achievement, but it has been necessary to put a sub- stantial proportion of the community on chemotherapy for an indefinite time, and it remains to be shown whether the ecological cost (and financial cost) is outrveighed by the benefits of such an undertaking. Immediately the cardinal question arises of whether a reduction of hypertension itself, i.e., primary prevention of arterial hypertension, is achievable and by what means and with what investment on research and even services. Since it is unlikely that a definite reply will be obtained in the immediate future, the subsidiary but eminently important question has to be asked: what are the possibilities lor optimizing hypertension control in the near luture? Despite its apparent simplicity, this question is difficult to answer. Important public health research policy issues are at stake. 26 Tentative analytical approach (o) Method It will now be attempted to identify thc dift'erent conrponents of hyper- tension control and their interrelationships. It is hoped that this analytical approach will be of some value in lormulating research policies and in desigt- ing research projects. The field under consideration is enormously complex. For the time being it defies anything but a schematic analysis. Even a cursory look at the well- known nosological relationships of hypertension with five other diseases (Fig. 2) shows how intricate these connexions are: any consideration of the care of hypertension as an isolated disease category would perforce be an oversimplication. Such simplification is as inadmissible in relation to health care as in any aspect ofreal life, and thus discussion ofhypertension research Fig. 2. lnteractions among hypertension and other major chronic diseases RENAL DISEASE D IABETES HYPE R- TENSION STROKE ATHERO SCLE ROSIS ISCHAEMIC H EAHT DISEASE 27 should take into account the other major cardiovascular, metabolic and re- lated conditions, which would lead automatically to an examination of the concept of comprehensive health care. However, although necessary, such an approach would detract from the discussion of the topic, and therefore hypertension will be analysed as a more or less self-contained cateSory. Fig. 3 presents a block scheme of the main components of hypertension control. Obviously the population with its normotensive and hyperten- sive members is at the heart of the system. Hypertension is not perceived unless detected through various channels with different levels of instru- mentality. These channels are part of the health services whose main task in this respect is to provide clinical care to hypertensives. The effects of such care are both positive (benefits) and negative (costs), and a balance must be achieved between the tw<1. Hypertension (including essential hypertension) has its causes and contributing factors which are also part of the system. It is at least a partly preventable condition and prevention itself, when it becomes a reality, has benefits and costs. Finally, it should be added that nonpreven- tion incurs great cost but is ofno benefit. In Fig. 4 the blocks from Fig. 3 are broken down, still schematically, into their components. (b) Components of hypertension contol Within the populotion at least five subcategories can be identified: normotensives; persons with borderline or mild hypertension; patients with established hypertension; those with complications due to hypertension such as stroke, ischaemic heart disease, hypertensive heart disease, renal failure, retinal haemorrhage, etc.; and fatal cases. fu indicated by the arrows, individuals may shift from one category to another, either spontaneously in the direction of deterioration, or in the opposite direction as a result of ap- propriate treatment. The subcategories are far from being clearly delineated, as will be shown below. Individuals may move in the direction of deteriora- tion without being aware of their condition and therefore detection of hypertension is the first requirement for control of the disease. Detection of hypertension may occur in four ways. The condition may be uncovered during routine health care when the physician is searching for the cause of some clinically manifest disease. Another way of detecting hypertension is by "casual screening", i.e., measurement of blood pressure at the time of any visit of patients to the health services. Casual screening has been much advocated in community control programmes. Systematic screening of entire population groups and self-measurement ol blood pressure by automated machines are further methods of detecting hypertension in the community. All four methods have advantages and disadvantages. The main problems are both overdiagrosis and underdiagnosis of hypertension. While detection 28 (nF tJ- tu z lrJ co Z >occ- <i >il =>f,E,, o- U)FO I.IJ LL lJ- I.IJ U)F at) o(J ,uJ(r> Ha>z -LUF oZV) r{P Fcn-iri uJ57F T. ra o= = -a fr ccXIDZY i=?v co l.l- ul a:zEr-tr'6=E33o z o F J) o- o- ]LUg> =u) Yurzl- trZ UJ aZurFL)< =uJ rF(,/)F FUJJE(ut[!(J -<z = tU ..E AJ -o LJ,J L!$ c-> -oF6 L 'F lti< 2= -UJ = -6-J LU zz -(J z o F LUF I.IJ o ; EoEo in (E o .9 c o) o) o, - at .d, Ll. 29 ;: z:: 1l -l:: ..1 :1. ri: - -'-- ': : ::t + .i :. +i . ... : : : : at =o) E o) ! C) i; (E(J tr o c(D o, o. - + .d, lJ- I I z a I o i9 -: ; : : = -tsr ic:!!co 1 st , Ii 5a c: 3 e3 30 \+ I : i -t Jal. < lz _, during routine health care tends to result in an underdiagnosis of hyperten- sion in the comnrunity, systematic screening and self-measurement may lead to an overdiagnosis. i.e., the results include a large proportion of false positive lindings which have to be elintinated on subsequent visits olpatients. All four approaches are complementary. It remains to be ascertained what mixture of the Ibur would best suit various local situations. What mattcrs is not only the immediate impact of any of these channels in detecting blood pressure elevation but also the impact on fbllow-up and actual treat- ment of the identified cases. Thus. for instance, it has been shown that cases detected by systematic screening are insufficiently lbllowed up and that the impact of mass screening on hypertension control is thereforc less than anticipated. The components of services provided to hypertensive patients are broken down according to procedures, and the health workers and institutions involved. The main types of procedure are the initial diagnostic work-up, long-term follow-up of diagnosed patients, hygienic and dietary treatment, and administration of hypotensive drugs. The health workers and institutions responsible lor the management of hypertension are general practitioners, a wide array of specialists such as cardiologists, nephrologists, paediatricians, geriatricians, internists, etc., nurses and allied health personnel (health visi- tors, social workers) and, of course, hospitals with their high-powered staff. All the activities of the health services are aimed at shifting individuals from a worse to a better subcategory in the population, as illustrated in the centre o[ the scheme. The effects of care delivered to hypertensive persons are broken down into positive and negativc consequences or benefits and costs. The bene- fits