Characteristics of Patients with Hypertension at a Nicaraguan Clinic Jennifer S. Lee, Mark Humphrey, Morgan Adams, Myriam Torres, Timothy N. Crawford, Jeff Hall Journal of Health Care for the Poor and Underserved, Volume 31, Number 3, August 2020, pp. 1281-1290 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/hpu.2020.0094 For additional information about this article https://muse.jhu.edu/article/763695 [ Access provided at 7 Oct 2020 18:39 GMT from Utrecht University Library ] ORIGINAL PAPER Characteristics of Patients with Hypertension at a Nicaraguan Clinic Jennifer S. Lee, DO, MPH Mark Humphrey, MD, MPH Morgan Adams, PharmD Myriam Torres, PhD, MSPH Timothy N. Crawford, PhD, MPH Jeff Hall, MD Abstract: Objective. Describe the characteristics and pharmacological management of hypertensive patients in a Nicaraguan ambulatory care clinic. Methods. The study analyzed a random sample of 349 charts of patients aged older than 18 years from an ambulatory care clinic in Nicaragua and analyzed those who were diagnosed or had a known history of hypertension. Results. Out of 349 patients, 19.77% (n=69) had a history of hypertension. Hypertensive patients were 66.2% female (n=45) with mean age of 56.1 years (SD=13.7). The most common comorbid condition was type 2 diabetes mellitus, which was present in 18.8% (n=13) of hypertensive patients. Other comorbid conditions included 10% (n=7) with chronic kidney disease and 75.8% (n=50) who were either overweight or obese. The most commonly prescribed antihypertensive medications were losartan, captopril, and enalapril. Conclusions. Hypertension is common in this clinic population and most commonly treated with angiotension- receptor blockers or angiotensin converting enzyme inhibitors. Key words: Medication adherence, cardiovascular diseases, Nicaragua, hypertension. N on- communicable diseases (NCDs) continue to be a rising problem in lowmiddle income countries (LMIC), including Nicaragua. Currently, the leading causes of mortality in both men and women in Nicaragua are ischemic heart disease, type 2 diabetes mellitus, and cerebrovascular disease.1,2,3,4 Hypertension is a chronic disease that can be easily diagnosed by a primary care provider. Most patients can be controlled with proper medications, leading to a significant reduction in mortality by reducing cardiovascular risk.5 In Nicaragua, however, there is limited research regarding the prevalence of hypertension and barriers to care, particularly in rural populations. JENNIFER S. LEE is affiliated with the Department of Family Medicine at Wright State University. MARK HUMPHREY, MORGAN ADAMS, and JEFF HALL are affiliated with the University of South Carolina Department of Preventive and Family Medicine. TIMOTHY N. CRAWFORD is affiliated with the Department of Family Medicine and the Department of Population and Public Health Sciences at Wright State University. MYRIAM TORRES is affiliated with the University of South Carolina Arnold School of Public Health. Please address all correspondence to Jennifer S. Lee, Wright State University, Department of Family Medicine, 725 University Blvd, Fairborn, Ohio 45324; phone: 937-245-7352, jennifer.lee@wright.edu © Meharry Medical College Journal of Health Care for the Poor and Underserved 31 (2020): 1281–1290. 1282 Hypertension in Nicaraguan patients One study conducted in northwestern Nicaragua reported hypertension prevalence as 22%.6 Other studies range from reports of stage I hypertension, defined as systolic blood pressure (SBP) of 140–159 milimeters of Mercury (mmHg) or diastolic blood pressure (DBP) of 90–99 mmHg, at 7.5% and stage II hypertension, defined as SBP ≥160 mmHg or DBP ≥100 mmHg, at 2.4% in the capital city of Managua up to 20 to 40% in rural areas.1,7,8,9,10,11 The Nicaraguan health system includes both public and private sectors. The public system is mainly funded by taxes and consists of the Ministerio de Salud (MINSA), the Army of Nicaragua and National Police force, and the Nicaraguan Social Security Institute (INSS).2,12 Ministerio de Salud is the primary health provider and covers 65% of the population’s health services, with 18% covered by the Nicaraguan Social Security institute, 6% covered by government and army medical services, and 11% by private facilities.2,12 In Nicaragua, the out-of-pocket expenditure (OOPS) per capita in U.S. dollars in 2015 was $59 with gross national income per capita (GNI) of $1,950 (U.S. OOPS