Introduction

Hypertension (HTN) is a major modifiable risk factor and a leading cause of mortality and premature deaths among the NCD’S [1–2]. It is reported that more than 1 billion people are affected globally [3]. Managing HTN is a significant public health concern [4]. The prevalence of HTN is increasing in low and middle-income countries (LMICs) than in high-income countries [3,4,5].

China has approximately 245 million HTN patients, with treatment and control rates of only 40.7% and 15.3%, respectively [6]. HTN is not only a risk factor for many unfavorable clinical outcomes but also has an adverse effect on other conditions like diabetes mellitus (DM), chronic kidney disease (CKD), cardiovascular diseases (CVD), stroke, and loss of cognitive function [7,8,9,10]. Therefore, even modest improvements in the management of raised BP might have a significant long-term positive impact, especially in patients with underlying comorbid conditions [7]. It is reported that two-thirds of hypertensive patients had underlying comorbidities such as DM, CKD, CVD, and dyslipidemia [11].

BP is not only diurnal [12–13] but also a dimorphic variable that can change at different rates in males and females throughout their life span [13–14]. These variations are caused by a combination of genetically (sex-related) and psychosocially (gender-related) determined variables [15–16], but overall, men are more likely to have other coexisting conditions in China [17]. The prevalence of HTN differs between males and females with comorbidities, as does their awareness of the condition [6, 18,19,20,21]. Sex disparities in the treatment of HTN with comorbidities, however, have not received enough consideration [22–23]. Sex disparities in HTN care, which have been overlooked, would hinder the Sustainable Development Goal (SDGs) of reducing non-communicable diseases (NCDs) mortality by one-third [24–25]. It would be challenging to reach SDG’s goal of 3.0 in Yunnan Province (a low-income region in south-west China) [26].

Based on the American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines [27] and the Chinese guidelines [6).

Supplementary file 7 shows the BP control rate in men and women with coexisting comorbidities in all eight study centers. Both male and female participants with dyslipidemia, CVD, CKD, and DM experienced a higher rate of BP control in the BPHS group than in the non-BPHS group. Despite having four comorbidities, men from the urban areas of “Guandu” (Fig. 1G in Supplementary file 7) and “Mengzi” (Fig. 1D in Supplementary file 7) in the BPHS group had a higher control rate than female patients.

Discussion

This study explored the effectiveness of BPHS policy in reducing HTN among those with pre-existing long-term comorbidities. Also, it revealed whether women and men benefited equally from BPHS policy. We presented the findings of a survey associated with the BPHS program to analyze BP control in hypertensive patients with comorbidities. We found that 70.7% (1076/1521) of HTN patients had at least one coexisting comorbidity, which was higher than the percentage found in studies from Hong Kong (47.4%) [57] and the UK (51.0%) [58].

Dyslipidemia was the primary comorbidity for the majority of the participants (43.7%), followed by CKD (35.5%), which is consistent with the fact that dyslipidemia was the most prevalent comorbidity in the Chinese hypertensive population (about 41.3%) [59–60]. HTN combined with hypercholesterolemia has become the most important risk factor for ischemic heart disease mortality among Chinese residents [61]. HTN has resulted in 32.75 million disability-adjusted life years in entire China [62]; hypertensive patients with low socioeconomic status, low health literacy, and having lower access to medical services [63] require considerable health resource input, especially in south-west China, where the population is aging in a higher rate. Attention was deemed necessary in the interim since China has the highest proportion of CKD patients in Asia (up to 159.8 million) [64].

ISH [7] and ACC guidelines [27] recommend lifestyle intervention for CVD prevention and non-pharmacological treatment of hypertensive comorbidities as an effective means to lower BP. Consistent with ISH and ACC guidelines, the Chinese national standards for BPHS (the third edition) [31] recommend primary healthcare providers to create personalized models of lifestyle modification for hypertensive patients, to supervise and track constantly, to provide patient counseling, and to encourage patients to follow the recommended lifestyle changes consistently. Thus, lifestyle modification was included as an essential component of managing hypertensive patients [28, 31, 65]. This study found that a higher percentage of male hypertensive patients with comorbidities in the BPHS group received services related to salt reduction instruction (BPHS 89.6% vs. non-BPHS 82.6%), alcohol consumption reduction (87.8% vs.81.5%), and stress reduction guidance (81.8% vs. 73.7%). It is observed that the more the primary healthcare practitioners provided health education and lifestyle modifications to patients, the more it enhanced health awareness, helped in BP control, and encouraged people to adopt a better lifestyle [66–67].

