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strategies to implement positive lifestyle choices in communities and notably
brought down the prevalence of hypertriglyceridemia, hypercholesterolemia,
abdominal obesity, and hypertension [ 63 ]. For individuals, it has been suggested to
be beneficial for hypertension to walk a minimum of 10 min a day [ 49 ], which
should be possible even in urban areas of developing countries.
It will remain difficult to implement clinical approaches to hypertension in
poorer countries for a variety of reasons. Many countries in the developing world
maintain no precise guidelines regarding hypertension management in their indi-
vidual setting, and as much as practitioners will be able to look to international
guidelines for guidance in their daily practice, the investigations, materials, and
medications indicated there may not be available locally. Moreover, in following
guidelines not adapted to local needs, considerable variation exists in which inter-
national guidelines are adhered to and at what point the practitioners begin to impro-
vise. Adherence to orderly norms in the successful treatment of hypertension is
required not just of practitioners, who must follow protocols regarding early detec-
tion, but also of patients, especially in taking their medication. Both practitioner
awareness of and adherence to protocol were found to be low even where national
guidelines had been introduced and broadly promoted among the clinical commu-
nity [ 56 ]. Despite the inevitability of encountering patients with a greater or lesser
degree of hypertensive resistance to treatment, the most common cause for poor
control of BP remains patient noncompliance with his or her medication regimen.
Stroke is a relatively immediate complication of hypertension under poor con-
trol, and reports from South Africa indicate that, among hypertensive patients, those
of African descent die at twice the rate of their European-descended counterparts
[ 53 ]. This likely stems from the fraught interplay of poor education, unequal access
to quality health care, and lack of patient compliance. The best way to encourage
compliance from a patient’s perspective is through education and making the medi-
cation regimens simpler. There was a treatment-adherence trial of 500-plus patients
for hypertension in Nigeria, both urban and rural but all new to treatment [ 64 ]. The
treatment program was led by nurses with a doctor for backup and involved the
administration of simple treatment of a b-blocker and thiazide diuretic to patients at
no charge. The patients were followed up once a month for 6 months. Impressively,
after 6 months, 81% of the patients were adhering to treatment, and 66% have con-
trolled hypertension. These excellent results likely come from high-quality patient
education, a simple regimen for medication, and the free service they received at the
hospital. In Africa, studies have shown that regular attendance at the clinic, avoid-
ance of prescription medication of non-Western origin, and social support were
among the factors positively affecting self-reported compliance [ 65 ]. Oddly or not,
compliance was not associated with beliefs as to the cause thereof. Furthermore,
similarly to the rest of the world, and regardless of the method of treatment (tradi-
tional or modern), many patients mistakenly believe that they can discontinue their
medication when they feel better [ 66 ]. Yet data from other countries in the underde-
veloped word demonstrates the avidity with which patients with hypertension, a
N. Keles et al.