was $1,061 with GNI per capita $56,300).12,13 For the treatment of chronic diseases, the MINSA uses the Family and Community Health Model. This model was adopted in 2007 as a new health model focused on universal access and comprehensive care, including access to medicines for hypertension, diabetes mellitus, epilepsy, arthritis, and asthma.2 A national drug policy and formulary provides access to essential drugs at no charge. Primary care services are provided at health centers that are usually staffed with general practitioners or nurses. Depending on the region, the population served varies, but on average, an ambulatory health center without beds has a patient panel population of 36,000 people.4,12 In 2014, physicians (per 1,000 people) were reported at 0.914 physicians and 1.384 nurses and midwives in Nicaragua.13 In comparison, the U.S. reported 2.568 physicians per 1,000 people (2014) and 9.884 nurses and midwives (2005).13 OneWorld Health (OWH) is a non- profit organization based in the United States with regional and medical directors in Nicaragua, Uganda, and Guatemala. In Nicaragua, OWH has established a private, ambulatory care network of six clinics in mainly underserved areas. OneWorld Health provides fee- for- service health care to those seeking care outside of the public sector. Their goal is to provide private health care at costs low enough to reach people who would otherwise be unable to afford private care, yet will allow the clinic to remain financially independent. As of 2019, OWH operates clinics in the towns of Tola, Sébaco, El Viejo, Jinotega, and two facilities in Managua. Based on the wide discrepancies in reported prevalence of hypertension in Nicaragua, OWH worked with the University of South Carolina Family and Preventive Medicine Global Health Fellowship to describe further the prevalence of hypertension and prescribing practices to treat hypertension in their El Viejo clinic. The clinic in El Viejo served as the primary research site for several reasons. El Viejo is a municipality with a population of about 40,000 located in northwest Nicaragua.14 The Ministry of Health reported hypertension as the number one chronic disease in the department of Chinandega in 2018.15 The region is also known to have a higher prevalence of chronic kidney disease (CKD), specifically Mesoamerican nephropathy (MeN).16 MeN is considered an endemic chronic kidney disease that affects predomi- Lee, Humphrey, Adams, Torres, Crawford, and Hall 1283 nantly young male agricultural workers who are, in this region, mainly sugarcane workers. Although MeN is not associated with hypertension or other causes of CKD, controlled blood pressure would further reduce the risk of CKD for patients in this region. Additionally, El Viejo is a municipality with a high incidence of extreme poverty at 44.6%, and understanding barriers may facilitate ways to improve accessibility of care.14,16 This study would serve as the initial step for the clinic toward implementing recommendations from the Global Standardized Hypertension Treatment (GSHT) project that was launched in 2012 by the Centers for Disease Control (CDC) and the Pan American Health Organization (PAHO) for treatment of hypertension in LMICs.17,18 The project targets improvement in medication adherence, medication delivery, and patient understanding of hypertension. Methods Study population and data collection. This study was a cross- sectional chart review from the OneWorld Health El Viejo clinic in Nicaragua. The study was submitted to the University of South Carolina’s Institutional Review Board (IRB). It was approved by the IRB as not human subjects research and was approved by OWH leadership in Nicaragua. A sample was drawn from existing paper charts that were stored in the clinic in alphabetical order with the date range of February 1, 2014 (the clinic opening) to January 1, 2017. When multiple visits were found in the patient’s chart, the most recent visit was used for data collection. Of approximately 5,000 charts, 1,500 charts were excluded because they were children (defined as younger than 18 years old). Of the remaining 3,500 charts, a 10% random sample, resulting in 349 charts, was used as the study population. The sample was selected using systematic random sampling with every 14th chart selected for review. The chart was rejected if the patient was younger than 18 years of age or the chart was illegible and the