Community-based hypertension screening in China is testament to the adage prevention is better than cure says Simiao Chen.

I spent my childhood living with my grandparents in the vast countryside of northeastern China. Up to this day I can still remember the hot summer afternoon when my granduncle cried in despair as he suddenly lost control of his left leg. He was diagnosed with a stroke after being sent to the nearest hospital hours later. His blood pressure was as high as 160/120 mmHg. However, before the stroke, he never knew he had hypertension. He had no symptoms and hence never measured his blood pressure. The stroke was severe, and he was paralyzed in his early 50s and had to spend the rest of his life with a limp and needed to use a cane. The burden on the family was not only financial, but also mental as the challenges he faced affected his moods.

When I saw the difficulties that this caused his close family, I always asked myself: what if he had known his blood pressure beforehand? What if he knew the risk and what to do after being diagnosed with hypertension? Would he have quit smoking, reduced his alcohol consumption, consumed less meat and salt, and lost weight? What if there was a convenient way for him to check his blood pressure and learn about this disease?

Stories like this happen every day in China. Currently, nearly half of Chinese adults aged 35-75 years are hypertensive, and a quarter of overall mortality has been attributed to high blood pressure, resulting in immense health and economic burdens at both the household and national levels. [1,2,3] Like my granduncle, many Chinese people prefer a diet with meat and salty food, and more than half of Chinese men are current smokers. To make things worse, more than half of those with hypertension in China are unaware of their condition, which is one of the most important modifiable risk factors for stroke and cardiovascular disease.

After discussing with my colleagues, we were curious about whether measuring blood pressure at a community level could reduce hypertension. This question is important because many people in China, as in other countries, are reluctant to go to hospitals or clinics to check their blood pressure. Community-based blood pressure measurement may provide a powerful alternative to facility-based screening—but will it make a difference without additional investment, such as financial incentives to follow-up on a screening test, or an infrastructure to bring hypertension treatment to people’s homes? Could raising awareness alone have the power to improve health outcomes? Is knowledge enough?

Surprisingly, we found that community-based hypertension screening had a large effect on reducing systolic blood pressure two years later by an average of 6-8 mmHg among very elderly adults in China. The effect of the intervention on systolic blood pressure could have resulted from several behavioral changes—not only healthcare seeking—including weight loss, reduced smoking, and reduced alcohol consumption. 

The findings are encouraging, because they indicate that, at least for older Chinese people, measuring blood pressure during household visits and encouraging those with elevated blood pressure to seek further care and adopt behavioral changes, can have substantial and long-term effects on systolic blood pressure at the population level. Community-based blood pressure screening should be integrated into routine healthcare in China. Community health workers, whose roots lie in the Chinese barefoot doctors, could systematically take on home-based screening roles—and future research should establish whether other home-based screening, such as for diabetes and dyslipidemia, could have similar health benefits as hypertension screening.

My granduncle died in his 60s. A lack of awareness of the risks associated with hypertension and prevention strategies shortened his life and lowered the quality of his life. While it is too late to save his life, it is never too late to start preventing more premature deaths like him and improving peoples’ health and wellbeing now by providing a convenient way to raise their awareness and motivate them to adopt preventative measures.

As William James Mayo put it, “The aim of medicine is to prevent disease and prolong life, the ideal of medicine is to eliminate the need of a physician.” 

Simiao Chen is an Assistant Professor at Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University. 

References 

1. Lu J, Lu Y, Wang X, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from 1· 7 million adults in a population-based screening study (China PEACE Million Persons Project). The Lancet 2017;390(10112):2549-58.
2. Institute for Health Metrics and Evaluation (IHME). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, 2017 [Available from: https://vizhub.healthdata.org/gbd-compare/ accessed Jan 27 2019.
3. Bloom DE, Chen S, Kuhn M, et al. The economic burden of chronic diseases: estimates and projections for China, Japan, and South Korea. The Journal of the Economics of Ageing 2018 doi: https://doi.org/10.1016/j.jeoa.2018.09.002