consist of the number ol "prevented" cases ol stroke, ischaemic heart disease. or other complications;they may also be measured by the decrease of mortality rates and by the improvement of health. The latter is more a theoretical consideration, since it is very difficult lo measure. The costs to the community include direct expenditures on care of hypertension, which are relatively easy to measure. Indirect costs are more dilficult to assess and the cost due to the competing clf hypertension care with other health priorities, although very real, is extremely difficult to deter- mine. The costs in terms ol manifest side-effects such as drowsiness, de- pression or impotence, may be expressed statistically but are hardly measur- able because lhey involve dilficult value judgements. Besides, there are a number ol hidden side-elfects whiclr can be perceived only at the epidemio- logical level, such as slight deterioralion of gluco-regulation or mild eleva- tion of serum-cholesterol levels. Such side-effects do not necessarily en- danger the individual but may definitely increase the community risk. More- over, there may be other. still unkntlwn, epidemiological side+ffects at- tributable lo long-term mass use ol ltypotensive drugs, which is a problem that calls for further research. 3l The general rule that efforts al prevention ofa disease start laler than thera- peutic activities applies to hypertension. Obviously, the possible causal, con- tributing or risk factors have first to be identified. The role of obesity and of oral contraceptives in contributing to blood pressure elevation has been lairly well documented. Studies have been conducted recently, and are planned, on the role of salt consumption as a contributing, or even causal, lactor. Studies of blood pressure in childhood compare the findings in youth to those in parents and siblings, and aim to establish link with salt consumption on the one hand and with psychosocial and behavioural factors on the other. Studies are also being made of the role of components ol the physical and chemical environment, such as salt and trace elements, and of occupational hazards such as excessive noise and heat. It is assumed that there is an unknown number of, as yet unidentified, causal and contributing factors which might be revealed by intensive research in the future. Should more knowledge become available on the causal and contributing factors, primary prevention of hypertension might become a reality. Some practical means to this effect are in fact already becoming available in the realrn of health education and environmental protection. However, much research will have to be done before it can be shown that hypertension is preventable. By the same token, just as hypertension is nosologically interrelated with a number of other diseases (Fig. 2), the care of hypertensive patients is intricately linked with many other aspects of health care. It is obvious that hypertension care cannot be dealt with independently from overall health care delivery, and it is only in order to make a conceptual analysis possible that in the present paper care of hypertensives is being considered in "splen- did isolation". It is understood that hypertension control (including preven- tion) is part of comprehensive cardiovascular control and, going lurther, chronic disease control, which again is part of overall health care. It is characteristic olthe systems approach (and this makes it particularly difficult to apply), that any system is part of a higher system and so on. Besides the theoretical considerations, this has, of course, many practical implications. For instance, when viewed lrom the standpoint of the preven- tion of ischaemic heart disease, hypertension treatment should be part of a multiple risk factor intervention and should go hand in hand with antismoking, lipid-lowering and similar action, whenever indicated. Withdrawal of an oral contraceptive from a hypertension-prone subject should imply giving advice on alternative methods of contraception. Health education on hypertension must not enter into unfair competition with health education in other fields. Examples are countless in this exceedingly complex domain. Quantitative relationships So far, the components of the care of hypertension have been discussed as qualitative categories. Now an attempt will be made to illustrate some relationships in terms of quantitative functions. 32 Fig. 5 shows a number ol problems in hypertension controlas interrelated quantitative lunctions. The backbone of the diagram is the cumuhtivc blood presvre dis- tribution curve. This curve is based on actual findings from a centre co- operating in the WHO study on community control o[ hypertension and refers to males aged 40-45 in the semirural population of a E,uropean coun- try. The values are derived lrom casual blood pressure measurements made during the screening of a population; the curue has been smoothed and idealized in order to elirninate irregularities due to digit preference of the observers and also to fit systolic and diastolic pressures into a single line. It is of great importance to note that about 3Wo of this population has 150/90nrmHg or above, and about 20% has l60l95mmHg or above. in- dicating that a considerable proportion is in what is usually considered the hypertensive range. On the other hand, only a small fraction of the population has blood pressure values which are in the range of "established" or "severe" hypertension. The great majority of hypertensives are in the "mild hypertension" range. Another point ol great importance is that the blood pressure distribu- tion curve is a continuous function showing no break at which a division between "normal" and "hypertensive" blood pressure values could be estab- lished. This means that no natural dividing line between the physiological and pathological conditions related to blood pressure is present and that any distinction between nosological categories is arbitrary from the quanti- tative point of view. The curve illustrating the "pathogenicity" ol blood pressure is also con- tinuous. It shows the risk that subjects with different levels olblood pressure incur, i.e., their chances of developing any complication olhigh blood press- ure; it is based on figures derived from the Framinghanr study, presented in the Coronary Risk Handbook ol the American Heart Association (7). The risk attributable to blood pressure is an exponential lunction of the blood pressure levels, not a linear one. The increment of risk is considerably greater at higher pressures than in the lower part of the curve. Nevertheless, even with the "normal" range of blood pressures there seems to be some increment of risk moving lrom the explicitly low to the "normal" values, i.e., those which are most prevalent. The pathological effects of high blood pressure, i.e., its complications such as cerebrovascular disease or myocardial infarction, can be lessened by drug treatment, as demonstrated by a United States Veterans'Admin- istration Study in 1969 and 1972 (8-10). Nowadays a large number of potent hypotensive drugs are at the disposal of the health prolessions;how- ever, any drug treatrnent