next chart was selected and reviewed. Pregnant women were not eliminated from the study. Each chart was assigned a study number to eliminate patient identifiers (e.g., names). The data were extracted using a form containing the study variables and entered into a password- protected database. A Spanish-to-English bilingual translator was trained by the principal investigator (PI) to extract the requested data by writing the information onto the form. The PI then reviewed the translation and if there were any concerns about the accuracy, completeness, or meaning of the translation, the PI would clarify with the translator. Primary outcomes included patient population demographic characteristics, reasons for seeking care, diagnosis of hypertension and other chronic diseases, and hypertension prescribing practices. Secondary outcomes were disease prevalence by body systems and medications prescribed by category. Statistical approach. Abstracted data were entered into EpiData 3.1 and analysis was performed using Statistical Analysis System (SAS) software, Version 9.4.19 The demographic information was analyzed via descriptive statistics with means, medians, standard deviations, and ranges for all continuous variables and frequencies and percentages for all categorical variables. Body mass index (BMI) was calculated using the 1284 Hypertension in Nicaraguan patients equation kiligrams divided by meters squared (kg/m2) and classified using guidelines from the Centers for Disease Control and Prevention (CDC). Results Hypertension and risk factors. Descriptive analysis of the data are presented in Table 1. Out of 349 patients, 19.77% (n=69) had a history of hypertension. The diagnosis of hypertension was second only to urinary tract infection. There were no known cases of pregnancy-induced hypertension. The hypertensive patient population of the clinic had a mean age of 56.1 years (SD=13.7) and was 66.2% (n=45) female. The majority of all patients (68%) lived within five kilometers (km) of the clinic. On a single visit, 50% (n=34) of the hypertensive patients had elevated blood pressure of ≥140/90 mmHg. Of hypertensive patients, 52.2% (n=12) of males and 47.7% (n=21) of females had uncontrolled hypertension. Comorbid conditions for cardiovascular disease were not documented regularly. Of those that were documented, 18.8% (13) had type 2 diabetes mellitus, 10.1% (7) had chronic kidney disease (CKD), and one patient had a documented cerebrovascular accident (CVA) in addition to comorbid hypertension. There was no documentation of any reported myocardial infarction or congestive heart failure. A large majority (96%, n=334) of the charts did not have any documentation with regard to either smoking or not smoking. Most of the patients (75.8%) met the CDC’s criteria for being overweight, with 36.4% (24) of hypertension patients classified as overweight and 39.4% (26) classified as obese (Table 1). A little over half of the hypertension patients (55.2%, n=37) had documented request for follow-up. Anti-hypertensive medication prescribing practices. Despite the high rate of hypertension reported, only 13% of patients were documented as currently being on an anti- hypertensive medication. Angiotensin converting enzyme inhibitors (ACE- I) and angiotensin receptor blockers (ARB) were the most common anti- hypertensive medications. Physicians most commonly prescribed losartan (n=12, 23.5%), captopril (n=8, 15.7%), enalapril (n=5, 9.8%), and atenolol (n=4, 7.8%), which are all medications found on Nicaragua’s national formulary and recommended in MINSA protocols for hypertension.20 Of the core set of medications endorsed by the GSHT project, the only primary antihypertensive that the El Viejo clinic used was losartan. Lisinopril is listed as the primary ACE- I antihypertensive, but the clinic used enalapril. The other medications, captopril and atenolol, were not on the GSHT core medication list.18 Discussion Hypertension findings. In this cross- sectional study from a single private Nicaraguan clinic, we looked at hypertension control in patients with a history of hypertension at a single visit. Of the entire sample, nearly 20% of all patients had a history of hypertension, which was the most prevalent chronic disease. This finding reflects the higher prevalence of hypertension in the area and a comparison of our findings to studies by Laux et al. and Alicea- Planas et al. highlight some associations