**6. Hypertension as a chronic disease**

Worldwide, the leading risk factor associated with morbidity and mortality from non-communicable diseases (NCDs) and the highest cause of premature deaths is reported to be of those of hypertension [33]. The global prevalence of hypertension in adults aged 18 years and over was around 24.1% for men and 20.1% for women in 2015 [33]. Based on the statistics of hypertension reports for the past years, the WHO predicts that, by the year 2025, almost 75% of the world's hypertension population will be found in developing countries [33]. However, the global action plan has a target of a 25% reduction of the global prevalence of hypertension [34].

Nonetheless, recent statistics on the prevalence of chronic diseases in Lesotho indicate that the presence of hypertension was reported to be at 41% in 2015 [35]. Inevitably, hypertension ranks among the top causes of morbidity and mortality and is the third-most common cause of hospital admissions in the country [2, 36].

An accurate measurement of blood pressure with a well-fitting calf remains an important part of diagnosis of primary hypertension [37]. In an adult, the normal blood pressure is said to be 120/80mmHg [38]. A definite diagnosis of hypertension is when their blood pressure reading is above 139/89 mmHg on three consecutive clinical visit within two days up to a maximum of 7 days in between [39, 40]. This definition is consistent with the one found in the Lesotho national guidelines on the management of diabetes and hypertension at PHC level. Regarding sign and symptoms of hypertension, the following are said to be associate and these are tiredness, headaches, confusion, vision changes, angina-like pain and the presence of blood in the urine, nosebleeds, irregular heartbeat as well as ear noise or buzzing sounds [41].

The WHO recommends that once a patient is diagnosed with hypertension, as based on the nation's guidelines, both pharmacological and non-pharmacological management measures must be initiated immediately [34]. In Lesotho, the treatment of increased blood pressure is guided by the national guidelines on the management of diabetes and hypertension at primary care level [39]. With regard to pharmacological management, the guidelines advise that diuretics, beta-blockers, calcium antagonists, converting enzyme inhibitors and angiotensin II receptor blockers are suitable for initial and follow-up treatment, as monotherapy and in combination [39].

Further advice on the prescription of the drugs, dosages and expected intervals for medication taking is included. However, treatment differs according to the individual's blood pressure and compliance to treatment at the time of check-up. Furthermore, the guidelines recommend psychosocial support in terms of the suggested lifestyle changes (exercise, reduced dietary salt intake, reduced alcohol and tobacco intake) [39]. Patients with uncontrolled blood pressure despite medication adherence and lifestyle changes are referred to the secondary level of care for further investigations and management [39].

The effectiveness of hypertension treatment and experiencing its benefits relies critically on strict compliance to treatment instructions [42]. Rao et al. mention compliance is to treatment as a primary determinant of the effectiveness of treatment, which intensifies optimum clinical benefit and promotes good health [43]. Additionally, it is a cost-saving measure for a larger society, because the incidence of complications is decreased leading to less need for additional medications [33].

Globally, in comparison with acute diseases, chronic diseases treatment compliance rates are typically low and continue dropping radically despite increased awareness of the effect of chronic conditions [44]. There is still a need for improvement even among populations with relatively high adherence rates. According to Ivarsson et al., good compliance is a requirement worldwide, as reported in a national population-based cohort study conducted in pulmonary arterial hypertension centres in Sweden [45].

Hacihasanoglu and Gozum report that in Turkey, 40% of hypertension patients did not take their medications as prescribed and 50% defaulted on their appointment dates [46]. In contrast, Mafutha and Wright argue that medication-taking behaviour is not affected by failure to comply with follow-up appointments to collect medications [47]. Their study at primary healthcare clinics in Tshwane, South Africa, reported that 81% of patients were compliant regarding medication-taking, yet 57% were non-adherent to follow-up appointments [47]. Perhaps appointment keeping should be viewed in a broader context as the patient may come to the PHC facility before or after the appointed date or pick medicines from other facilities.

Some of the factors that are associated with missed appointments include lack of hypertension knowledge, experience of medication side effects, forgetfulness, transportation challenges, a feeling that appointments are not helpful, lack of trust and health professionals' communication behaviour during consultations [48, 49]. Consequently, a particular factor associated with non-compliance of an individual

#### *Use of Primary Healthcare Facilities for Care and Support of Chronic Diseases: Hypertension DOI: http://dx.doi.org/10.5772/intechopen.101431*

hypertensive patient should guide interventions that improve appointment keeping compliance [49, 50].

There are few studies that address the compliance of patients suffering from non-communicable diseases in Lesotho. Most of the published research works on hypertension compare the knowledge of patients regarding antihypertensive treatment with treatment outcomes. Khothatso, et al. conducted an observational, descriptive cross-sectional study at a district hospital in Lesotho, the main findings are that there is low level of knowledge regarding their treatment and its adherence among hypertensive patients [51].