als<.1 has unwanted effects, first ol all side-effects of the chemical substance. In the graph, the side+lfects are tentalively shown by a straight (dotted) line which is based on the general assumption that side+flects are dose-related and that the doses are pressure-related. Also, -1J Fig. 5. Some quantitative relationships in hypertension care: a conceptual scheme The bars illustrate the community attributable risk of hypertension The blood pressure distribution curve has been idealized in order to accommodate both systolic and diastolic pressures on a single curve cost/effects = the ratio of the cost and effects of hypotensive pharmacotherapy 14 16 18 20 22 24 26 28 kPa SBP 100 110 120 130 140 150 160 170 t80 190 200 210 220 mm Hg 10 9 I 7 6 5 4 ^ ,nc oP60og c o:s0 =eoo E40 c 3so 100 90 80 I I NUMEERS I BEOUTREo I FoR rRrAL I .e- c5 = € 20 10 0 I0i 55 70 75 80 85 90 95 100 105 110 115 120 125 mm l-l OBP I 10 15 16 kPa Source: Strasser (6) et BLOOO PRESSURE OISTRIBUTION PATHOGENICITY(RISK) 34 11 '12 13 t4 3 2 combinations of drugs may have sideeffects. Although this broad state- ment may not hold true in individual cases, it might be accepted as a valid general assumption. In severe hypertension the therapeutic effects of the medicaments are considerably greater than the side-effects. In the gaph this difference is illustrated by the area between the risk curve and the line representing the side-effects. However, at slight elevations of blood pressure the thera- peutic effects of drugs must be assumed to be smaller than their side+ffects. At some point these two functions cross. In the graph this crossing is hypo- thetically placed between 100 and l05mmHg diastolic pressure or 170 and l80mmHg systolic pressure;the true place is not known but this is a point of major interest in present-day hypertension research. At least eight major therapeutic trials are currently under way to determine the blood press- ure levels at which drug treatment of hypertension should be instituted, i.e., to establish the level above which drug treatment is useful and, vice versa, the level beneath which hypertensive drug treatment is not to be recommended (11). Such therapeutic trials are difficult and expensive to conduct. The num- ber of subjects to be studied in the trials is shown in the graph as a functionof the pathogenicity of high blood pressure. It is in fact the inverse function of the risk of hypertension. At very high blood pressure elevations the bene- ficial effects of hypotensive treatment can be shown already with small num- bers. However, in moving to lower blood pressure levels, the numbers of sub- jects required for a therapeutic trial increase exponentially as a reflection of decreasing risk. In the zone of "borderline" blood pressure elevations, the numbers required for a trial may attain astronomical dimensions. A further consideration of paramount importance, especially from the public health point of view, is the community attributable risk of various levels of blood pressure. The bars in Fig. 5 give an approximate picture of the total risk the community incun at various levels of blood pressure, expressing the paradox that the community attributable risk is higher in the mild hyper- tension zone than in the zone of severe blood pressure elevations. Although the individual patient is exposed to a considerably higher risk at, say 125 mm of diastolic pressure than another patient at 100 or 90mm, when the slight individual risk is multiplied by the huge number of such individuals in a population it becomes clear that the total community risk is considerably higher in the range of mild blood pressure elevations than in that of severe hypertension. This is an important point since it shows that the public health problem mainly concerns the zone of mild hypertension (12), that part of the blood pressure distribution where the appropriateness of treatnrent is most controversial. A further important consideration, especially from the health care point of view, is the cost-effecl relationship of hypotensive treatment. The cost- effectiveness function shown in the graph is based on the work of Weinstein 35 & Stason (1-?) and illustrates the fact that this ratio is an inverse function of the height of blood pressure. This finding is understandable since the cost- eflectiveness curve is a complex function of , inter alia, both the pathogenicity of hypertension and the blood pressure distribution in the population. The above theoretical considerations serve merely to illustrate the com- plicated quantitative interrelationships between various epidemiological and clinical attributes of blood pressure and of its elevations, and the schema presented should be regarded as a conceptual model from which many numerical elements are still missing but which could and should be clarified by further research in the future. Situation of research in the European Region today We shall now consider the current situation of hypertension research related to health care in the Region and, in a second stage, discuss the re- search findings in the light of the foregoing theoretical considerations. Table I (p. 44) shows the distribution and scope of hypertension studies related to health care in countries of the WHO European Region. In prep- aration for the present meeting the WHO Regional Director for Europe invited the governments of all Member States of the Region to provide information on planned or ongoing projects in this field. Up to 23 July 1979, when this paper had to be concluded for technical reasons, replies had been received from l5 Member States. The information was supplemented from other sources for 22 countries, while no information was available for 3 countries. The information presented in Table I is by no means complete. The reports received were of uneven quality: while a few gave a detailed descrip- tion of various projects, others mentioned only the titles of the studies or gave a cursory outline of hypertension research in the country. Similarly, the supplementary information, sometimes based on personal knowledge of the projects or on congress reports, varied from in-depth to rudimentary. There- fore, the table should be considered as an indicator rather than an inventory of the research. Information on 135 studies was reviewed, including ongoing and pro- posed activities. The information on 66 studies was derived from the replies of governments (supplemented, when necessary, by personal knowledge), while information on 694 studies was obtained from other sources. It may be a fair assumption that information on about one-third of the studies in this field is missing and that the total number of ongoing and proposed studies 36 a In 7 cascs, government information was combined with data from other sources. may be around 200. However, it is unlikely that many major studies have been overlooked and thus the overall information contained in the table should be considered as providing a valid picture of the situation. Since no definition ol "hypertension research related to health care" has been established, in some cases it was difficult to delineate this type of research from clinical and fundamental