and points of interest. Laux et al. did a cross- sectional survey of 1,355 adults aged 20–60 years in six Lee, Humphrey, Adams, Torres, Crawford, and Hall 1285 Table 1. CHARACTERISTICS OF EL VIEJO CLINIC PARTICIPANTS WITH HYPERTENSION (N=69). EL VIEJO, NICARAGUA, 2017 Characteristic Age in years Blood Pressure Systolic Diastolic Body Mass Index (BMI) 18.5–24.9 25.0–29.9 30 and + Sex Female Male Comorbid Conditions Diabetes Chronic Kidney Disease Hyperlipidemia Cerebrovascular Medical Conditions by System Cardiovascular Musculoskeletal Respiratory Gastrointestinal Renal Blood and Lymph Genitourinary Endocrine Psychiatric OB/GYN Skin/Derm ENT Neurologic Other Follow-up Yes No High Blood Pressure 140–149/90 or higher 150/90 or higher n % Mean=56.1; SD=13.7 Median=55.0; Range=26–86 Mean=134.0; SD=26.3 Mean=82.5; SD=6.5 Median=130.0; Range=80–220 Median=80.0; Range=56–120 16 24 26 24.2 36.4 39.4 45 24 66.2 33.8 13 7 2 1 18.8 10.1 2.9 1.4 32 6 4 14 14 3 12 19 3 2 1 4 1 1 46.4 8.7 5.8 20.3 20.3 4.4 17.4 27.5 4.4 2.9 1.5 5.8 1.5 1.5 37 32 55.2 44.8 34 30 50.0 44.1 1286 Hypertension in Nicaraguan patients Nicaraguan communities (five rural and one urban) to describe the prevalence of hypertension and associated cardiovascular risk factors including diabetes, smoking, and obesity. Five communities were in the northwest in Leon and Chinandega, the same region as the El Viejo clinic, and one was in Matagalpa. A questionnaire was conducted at the participant’s homes and lab studies were obtained in a mobile lab. In these communities, the prevalence of hypertension was 22%; 24.2% of women and 19.2% of men had hypertension. Hypertension was controlled in 55.1% of women and 31.0% of men (uncontrolled HTN was defined as ≥140 mmHg SBP or ≥90 mmHg DBP). Half of the sample had at least one cardiovascular risk factor and 13.4% had at least two risk factors. Increasing age and obesity were greater risk factors for women. Completing primary school was independently associated with a decreased prevalence of hypertension in women. Comparing our clinic sample with the communities studied by Laux et al. allows our clinic findings to be viewed in context of the surrounding communities and brings attention to areas for future study. It is notable that of hypertensives, the mean age of patients in our study was higher (39.7 years vs. 56.1 years) and the percentage of those with diabetes was higher (7.7% vs 18.8%) than the patients with hypertension found in the Laux et al. study. Type 2 diabetes mellitus was the most prevalent comorbid disease in our sample, but Laux et al. found a higher precentage of CKD in their hypertensive population (33% vs 10%). It is expected that an older population would be accessing healthcare and contribute to the mean age difference seen here. The finding of a higher percentage of CKD in the community samples could be attributed to their testing of each individual to determine renal function and suggests that CKD might be underdiagnosed in the El Viejo clinic population. Another possibility is that those seeking care provided by work- site clinics for agricultural workers may limit the representation of MeN in our clinic. Assessment of the screening practices of CKD in the El Viejo clinic patients could lead to an opportunity for more timely identification and treatment of CKD. As with Laux et al., we found that women were more likely to have hypertension (62.1% vs 66.2%) and were also more likely to have controlled blood pressure compared to men. Laux et al. suspected that poorer blood pressure control in men could be partially due to men working during clinic hours and therefore less frequently accessing health care. More hypertensive clinic patients were overweight (33.9% vs 36.4%) and obese (35.2% vs 39.4%) than the community sample of hypertensives and had a higher mean BMI (28.3 (6.0) vs 30.0 (6.46)). The mean blood pressure of hypertensives in our study (135/82.5) was similar to that reported by Laux et al. (134/81.0). Alicea- Planas et al. conducted a study on the prevalence of hypertension in rural coffee farm workers in north central Nicaragua in the department of Jinotega. This sample is outside of the Chinandega department, but is still important given that it is a study on hypertension in agricultural workers and provides insight into access to care among other findings. This was a small sample size of 184 adults, the majority of whom were men (58.7%) and overall