The study of Mugomeri, et al. reported that inadequate knowledge about antihypertensive treatment is significantly associated with uncontrolled high blood pressure and the associated complications [52]. A study conducted at Domicilliary Health Clinic in Maseru, Lesotho, reports that the prevalence of chronic, uncontrolled high blood pressure remains high in patients on treatment and claims an important intervention in this population would involve identifying factors that can help improve compliance to the hypertension treatment [36]. A report of a selective literature review study in various countries indicates, furthermore, that it is desirable to carry out studies on the promotion of compliance in Germany and countries facing the same national challenge of conditions prevailing in the healthcare system [53].

In their study, Wells et al. found that hypertension appeared to be one of the highest risk factors of heart failure [54]. Hypertensive patients have a higher risk of having heart attack, heart failure, stroke, kidney disease than normotensive people [55]. Saseen mentions that hypertension complications include atherosclerotic vascular disease which can be coronary artery disease, carotid artery disease, peripheral arterial disease and abdominal aortic aneurysm [56]. Other complications include cardiovascular diseases (CVDs) such as heart failure, chronic kidney disease and retinopathy.

Beaglehole et al. stated the need to distinguish approach between the management of chronic diseases and acute illnesses; they further mentioned the importance of the organisational or structural interventions in managing chronic disease [57]. It was highlighted that the PHC needed to be strengthened in order to undertake opportunistic case finding, for assessment of risk factors, early detection of disease and identification of high risk status for chronic disease can be carefully undertaken [57]. The development of management plans must take into account patients' needs and preferences as chronic patients are said to be their own primary carers [57]. According to Siantz et al., in order to minimise functional limitations and disability, effective management of chronic conditions requires behavioural and lifestyle adjustments [58]. Therefore, an appropriate theoretical framework fitting the health problem of interest to change behaviour needs to guide the planned organisational interventions [59].

Patient must take up an active role in knowing and managing their own health, by expressing their concerns, preferences and participating in medical decisions; this can be achieved through patient empowerment, patient involvement and shared decision-making [60]. It is believed that informed patients improve their decisions by collaborating with their healthcare providers [61]. This results in increased patient's involvement leading to a positive effect on the health outcomes.

On the other hand, Maimela et al. mentioned that PHC professionals often lack the resources such as quality equipment's and promotional materials which could be used to assist local community self-management support services such as education programmes [62]. More so, the lack of continuous availability of medicines has become another important barrier for chronic disease management (CDM) in practice, and this plays an essential part in the provision of health care for chronic conditions [63]. The study of Wagner et al. suggested the need to transform a health system from responding mainly when a person is sick which is being reactive, but, rather be proactive and focused on keeping a person as healthy as possible which eventually improves the health of people with chronic illnesses [64].

#### **7. Interventions models**

It is noteworthy that Nyangu and Nkosi mentioned that registered nurse midwives and nurse clinicians manage the majority of PHC facilities, and their professional titles did not affect service provision [65]. However, it was suggested that there is a need to provide more staffing to address staff shortages and reduce patients waiting times at facilities [65]. Ideally, Uys and Klopper recommended that at least one specialist nurse, five registered nurse midwives and four enrolled nurses were needed for the effective running of PHC settings [66]. Additionally, the finding of Rampamba et al. revealed that encouragingly, the pharmacist intervention highly satisfied patients in PHC facilities in South Africa, and this laid a strong foundation for improving collaboration in the future [67]. Consequently, the study recommended that this intervention model be further developed and tested, with a greater focus on lifestyle changes and clinical outcomes. Pharmacists can further improve future control of blood pressure (BP) by routinely investigating and reviewing patient diaries [67].

Similarly, in Ghana, pharmacy curriculum for training pharmacists includes health promotion and health education, making it possible to undertake health promotion and disease preventative activities [68]. However, the national policy on prevention and control of chronic NCDs acknowledges the role of primary community facilities with no mention of community pharmacies [69].

Additionally, Afia et al. state that due to the increasing level of hypertension in low-income countries, community pharmacies could participate more in hypertension management interventions [70]. Nevertheless, the requirements for meaningful participation should be considered and realised which include the relevant staffing compliment, health promotion skill, pharmacy setting and referral systems [70]. Moreover, this service requires the constant presence of a pharmacist, screening space with privacy for counselling, staff training and referral linkages with the nearest health centre/clinic/hospital for referrals [70].

Furthermore, Omboni evaluated blood pressure telemonitoring (BPT) programmes involving a pharmacist; it was stated that this may require investment in laboratory monitoring and technologies [71]. Again, larger use of medications and more contacts with patients than standard care occur, there was a significantly improved BP control at relatively low cost or with an only minimal increase in healthcare costs compared with usual care. This would consequently lead to the reduced cost for future cardiovascular events. Interestingly, the economic analyses suggested that pharmacist case management provided the clinical gains as the current evidence to high-risk patients with stroke, evaluating the longer-term impact and cost-effectiveness of BPT with suggested by [72]. More so, the future analysis must consider cost savings from a reduction in cardiac events and long-term complications, as well as indirect or intangible costs such as travel time to clinic or time missed from work that would be relevant to an economic analysis from the societal perspective, particularly over several years [71].

#### **8. Clinical management pathways**

It is noted that the investment in predisposing factors awareness and health promotion with full participation of patients holds manifestation of the disease.