hypertension research. Ob- viously, even seemingly acadentic fundamental research may eventually be of the greatest public health importance. Nevertheless, in order to be practical, in borderline cases a judgement was made as to how directly the eventual results of the project might be related to health care prac- tice. Thus, certain therapeutic trials were included in the analysis, while some other clinical sludies were excluded, particularly when dealing with questions of primary interest to specialists in cardiolory or hypertensi- ology. Information on animal experimental studies was not included. As regards this type ol' research, the projects were classified into several groups. Obviously some projects qualified fbr inclusion in several groups at the same time since they had descriptive, intervention, community con- trol and other components. Here again, arbitrary assessments had to be made. Studies were classificd by preference according to their most soph- isticated component, following the left-to-right sequence in the table, but certain studies qualified equally for two or more groups and are therelore shown in more than one column. According to this grouping almost 4U7o of all projects reviewed be- long to the category ol- descriptive epidemiological studies. The number of intervention studies and community control studies is about half that ol the descriptive studies. Therapeutic trials are being done in great numbers; however, only those with a blind or double-blind design were included in the analysis provided they involved considerable numbers of subjects, preferably with multicentre cooperation. Health care studies are designed to answer questions on the effectiveness or elficiency of health care de- livery, and there are rather few of them. Only about 7% of all projects tackle in one way or another the problem of primary prevention of arterial hy- pertension. The research has several encouraging [eatures. A considerable num- ber of studies deal with blood pressure or hypertension in childhood and adolescence. Although many of the 30 studies of this type reviewed in the table are oI a descriptive characler, primarily investigating blood press- ure distributions in children, the great interest in blood pressure studies in youth indicates that the scientific community has become aware of the importance of studying the precursors and early stages ol disease as a pre- condition ol primary prevention. Another encouraging finding is the fact that 48 studies, i.e., one-third of all those reviewed, are being done with some kind o[ international cooperation. Some are coordinated by or con- ducted in association with WHO, such as the WHO cooperation study on 37 community control of hypertension, the WHO atherosclerosis precursors study, or the mild hypertension therapeutic trials linked with the Joint V/HO/ISH Liaison Committee on Mild Hypertension Trials. There are, how- ever, a number of other international cooperative studies not associated with WHO which came into being because the investigators themselves realized the importance of international cooperation, its usefulness, some- times even its necessity. The scene becomes less encouraging when viewed in the light of the theoretical considerations outlined in Fig. 4. A number of important com- ponents of hypertension care are under-represented among the items spe- cifically mentioned by countries in the information provided on the studies. There seem to be few studies dealing with questions of health services from the management point of view, or with the effects of care, both its costs and its benefits. Questions which still require scientifically documented answers include the following: what is the optimum use of various types of health worker (general practitioners, specialists, nurses and allied health personnel) in the management of hypertension? How can overstraining of diagrostic services be avoided, and the diagrosis of hypertension in the community be made fully effective? What is the correct place of hyper- tension control in overall health care in various countries, when the costs are assessed in a comprehensive way? What are the possibilities of cost con- tainment in hypertension care, both in absolute and in relative terms, when compared with the costs and benefits of drug treatment of other disease categories, e.g., rheumatic diseases or psychoneurotic disorders? There seems also to be an imbalance in the research objectives with regard to possible causes and contributing or risk factors. There are re- markably few investigations of psychosocial factors and of physical and chemical environmental factors. Study of genetic factors is absent from the present scene, perhaps because it is not possible to intervene with regard to heredity. Nevertheless, early identification of hypertension- prone individuals might prove a viable approach to primary prevention or, at least, be a potentially rewarding research topic. The modest num- ber of studies concerned either directly or even marginally with the pri- mary prevention of arterial hypertension has already been mentioned. The trend, however, is rather favourable since the studies on salt con- sumption are of quite recent origin and might gain further impetus in the near future. On the whole, the hypertension research related to health care, con- ducted in the European Region today, has both positive and negative charac- teristics. The trend towards international cooperation and towards studying blood pressure early in life is an encouraging, positive feature. The imbalance in the topics studied is a feature that calls for correction. Whether the large number of projects in various countries should be perceived as wealth or plethora may be a matter for debate. 38 Future development of research (a) Immediate rasks The nrilestones in the course ol-hypertension control during the past three decades include the discovery ofhypotensive drugs, the realization that hypertension is a nrajor public health problem, and the demonstration o[ the failure of hypertension care despite the availability of appropriate drugs. As mentioned, the present research is lbcused on correcting this insufficiency of the health services. No doubt the immediate task should be to bring the present undertakings to completion. The large number of descriptive epidemiological studics hardly needs increasing. What matters is to make the best possible use of the research. This calls for effective international exchange of infomration on the ongoing studies and on their results. lnformation exchange and interstudy comparison may be facilitated by setting standards lor reporting the results. For instance, publication ol blood pressure distributions (preferably in percentile ranges), is of much greater value than the mention of "prevalence rates" of hyperten- sion. Similarly, it is indispensable not only to describe the methodsolblood pressure measurenrent but also to state whether one or several measurements were made and whether arithmetic means were computed or the lowest or the highest values were reported. It might be of intcrest to consider the re- porting standards in more detail. With regard to the intervention and