were younger, with a mean age of 35 (SD 14.6) years (range 18–80). The overall prevalence of hypertension in this study was 20.7% and as with Laux et al. and our study, hypertension prevalence was higher in women. They found, however, that prehypertension had a higher prevalence in men than women Lee, Humphrey, Adams, Torres, Crawford, and Hall 1287 and more women reported having had a prior blood pressure measurement (72.4% vs 50.9%). The authors suspected that this was related to the provision of prenatal care at an on- site clinic. At that time, the on- site clinic did not provide primary care prevention and was identified as a future opportunity for clinically relevant intervention. The findings of all three studies suggest that women may be more likely to access healthcare and contributes to better hypertension control in women. Additionally, a 2016 OWH internal Quality Control Survey found that the El Viejo clinic’s general patient population was predominantly female (56%), which is 4% higher than the female population of Chinandega.14 Further studies are needed to determine to what degree clinic hours, clinic services, and patient understanding of disease influence healthcare access and treatment adherence, and how barriers to care may differ between men and women. The finding that half of the patients with a history of hypertension had an elevated blood pressure at their visit suggests that hypertension may be inadequately controlled in this patient population. Follow up rates are of particular interest in chronic diseases where the disease and treatment require ongoing monitoring. While the recommendation for follow-up was documented in more than half of the patients, due to the nature of the study, we were unable to calculate the actual rate of follow-up. The lack of documentation of comorbid diseases could be a reflection of the lack of insight into the interconnection among different chronic diseases and optimized management of hypertension and is unexpected in a fee- for- service clinic. Similarly, the lack of documentation regarding cigarette smoking suggests that the link between smoking, hypertension, and cardiovascular diseases in general could be overlooked by providers in this setting. These findings highlight the need for closer attention to blood pressure regulation, improvement in documentation, and further studies in order better to understand hypertension management at this clinic. Prescribing practices. Determination of hypertension medications prescribed by the clinic’s physicians was of interest to provide insight into the prescribing patterns of physicians in a private clinic setting. A study in 2010 found that only 35.6% of patients obtained all their medications in the public sector and 56.1% obtained at least one medication in the private sector in Nicaragua.1 In another study, the availability of medications in Nicaragua was found to be 73.7% and 84.2% in the public and private health care sector, respectively.16 With such significant medication shortages in the public system, a consistent and affordable source of medications outside of that system, such as that offered by OneWorld Health and other private clinics, could improve medication access, and in turn improve adherence and treatment, particularly for chronic diseases. This study suggests that physicians most often prescribed hypertension medications that were the least expensive and on the national formulary, mainly losartan, enalapril, captopril, and atenolol. The 2016 OWH internal Quality Control Survey found that over 90% of those surveyed indicated that medications were accessible at current prices, but 27% recommended increasing the pharmacy’s stock and 4% recommended lowering pricing (OWH). Inability to obtain medication in the OWH pharmacy is both an inconvenience and a missed opportunity for physician to pharmacist communication. The OWH pharmacy was staffed by a single pharmacist, a seasoned general medicine physician at all times, and specialists on designated days, including a visiting American 1288 Hypertension in Nicaraguan patients nephrologist. “We always have to turn people away if they are prescribed brand names or if they are prescribed anything that is not captopril, nifedipine, losartan, or enalapril,” said the pharmacist in an interview of the clinic staff (Hypertension Questionnaire of Staff, March 13, 2017). The pharmacy offered competitive prices, but a limited stock