#### *Use of Primary Healthcare Facilities for Care and Support of Chronic Diseases: Hypertension DOI: http://dx.doi.org/10.5772/intechopen.101431*

Similarly, the key elements of management of chronic disease such as hypertension are in maintaining normal blood pressure, which leads to prevention of progression of disease and consequently its complications. Therefore, service provision takes into consideration prevention of disease, treatment of the disease, compliance to treatment, periodic reviews and close disease outcome monitoring. Is it possible to cover all this in the primary health care that has competing interest such as those imposed by communicable and acute illnesses? Is primary health care not burdened with mother and child health services, such as antenatal clinics and post-natal service?

Eventually, what remains unclear is, are the general nursing skills sufficient to carry the disease burden to desired treatment outcomes, for all the diseases in Lesotho? Is it time to look at how other countries manage hypertension using other professionals whose aim is to achieve desired treatment outcome? Is a pharmacist viewed in the context of medicines chain supply and dispensing or his/her clinical role in the management of diseases recognised? Is the pharmacist in a good position to play a role in the management of chronic diseases either in community pharmacy or primary healthcare setting? Is the pharmacist exposed to clinical pharmacy throughout the training, covering clinical management of diseases and pharmacy practice clarifying the role of a pharmacist in disease management, not only covering drug supply chain but also covers responding to symptoms in the pharmacy, pharmacoepidemiology, pharmacovigilance, pharmacoeconomics and drug utilisation reviews? Will these in due course benefit treatment outcomes of hypertension, improve treatment adherence, manage medication adverse drug reaction and based on treatment outcome in order to select the best treatment for the patient and carry out appropriate referral where needed?

Accordingly, study of Hallit et al. clarified that the PHC strategy of the Ministry of Public Health (MOPH) includes several programmes: communicable diseases, immunisation, mother and child health, nutrition, environmental health, noncommunicable diseases, health awareness and essential medication [73]. Based on the above scenarios, in order to prevent disease progression, hospitalisation and poor prognosis of patients with hypertension, the following are proposed:

1.Retail pharmacists can be viewed as primary healthcare facilities, as patients who do not want long queues in the public sector sort services for their ill health. Currently, services include management of minor illnesses through over-the-counter (OTC) medicines and referrals where necessary. Also chronic diseases screening, prescription refills, monitoring and follow-up. Sale of gargets for blood pressure monitoring and education on how to use them to monitor their response to treatment at home.

Consequently, collaboration or community pharmacy with the public sector in terms of referral and further management is necessary. What is proposed as new is a service agreement with the public sector whereby patients who would otherwise be seen at the PHC clinic come to the retail pharmacy to receive care and treatment at the cost of public sector. This is already being done through contracted service in many countries; it just needs to extend to the resource-limited countries. For example, in England, the study of Albasri et al. showed that there is strong trial evidence for the involvement of community pharmacy in the long-term management of hypertension [74]. Systematic reviews and meta-analyses of these trials demonstrate that when compared with usual care, the results consistently show a 6–7 mmHg reduction in systolic blood pressure [74].

2.The PHC facilities that are run by nurses could also include the services of pharmacists, who have competencies to run pharmacy-led chronic disease clinics. This addition will complement the skills of nurses and give them time to

#### **Figure 2.**

*Summary of the role of a pharmacist in the management of hypertension in the community pharmacy and primary health care clinic.*

manage other programmes in the PHC facilities such as mother and child services immunisations. If Lesotho has high disease burden, doing similar activities have to be avoided because poor results in maternal mortality rates, infant mortality rates and failure in other programmes will prevail. It is suggested that pharmacist-led chronic disease management be included in the policy and treatment guidelines.

The study of Buis et al. considered primary care patients with uncontrolled hypertension whose blood pressure was effectively reduced by a pharmacist-led mobile health (mHealth) intervention which was intended to promote the home blood pressure monitoring and clinical pharmacist management of hypertension [75]. The data in this study also support the feasibility and acceptability of these types of interventions for patients and providers [75].

In Sweden, when collaboration between community pharmacy and primary health care was reflected, it was viewed as a golden opportunity [76]. The primary health care has strategic plans and national policy documents which do not include community pharmacy as a partner, and this is considered as a major challenge [76]. This was a similar case to Ghana community pharmacy and primary health care [69]. **Figure 2** summarises what the pharmacist will be doing at the community pharmacy and at the PHC clinic if he/she works for the facility. This has to be done through government policies and be properly regulated through relevant laws.

#### **9. Conclusion**

Primary health care is a good place to manage preventable diseases. Treatment outcome can be monitored at the PHC level and lifestyle modification can be instituted according to patients' needs. There is evidence that involvement of pharmacist at the community pharmacy and at the primary healthcare facility can improve treatment outcome of hypertension.

Therefore, it is recommended that there should be policy change that allows for involvement of pharmacy in the management of hypertension.

*Use of Primary Healthcare Facilities for Care and Support of Chronic Diseases: Hypertension DOI: http://dx.doi.org/10.5772/intechopen.101431*