community control studies, it is important to analyse the extent to which the experience gained from special- ly designed, limited research projects can be extrapolated to hypertension control in larger population groups or total populations. What has been said about the need for appropriate exchange of information on the descriptive epidemiological studies applies equally to these studies. It may be uselul to arrange lor monitoring of the international situation of hypertension re- search as it seems desirable that similar studies in different countries benefit frorn exchange o[ information on the methods used, and that interim results and methodological data are fed back to the interested investigators while the research is under way. Some topics are under-represented in the present research, as mentioned above and shown in Table 2 (page 54). Promotion of studies in these areas seems to be desirable in order to complete the current range olactivities. (b) Next stage Once the immediate tasks have been completed, the question will arise: where to go from here? Forecasting in medicine is particularly hazardous, and planning seems to be only slightly less subject to risk. On the whole, however, research 39 seems to move, mostly inadvertently, towards goals determined by societal needs. If these needs can be identified, the desirable directions of research may be oullined and. by skillul catalytic influences and supportive mech- anisms, the international research be modulated to attain the goals. Two nrajor societal needs seem to be in the foreground. As mentioned earlier, drug treatment, even if administered to all hypertensives, is but a short-term solution. In the long run the answer necessarily lies in the pri- mary prevention of hypertension, and long-term research in this direction should be stimulated. In the immediate future, however, it is hypertension care that needs to be irnproved. With negligible exceptions, societies are nowadays moving towards the containment of expenditure and regrettably, but undeniably, the overall slowing down of growth seems to have its most trenchant repercussions in the field of health. Thus research on the means to optimize hypertension care seems to be a goal of paramount societal importance. Optimization presupposes quantitative knowledge of the components of a system. Examples of such quantitative information and of the inter- relationships of a few parameters are given in Fig.5. The system is, however, extremely complicated, as hinted at in Fig. 4. Nevertheless, appropriate quantification of the components and subsystems of hypertension care is essential in developing a rational design for such care. As the above remarks may appear too theoretical, a lew practical pro- posals will now be given concerning research topics (see also Table 2). (c) Research topics Optimization of hypertension core. Practically all the components mentioned in Fig. 4 in relation to health services (detection, management and treatment) and to the effects of care call for lurther quantitative studies. The problem, however, does not lie in designing more potentially disconnected studies, but in developing comprehensive and coherent studies to lurnish results that can eventually be pooled and compared, or at least provide ex- perience that can be exchanged. Thus, lor instance, methods of measuring and expressing both costs and benefits should be comparable. Definitions of side-effects, both manifest and hidden, and methods for their assessment should be standardized. Systems of information on the incidence ol hypertension- related morbid events should be improved, possibly within the framework of an overall modernization of medicostatistical intelligence. Research on hypo- tensive drugs needs to be put into an epidemiological context; instead of stressing marginal clinical benefits of new drugs and of their combinations, standardized comparative studies should be conducted on the epidemiological implications of the use of various old and new drugs. The effects olhygienic and dietary treatment, particularly in mild hypertension, should be studied using standardized methods. The achievement of a population-wide shift of 40 the blood pressure distribution to the left shouldbestudied and,if leasible,the possible benelits be convincingly demonstrated. The optimal use ol various types of health personnel should be studied quantitatively and comparatively, in order to deline the best fitting distribution of health workers in different systems of care. The list of possible or desirable topics in this field is nruch longer, but a more inrportant concern than the scope of the research is its coherence at both national and international level, in view of the need to contain future health care inflation. Prinury prevention. Once again. relerence is rnade to Fig. 4, showing sorne possible causal, contributing and risk factors and their interactions, as well as rnethods of primary prevention that may act on these factors. As shown in Tablc I , present reseach - with two notable exceptions - does not seenr to be sufficiently concerned with this aspect of hyperten- sion control. Thc exceptions are the studies on blood pressure in children and salt consumption. It should be emphasized, however, thal the blood pressure studies in children are jeopardized by the fact that many of them are disconnectcd. Thc exarlple may be mentioned ol'a country where at least l0 such studies are under way, their only comnron denominator be- ing that they were reported at one and the same meeting. The cflorts to develop structured, coordinated research should therelore be increased, and by avoiding redundant work nrore resources could be allotted to the advancenrent of this inrporlant field. The sarne applies to the studies on salt consumption; although thcre are lewer of these studies, the possibil- ity ol creating a cluster ol' incoherent projects should be prevented as fronr now. Procedure WHO could play a key role in setting the stage fbr the lorthcoming period of hypertension research related to health care. The existing trend towards international liaison and cooperation should be endorsed and re- inforced. By allotting a tnore generous budget to the ongoing international cooperativc studies, the standardization ol methods could be promoted, the exchange of inlilrmation and experience among studies be given more force, new ideas and projects be stimulated, and redundancy be prevented. The organizers of internationally coordinated projects not at present connected with WHO could be conlacted by WHO and cooperation offered to them il opportune, rnoral, and/or nrethodological support could be offered lor such studies. The organizers ol' national projects showing signs of vitality and expansion could be encouraged to seek contact with WHO, which may fbstcr develt)plnent ol' the rescarch into international conrparative studies, 4t if appropriate. Some examples ol activities in the past have shown how useful WHO can be in such situations. The development of a network of coherent hypertension care studies and research on primary prevention could be promoted by WHO, first of all by establishing working groups to elaborate a