of brand name and combination hypertension medications left patients to find these medications at other pharmacies when prescribed. The implementation of the GSHT project’s formulary could improve availability of prescribed medications. An important consideration with regard to accessibilty of medications will be determining whether patients find prices affordable for medications to treat chronic disease as compared to a one- time purchase for an acute disease treatment. For this reason, a formulary of affordable medications that can be consistently stocked is imperative. Health care access. With 35–40% of the population lacking access to health services, one of the main determinants for seeking health care is location.1,4,21 The majority of patients (64%) that used the clinic lived within three kilometers. Although we did not specifically survey patients for this information, the decision to use private clinics may be made in an attempt to overcome public sector barriers including difficulty accessing needed services, inconsistent availability of medications, low health literacy, and dissatisfaction with the public sector service quality. Historically, both public and private sectors have imposed insurmountable barriers for patients, leading to a deficiency in the delivery of health care.1 The strategy to place OWH clinics in an accessible area with reasonable costs for care should help to overcome this. USAID defines extreme poverty as living on less than US$1.90 per day.21 The OWH El Viejo clinic is serving in an area with high levels of extreme poverty and the majority of patients are at or below the poverty line, but only 1% of patients were categorized as “extreme poverty” in the 2016 internal Quality Control Study.14 The majority of patients (69%) were living on less than $8.00 per day and 20% lived on less than $3.75 per day. Given that this is a fee- for- service clinic, the low utilization of the clinic by patients in extreme poverty is not surprising, but it underscores the vulnerability of this population and necessitates decreasing barriers to care for them in the clinic and in the public sector. Limitations and strengths. Further study is needed to demonstrate whether uncontrolled hypertension in this patient population is a true representation of the larger community. Due to limited documentation of comorbid conditions and hypertension medications, our data may lead to an underestimation of the number of patients taking anti- hypertensives and the existence of comorbid conditions. This study did not attempt to determine the rate of return for patients requested to follow up. The cross- sectional design of the study is a limitation that does not allow assessment of treatment adherence, follow up, and rate of control. The study was conducted in a single Nicaraguan clinic and therefore, the generalizability of the findings to other settings may be limited. Despite these limitations, our findings provide insight into hypertension in this population and adds to the limited body of knowledge for future studies and hypertension treatment endeavors. Conclusion. Hypertension is a common diagnosis among the population served by this private ambulatory clinic in Nicaragua. The propensity of the nearby population to use the clinic suggests that private clinics help to fulfill the need for accessible care, Lee, Humphrey, Adams, Torres, Crawford, and Hall 1289 but barriers to access and treatment still exist. Treatment of chronic disease includes access to medications for long- term treatment and continued monitoring, which presents challenges for this vulnerable population that must be recognized when determining interventions. Understanding and overcoming barriers in the public and private sector will be vital in the improvement and continuity of hypertension management. A simplified medication treatment regimen for hypertension may be an important strategy for better care in the El Viejo clinic. Further studies on physician prescribing practices, decision- making, and patient barriers to care are needed to facilitate the design and adoption of health care interventions. More robust documentation is needed to determine cardiovascular risk factors in this population as improved surveillance programs are initiated. References 1. 2. 3. 4. 5. 6. 7. 8. 9. Emmerick CME, Luiza VL, Camacho LAB, Vialle-Valentin C, Ross- Degnan D. Barriers in household access to medicines for chronic conditions in three Latin American countries. Int J Equity Health. 2015 Oct 31;14:115. https://doi.org/10.1186/s12939-015-0254-z PMid:26521237 Pan American Health Organization (PAHO). Health in the Americas: Nicaragua. Washington, DC: PAHO, 2020. Available at: http://www.paho.org/salud- en- las - americas- 2017/?p=4286. World Health Organization (WHO). Noncommunicable Diseases (NCD) Country Profiles: Nicaragua. Geneva, Switzerland, 2014. Available at: http://www.who.int/nmh /countries/nic_en.pdf. Sequeira M, Espinoza H, Amador JJ, et al. The Nicaraguan Health System. Seattle, Washington: PATH, 2011. Available at: https://www.path.org/publications/files/TS - nicaragua- health- system- rpt.pdf. Siu AL, U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015 Nov 17;163(10):778–86. Epub 2015 Oct 13. https://doi.org/10.7326/M15-2223 PMid:26458123 Laux TS, et al. Prevalence of hypertension and associated risk factors in six Nicaraguan communities. Ethn Dis. 2012 Spring;22(2):129–35. Pan American Health Organization (PAHO). Health Systems Profile in Nicaragua: Monitoring and Analyzing Health Systems Change/Reform. Washington, DC: 2009. Available at: http://www1.paho.org/hq/dmdocuments/2010/Health_System_Profile - Nicaragua_2008.pdf. Alicea- Planas JA, Greiner L, Greiner PA. Hypertension and related lifestyle factors among persons living in rural Nicaragua. Appl Nurs Res. 2016 Feb;43–6. Epub 2015 May 23. https://doi.org/10.1016/j.apnr.2015.05.010 PMid:26856487 Blondin NA, Lewis J. Prevalence awareness, treatment and control of hypertension in 1290 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Hypertension in Nicaraguan patients a rural Nicaraguan sample. J Hum Hypertension. 2007 Oct;21(10)815–7. Epub 2007 May 3. https://doi.org/10.1038/sj.jhh.1002225 PMid:17476285 U.S. Department of Health and Human Services, National Institutes of Health, Lung, and Blood Institute. The Seventh Report on the Joint National Committee on Prevention, detection, evaluation, and treatment of high blood pressure. Bethesda, MD: National Heart, Lung, and Blood Institute, 2004. Available at: https://www.nhlbi.nih .gov/files/docs/guidelines/jnc7full.pdf. James PA, Oparil S, Carter BL, et al. 2014 Evidence- based guideline for the management of high blood pressure in adults report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507–20. https://doi.org/10.1001/jama.2013.284427 PMid:24352797 World Health Organization (WHO). Global Health Expenditure Database. Geneva, Switzerland: WHO, 2014. Available at: http://apps.who.int/nha/database/ViewData /Indicators/en. The World Bank Group. The World Bank Data: Nicaragua. Washington, DC: The World Bank Group, 2019. Available at: https://data.worldbank.org/country/nicaragua. Nicaragua National Institute of Information Development. Chinandega in figures. Managua: Nicaragua, 2008. Available at: https://www.inide.gob.ni/censos2005 /cifrasmun/Chinandega/CHINANDEGA.pdf. Ministerio de Salud. SILAIS Chinandega: Enfermedades crónicas, 2018. Managua: MINSA. Available at https://web.archive.org/web/20191118035445/http://mapasalud .minsa.gob.ni/mapa-de-padecimientos-de-salud-silais-chinandega/#c2016/ Kupferman J, Amador JJ, Lynch KE, et al. Characterization of Mesoamerican nephropathy in a kidney failure hotspot in Nicaragua. Am J Kidney Dis. 2016 Nov;68(5):716–25. Epub 2016 Aug 26. https://doi.org/10.1053/j.ajkd.2016.06.012 PMid:27575010 Patel, P, DiPette, DJ. Hypertension- related congestive heart failure in West Africa: a framework for global blood pressure control. J Clin Hypertens (Greenwich). 2015 Apr;17(4):260–2. Epub 2015 Feb 16. https://doi.org/10.1111/jch.12494 PMid:25688849 Patel P, Ordunez P, DiPette D. Improved blood pressure control to reduce cardiovascular disease morbidity and mortality: The Standardized Hypertension Treatment and Prevention Project. J Clin Hypertens (Greenwich). 2016 Dec;18(12):1284–94. Epub 2016 Jul 4. https://doi.org/10.1111/jch.12861 PMid:27378199 Lauritsen JM & Bruus M. EpiData (3.1). A comprehensive tool for validated entry and documentation of data. The EpiData Association, Odense, Denmark, 2003–2005. Division of Rational Use of Medical Supplies. National Drug Form, 7th ed., Managua, Nicaragua: Ministry of Health, 2014. U.S. Agency for International Development (USAID). Vision for ending extreme poverty. Washington, D.C.: USAID, 2015. Available at: https://www.usaid.gov/sites /default/files/documents/1870/Vision- XP_508c_1.21.16.pdf.