methodological basis lor research coordination. The proposals in this paper. or for that matter any other pertinent points, should be considered in depth; a plan of action may then be drawn up, showing the sequence in time of the numerous methodo- logical discussions needed to develop a coherent, comprehensive programme of research on the upgrading and optimization ol hypertension care in the European Region. Summary Hypertension is still underdiagnosed and undertreated in many popula- tions, but successful pilot community control programmes show that the in- sufficiency of care of hypertension can be greatly alleviated. In fact, the pendulum may easily swing to overtreatment, as viewed from the ecological standpoint. No simplistic solutions are acceptable, and the future of hyper- tension control depends on further research. An analytical approach to the theory of hypertension control is com- bined with an analysis of the current situation of hypertension research related to health care in the European Region. It emerges that there is an imbalance in the topics now studied: research on health services from the management point of view, the costs and benefits of care, causal and risk factors and, most of all, primary prevention of arterial hyper- tension are underrepresented. On the other hand, there is an encouraging trend towards international cooperation and the study of blood pressures in childhood. In the immediate future, the current research ought to be brought to completion, and a number of practical suggestions are made for enhancing its impact. The work could be facilitated by developing an institutionaliz-ed or other system for exchange of information among ongoing projects, and by setting standards for reporting findings. In this respect it is understood that methodological standards for blood pressure measurement and similar items, formulated earlier by WHO, are being observed. The international situation ol hypertension research needs to be monitored systematically, in order to pro- vide a fleedback to the scientists engaged in the studies. The focus of the next stage of research should be on means to optimize the control of hypertension. For this purpose, the functioning of the care system, with its different components, should be analysed as a whole. The real future of hypertension control, however, lies in primary prevention. Since this is a practically virgin field, considerable efforts will have to be in- vested in such research. 42 With the collaboration of the international scientiflc comntunity, WHO may take the initiative in developing a plan of coherent and comprehensive action on these lines. The nrethodological basis of such an undertaking would have to be established. REFERENCES l. The Work of WHO, 1972 - Annual Report of the Director4eneral to the World Health Assembly and to the United Nations. llHO Official Records, No. 205 (1912). 2. Strasser, T. Hypertension: a public health challenge.In: Thurm, R., ed. Essentiol hypertension Chicago - london, Year Book Medical Publishers, 1979. 3. Strasser, T. Hypertension: drug treatment and community control. 1rz.' Lucchelli, P.8., ed. Proceedings oJ' the Second Internatiorwl Meeting of Medical Advisers in the Pharmaceuticol Industry, Florence, l3-15 Octo- ber 1975. Amsterdam, Excerpta Medica, 1976.pp.7 -lO. 4. Community control of hypertension: methodological considerotions an<l protocctl of a llltO cooperative project. WHO document CVD/74.3(ll), Appendix I. 5. Strasser, T. Community control of hypertension: international activities. Health services reports, 88(5): 387-390 (197 3). 6. Strasser, T. Bluthochdruck: eine globale Betrachtung. Argtment,Sctnder- band, AS27 : 64 -78 ( I 978). 7 . Coronory Risk Handbook. New York, American Heart Association (1914). 8. Veterans' Administration Cooperative Study Group on Antihypertensive Agents: Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging I l5 through 129 mmHg. Joumal of the American Medical Association, 202: 1028 ( 1967). 9. Veterans' Administration Cooperative Study Group on Antihypertensive Agents: Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressures averaging 90 through I l4 mmHg. Joumal of the Americal Medical Association, 213 I 143 ( 1970). 10. Hypertension-Stroke Cooperative Study Group: Stroke recurrence after antihypertensive therapy. Circulation, Suppl. IV: 84 (1973). I I . Joint WHOIISH Liaison Committce on Mild Hypertension Tnals.' Report of the 4th meeting, held in Susono, Japan,22 September 1978. WHO docunrent CVDl78.4. ll. Gross. F. & Strasser, T., ed. MiA hypertensktn: natural history and nwnogement. Tunbridge Wells, Pitman Medical, 1979. l-1. Weinstein, M.C. & Stason, W.B. Hvpertension: a policy perspective. Canrbridge, Mass., Harvard University Press, 1976. 43 c ,9 c E c F l '; E ! o o 6 x x x x x x x x x x x x x I lo l9 I: I I c E c o .: c '6 E t 9 x c Ec .: c 6 .9 -d ': o c o t o = .9 x x Table 1. Distribution and scope of hypertension Tvpe of study clot el EI ctot -t EI o l c u c c ! o E =Eo o .9 c o c o f ;l q ot o x x x xx x x x x x x x x x x xx x 44 o a ;E a o oo x x x x x x x x x x c ', o .6 c ,9 c o c ) t o x x x x I o cI cc x x x x x x x x x x x x x x x x x x x x x x ! E f c f I 01 0l 01 02 03 04 05 06 01 08 01 0r 02 03 04 05 0l 02 03 04 0l 02 03 04 05 06 07 08 09 't0 1'l 12 Co untry Algeria Austria Belgi um Eulgaria Czechoslovakia Denmark Finland x x x x x x x x x t, E c o '6 c o c p c x x .E o J c oc v F x x c I oo E 6 f o x c .9 c o c o ! x x c ,9 c c - i, lfi! l< E ot: lc lo X x x x x c Ec o;c o c oF o L c: c c E o o E D c o c o .9 a E oo -: cl E E o ,2. c o I !6 45 x x x xx studies related to health care in the European Region Items mentioned specif ically x x c o f ! ,z c c E .9 C6 c E o a o c o E 8 ,| .F E x x x x x x x x xxx x c .9 E o c E ,9 c r c - 6 t E a X l c og o CE 6 o oE o 3 o(E o I x o l o] ,9 o c .9 c E l E r E ! c l x .9 oco .!Do l x x x x x x x cs la x x x x x X x c Ec o 't c c E o .; c c o Table 1 (mntd) Country Finland (contd) Type of study tr ., e o .6 c o ., c s g o .T lz xx13 14 xxx x x x x x x x x x x xxx x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 01 02 03 04 05 0l 02 03 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 01 02 03(X 01 02 F ra nce German Dem Rep. Germany, Fed. Rep. of Greece Hungary x x xx x x x x x x x x x x x x x x x x x x o a coo E o ,- q El c oo =E to o ) ,9 E o co C .9 c E. E o cg r t E l c !l o g a e G. !f ;E p o o o !f c oEc c E c .E) E E oo i .I !f s r c 'e c a a .E q og o o G o g 0 E oE =E O o o c .9 f! ,9 ! @) o 8I co x 46 9t l o E o x x E: E o ! c o o .; o E: or c o E o 6 o 8 oc c .9 c C E c .: tr q .9 f 6c c o o Items mentioned specilically x x x x '6 f c FI = = c o o f E E EI o ': c 6 o p U' E o Ec .9E E 8 = E c E .9 tr o r o p os o 8, = Io F x x x xx x x x x x x x x x xx x x x x x x x x x x 47 x x 6cq o t E =oot E 3 x $t lg o 'r= o II-lc IElo ll IE l+ l8 x x x o .9E Ecf x c o .E tr o I l x x c 'a c d 9 c x x x x x x x x x x x c o l '= t l E6Io x x x x x x : .9 E oc o .9 I x c .9 fz x x X g E tr o .: c o a Eoto c E c o .: tr o E 4 c x o g o q !f o E EoI x Table 1 (contd) Country HungBry (contd) lceland I reland Itsly Luxembourg Morocco Netherlands Type ol study c o e 8 c o o tr o c b c o(, : l E E 8 8 = o 'E ll o x x x x x x x x x x x x x x 03(x 0l 02 03 0r 01 02 03(x 05 06 07 08 09 10 11 12 13 14 15 r6 17 18 19 0l 02 03 0'l c1 02 03 xx x xx x x xx x x x x x x x xx x x x x x x x x x x x x x x x x x o o o cI E E l o E o 3 Elt E U) o x 48 x x x x x x l o !q c o t o c =c J F x x x c c oo E ii f d E o !I c .9 c o c o l ! c: t G c c o c f, E E o c E .9 E oc oo E c o Ec c o E - o f t! l9 l>Itld t- I xxx x x x x x x x x x x x x xx x x x x x x x x x 49 x xxx Items mentioned specif ically c E .9 c '6 I o c o c E f E o .g c o l xx x x x x x x x x x x x xx x o l c og o x ! 3 o c u x x I ctoo lc!o EE!> !+iio3Ir :]C BisOlo -J" t, i x ix I I x xx I I ,1, xx x x x x x x E oc q '6 E x x x IE IElc le lco E ol4[o =ll=ol lo5l lE ol ic!l lo El l= ol lo o I t_ =l>lcYIF o siuF li lll !l rli iii iil o co o l o o E = o o o c x x E o x x I Type ot study !f t I E c o - l E E !f c .9 c c ! , ;E 'a o oo x x x x x x x x x x x x x x x x x x x x c '! o o6 E c ,9 c c l o I o c d o E. E El C !f a 04 05 01 02 01 02 03 04 05 06 o7 01 02 03 01 01 02 03 M 0r 02 03 0t 02 03 04 05 06 07 08 09 x x x x x x x x x x x x x x x x x x x x 50 Table 1 (contd) Country Nethe rla nds (contd) Norway Poland Portugal Romania Sweden Switzerland Spain x x c o; l z x 1 c o c 9 o a iE lI I I x x x x x x x x x x x x x x x x x x 8, ! c o c d t o c p oc o ,9 o c ! I E f c F I ! 5 i l (-) c .9 o t o !f L Itr c E o oI c o ., .9 E. E .c ,! c tr E E o o ': c 6 .9 E o c o ; 5l x Items mentioned specif ically c o c o f ! E c c o o l p ,: c I r c E c E c c o o ! .9 E 'a 6 € {= o 6 c o og C E) ,9 oco .9 ! c l o ,9 c o l c .g a E oo ocs 'd .9 o c! I c o x X x x x x x x E c o E o c x x x x xx l c o o o .E, o 6ao C o o E o o o G o o ocoo .E o E a o z a ooo Co .6 o l .9 E o6 2 o!o o .G Ed c Eg o c .9 Eo o o .9 E oc oo E '6 3 g o lD .; ! ) o o 8 o ao c o 'a c & E o cg o C c o t o o c o c s Type of study c o .F c o a E L E c oo z c E E x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 7 4 8 1 ? 11 10 4377 48 57 24 4 14 tl 10 1 31 l1 6 c o .;)z ! 8E = Eo oo l o ! E f c Table 1 (contd) Country Turkey USSR Yugoslavia 02 03 04 05 06 07 08 01 02 03 04 05 United Kingdom 01 52 El o E oI = o f e E F a oo r l c c E o 01 01 02 03 04 05 06 o7 o c .9 E. E oo c E .! l o 't E! - E c .9 E o s .9 E c oo; o o p t/) 2 c l E E oo o E c oo c o c o .9a E oo Ics '6 )(n l-lc rlF olYE l.; filo EIE :lo Hl e:la c .9 o l !! E G c 0 c ac a c o t,!3i o cY c !t .= ct o F c o g o o ! oc s ! o x x x x x x 3 t1 4 14 6 2 3 5 4 7 6 2 1 4 Items mentioned specif ically c o 3I ! c E a .2t E J c c o l! c .9 L o c c .2 oc .E ! o s t ! c f a x B oco .g o q E l o E I ,F o G ocg o I o E. '6:q oE og o E, o f c o o E. '6 c c o oo E! c E 3 x c E .9c I x x x x x x x x x x 1l 5 5 4 ll 2 2 ,| l7 ! c E o l 3 3 2 7I 53 x Table 2. Examples of subjects for further research H ea I th se rv i ces rcsea rc h Optimum use of various types of health worker Optimum use of diagnostic services Place of hypertension control in overall health care delivery Cost containment - absolute and relative value Epidemiological resarch into cauel and conributing factors Studies of psychosocial contributing factors Studies of genetic factors lnfluences of the physical and chemical environments Early identification of hypertension-prone individuals Sodium intake and its reduction Behavioural rcsearch Studies of compliance with therapeutic regimens Studies of physicians' attitudes towards treatment and control of hyper- tension Public knowledge of and beliefs associated with hypertension and its treatment Studies of target-specific and of general health education in relation to hypertension 54 Annex II GUIDELINES ON UNIFORM DATA PRESENTATIONA The purpose of uniform presentation of data is to facilitate comparison between data sets from dilferent studies. The lormat suggested should be considered as a mandatory minimum. Any additional tbrms of presentation (tables, graphs, statistical measures), if inf<rrmative, are welcome. l. Age l.l ASe distribution Days Years (Period) 0-6 (Neonatal,early) 7-27 (Neonatal,late) 28 - 364 (lnfancy) l- 2- (Transitional) (Period) | 1_ ;;_ (Schoolchildren, ,;_ older) l5- l6- (Adolescents) t]- i3- (Young adults) 20-24 25-29 (Adults) 30-34 and so on Years 3- 4- 5- 6- 7- 8- 9- l0- ll- (Preschool children) (Schoolchild ren, young) (Schoolchildren, nriddle) Note.' The youngest ages are relevant to the morphological study (in the planning stage). Adults: parents. a As cslablished by the Working Group on Pilot Projects tbr the Study and Control of Atlrerosclerosis Precursors in Childhood, Geneva, l2-14 Seplember 1979. 55 1.2 Mean age Arithmetic mean and standard deviation to be given within each category (preschool, young schoolchildren, adolescents, etc.). 2. Height (cm) Height in children, to be read up to millimetres. In adults, values to be computed to closest centimetre. Central values: arithmetic mean and standard deviation to be given according to year (or age class). Distribution: fifth, tenth, twenty-fifth, fiftieth, seventy-fifth, ninetieth and ninety-fifth per- centile value. 3. weisht (kg) State values to be computed in kilograms, to one decimal place. Central values and distribution to be given as above. 4. Quetelet's index Weight/height2 to be expressed as above (kg/m'), to one decimal place. 5. Skinfold thickness To be given in millimetres, as above, separately for subscapular and triceps. 6. Blood pressure Systolic and diastolic readings to be given in mmHg (to the closest 2 mm reading) separately, with mean and distribution for each age class as above. 7. Serum cholesterol The protocol foresees measurements in mg/dl. However, results should be expressed in mmol/l to comply with the recently adopted SI system of measures (mmol, to one decimal place). Means and distribution to be given as above. 8. Triglycerides Values to be computed in mmol/l (to one decimal place). Means and distribution to be given as above. 9. Glucose tolerance To be expressed as mmol/I, to one decimal place. Means and distribu tion to be given as above. 56 10. Sexual maturity Frequency count of codes I -5 to be given for both items for each year of age, and for menarch (yes, n<1. not asked). I l. Smoking Age distribution to be given for persons answering the question "How old were you when you started snroking?". For the question "How many cigarettes do you smoke per day (on the average)?", distribution (for each year) to be given according to the following classes: < l, l,l, -1,4,5,6-9, l0-14, l5-19,20+. For the questions "Do you smoke every day?" and "Have you ever smoked or lit a cigarette?", frequency counts of "yes" and "no" answers to be given lor each year (class) of age. 12. ECG Frequency counts of Minnesota code items to be given for cach year (class) of age, as outlined on p. 24 of the protocol (il recorded). 57 Annex III UST OF PARTICIPANTS Algeia Austria Dr J. Mlczoch, University Clinic of Cardiolory, General Hospital of the City of Vienna Dr A. Rolleder, Adviser to the Federal Ministry of Health and Environ' mental Protection, Vienna Belsium Profesor A.K. Amery, St Raphael Teaching Hospital, Louvain Czechoslovakia Professor J. Widimsky, Chief, Department of Medicine II, Institute of Clinical and Experimental Medicine, Prague Denmsrk Dr B.J. Harvald, Danish Medical Research Council, Medical Depart- ment B, Odense Hospital Dr A. Leth, Department H, Directorate of Health, Copenhagen Mr B. Lind, Deputy Director, Danish Hospital Institute, Copenhagen Finlond Professor K. Pyorili-, Department of Medicine, University of Kuopio France Professor M. Feghoul, Head, Department of Cardiology, Parnet Hos' pital, Algiers 58 Dr J. Mdnard, Department of Arterial Hypertension, St Joseph Hospital, Paris Dr P. Meyer, Professor of Experimental Medicine, Ren6 Descartes Uni- versity (Paris V), Necker Hospital, Paris G erman De mocra t ic Re pub lic Dr W. Barth, Deputy Head, Department ol Research on Cardiovascular Diseases, Faculty <lf Medicine, Humboldt University, Berlin Prcrfessor H.D. Faulhaber, Central Institute for Cardiovascular Regula- tion Research, Academy of Sciences, Berlin - Buch Germany, Federal Republic of Dr U. laaser, Head, Department of Epidemiology and Statistics, German High Blood Pressure Research Institute, Heidelberg Dr P.C. Weber, Medical Clinic, Munich Greece Professor E. Voridis, Head, Department of Cardiology, Evanghelimos Hospital, Athens Hungary Dr B. Szekacs, Assistant Professor, National Institute of Medicine. Budapest Dr Esther Tcjrcjk, Senior Researcher, Hungarian Institute of Cardiology, Budapest Ireland Prolessor K. O'Malley, Medical Research Council, Dublin Prol'essor D.J. O'Sullivan, Cork Regional Hospital, Wilton Italy Dr A. Menotti, Higher Institute of Health, Rome Luxentbourg Dr H. Kijntziger. Departrnent of Nephrology, Luxembourg Hospital Centre 59 Morocco Professor Berrada Allal, National Cardiology Service, Avicenne University Hospital Centre, Rabat Professor A. Srairi, Head, Department of Cardiology, Averrods Hospital, Casablanca Netherhnds Dr F.H. Bonjer, Coordinator, Heart Disease Research Planning, Council for Health Research (TNO), The Hague Dr J.J.L. Pieters, Inspector, Non-communicable Diseases, Ministry of Public Health and Environmental Protection, lridschendam Norway Dr H. Waaler, Group for Health Services Research, Norwegian Research Council, Oslo Poland Professor W. Januszewicz, Head, II Clinic for lnternal Diseases, Warsaw Medical Academy Dr M. Miskiewicz, Department of Medical Care and Rehabilitation, Ministry of Health and Social Welfare, Warsaw Portugol Dr J. Lopes Dias, DirectorCeneral of Health, Lisbon Dr F. de Padua, Professor of Internal Medicine, Faculty of Medicine, University of Lisbon (Choirmon) Spain Dr Jimenez Casado, President, Spanish Association against Arterial Hypertension and Head, Department of Internal Medicine, "Con- cepcion" Clinic, Madrid Sweden 60 Dr S. Als6n, National Board of Health and Welfare, Stockholm Professor B.M. Htjkfelt, Chairman, Department of Medicine and Clinical Endocrinology, General Hospital, Malmd Dr L. Wilhehnsen, Chief Physician, Department of Medicine, Cjstra Hos- pital, Gothenburg Switzerland Dr P. Weidmann, Associate Prolessor of Medicine and Associate Director, Medical Polyclinic, University of Berne Turkey Dr Y. Erkoqak. Head, First Clinic of Internal Diseases, Ankara Model Hospital US,SR Dr M.A. Ahmeteli, All-Union Cardiological Research Centre, Academy of Medical Sciences of the USSR, Moscow United Kingdom Dr M. Ashley-Miller, Director, Chief Scientist Office, Scottish Home and Health Department. Edinburgh Dr R. St J. Buxton, Principal Medical Officer, Department of Health and Social Security, London Dr S.G. Owen, Medical Research Council, London Yugoslavio Dr D. Komadina, Under-Secretary, Republic Committec for Health and Social Wellare, Ljubljana Dr D. Kozarevic, Director, Institute of Chronic Diseases and Gerontolory, Belgrade Represen ta t ive s o f O t her O rganiz at b ns Commission of the Euntpeon Communities Dr L. Karhausen, Senior Administrator, Directorate-General, Employ ment and Social Affairs, Brussels, Belgium 6l European Advisory Committee for Medical Research Professor S. Bergstrtim, Karolinska Institute, Stockholm, Sweden Dr D. Dorossiev, Chief, Department of Cardiac Rehabilitation, Sanator ium for Cardiovascular Diseases, Bankja, Bulgaria Ewopean Medical Research Councils Professor J. Ofstad, University of Bergen, Norway Eurupean Society of Cardiology Professor H. Denolin, University of Brussels, Belgium I nt ernotio rwl Federat io n of Pharmac eu t ic al Manufacturen Assoc iat io ns (IF?MA) Dr B. Arrigoni-Martelli, Head, Department of Pharmacology, lro Phar- maceutical Products, Ballerup, Denmark Dr D. Chu, Medical Specialist, Hoffmann-La Roche Ltd, Basel, Swit- zerland Dr B.C. Dawson, Organon International Ltd, Strategy Department, BH Oss (N.B.), Netherlands Dr J.{. Garnham, Head of Medical Prevention, CibaCeigy Ltd, Basel, Switzerland Dr I.M. Slessor, Senior Medical Adviser, Glaxo Group Research Ltd, Greenford, Middlesex, United Kingdom Intenatiotwl Society and Federation of Cardiology Profesor P.H. Gross, Department of Pharmacology, University of Heidel- berg, Federal Republic of Germany Observers Dr H.N. Colburn, Coordinator, Cardiovascular Diseases, Health Services Directorate, Department of National Health and Welfare, Ottawa, Canada Mr G.W. Ward, Chief, Health Education Branch, National Heart, Lung and Blood Institute, Bethesda, MD, USA 62 WorA Health Organization Regional OfJice fttr Europe Dr Z.J. Brzezinski, Regional Officer for Epidemiology Dr G. Lamm, Regional Officer for Chronic Diseases (Secretary) Dr B. Nizetic, Regional Officer for Research Promotion and Development Dr M. Postig.lione, Director, Disease Prevention and Control HeaCquarters Dr Z. Pisa, Chief, Cardiovascular Diseases Dr T. Strasser, Medical Officer, Cardiovascular Diseases (Rapporteur\ 63 No.20 No.2l No.22 No.23 No.24 No.25 No.26 No.27 No.28 No.29 No.30 No.3l RECENT ISSI.]ES IN THE SERIES EURO REPORTS AND STUDIES Research on simulation models fttr health nrunogement.' report on a WHO Working Group. 1919,24 pages, Sw.fr. 4. Health aspects reloted to indoor air quality: report on a WHO Working Group. 1919,32 pages, Sw.fr. 4. Nuning services: report on a WHO Symposiurn. 1979, 39 pages, Sw.fr.5. Trairing of senior public health administrqtors.' report on a WHO Working Group. 1980,42 pages, Sw.fr. 5. Early detection of chronic lung diseases: report on a WHO Working Group. 1980,32 pages. Sw.fr.3. Changing pattems in mental health care: report on a WHO Working Group. 1980, 50 pages, Sw.fr. 4. La prOvention des accitlents de la circulation chez les enfants: rap- port d'une 6tude r6alis6e avec la collaboration du Centre inter- national de I'Enfance et de I'Universit6 d'Uppsala. 1980,58 pages, Sw.fr.4 (English in preparation). The Gabrovo Health Services Model in the People's Republic' of Bulgaia: report on a Study. 1980,94 pages, Sw.lr.6. Chrunic respiratory diseases in children in relation to air pollutktn: report on a WHO Study. 1980,89 pages, Sw.fr.6. The environmental health officer in an industrial soc'iety: report on a WHO Consultation. 1980,31 pages, Sw.fr.3. Earl_v detection of handicap in children.' report on a WHO Working Group. 1980,45 pages, Sw.fr.3. Health aspects of wellbeing in w<srking places: report on a WHO Working Group. 1980, 28 pages, Sw.fr. 3. 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