This study also found that BPHS group patients with comorbidities had a higher proportion of taking a single drug (BPHS group 54.3% vs. non-BPHS group 37.2%) or combination of drugs (17.3% vs. 8.6%) than those in the non-BPHS group, which is in line with a report stating that HTN patients with comorbidities typically took more medications for a longer period of time to manage their blood pressure [7, 29]. ‘Consistency’ could be the key to effectively controlling BP in comorbid patients in the BPHS group. A patient-centered approach to clinical practice and the use of herbal medications were linked to optimum BP control in earlier studies, which may offer guidance for future BPHS policy amendments [68–69].

Moreover, our study observed lower DBP and SBP in the BPHS group, regardless of the different types of comorbidities or accumulated comorbidities. As hypertensive dyslipidemia or DM, patients were 2.169 times and 2.785 times more likely to receive BPHS management, respectively, and a similar trend was observed in patients with comorbidities clusters. The above findings further provided sufficient evidence that BPHS can effectively manage HTN with comorbidities in the low-income provinces of south-west China. However, the adjusted model from HTN patients with CKD was not statistically significant (p > 0.05), and the results imply that “anti-hypertensive medication” appears to be a substantial and important predictor of BP control, which detracts from/influences the potential association between the independent variable (BPHS management) and the dependent variable (BP control). It is evident that the BPHS management system should be a priority consideration for hypertensive patients with comorbid CKD. Unlike the current clinical practice recommendations, which primarily address managing HTN from a single comorbidity [70], our findings support the trend among primary healthcare providers to monitor BP and assess risks to manage the targeted BP better and provide high-quality services, as per international guidelines for the treatment of hypertensive patients with multiple and accumulated comorbidities.

In addition, this study demonstrated that, compared to the non-BPHS group, the BPHS care group was beneficial in lowering SBP and DBP with multiple comorbidities in both sex. In some high-income urban survey centers, men appeared more likely to have their BP well under control. Previous studies from Denmark and the United States have reported differences in BP control rates depending on the presence of different diseases in men as compared to women [53, 71]. Current HTN recommendations give sex disparity relatively minimal consideration [23, 72]. Therefore, national health initiatives like BPHS must consider this inequality. This can be achieved by providing additional BPHS resources, particularly in areas with limited access to female patients with multiple comorbidities.

The study reveals that BPHS would significantly contribute to the ‘targeted BP control’ among patients with comorbidities and encourage them to adhere to BPHS-assisted lifestyle changes. Furthermore, by imparting the most recent information and experience, it would benefit prospective policies in LMIC regions.

Limitation

The results could have been impacted by the duration and occurrence of CKD, CVD, and DM, but we did not validate this interdependency in this study. The relationship between BPHS management and BP control should be evaluated cautiously due to the limitations imposed by the cross-sectional study methodology. Secondly, the efficiency of HTN management could have been unintentionally underestimated in hypertensive patients with comorbidities (1, 2, 3, or more comorbidities) owing to the short duration of BPHS services provided. Thirdly, this study identified four comorbidities as the most prevalent comorbidities (dyslipidemia, DM, CKD, CVD) in the Chinese populace, and thus only these four were considered in inclusion criteria, and minor comorbidities like Gout, rheumatic changes, dementia, and tumors were excluded from the study. Due to a very small sample size of patients in the group with four major comorbidities in some survey centers attributed to a lack of ‘scientific literacy’ in general, therefore both BPHS and non-BPHS enrollment trajectories declined significantly. This is inexorably shown on individual study center maps, which presents as extreme values of cases with control rates of “0 “or “100”, especially “Anning” study center (see Supplementary file 7).

Our recommendations to health policymakers are: (a) Future prospective cohort studies should consider enrolling a larger sample size, as doing so could help to better assess the effectiveness of BPHS in lowering BP, reducing related disability, and preserving medical and health resources in hypertension patients with complications. (b) NCD’s awareness camps should be conducted prior to study, as centers like “Anning” seems to lack ‘scientific literacy’ in general. (c) Furthermore, an emphasis on extensive research is necessary to comprehend the mechanisms by which sex influences the onset of HTN and vascular aging, as well as how this correlation can help in the early prevention of other comorbid conditions. (d) Due to the constant changes in the guidelines [73] for treating HTN, there should be an introduction of Chinese HTN education program recommendations for the management of hypertension, which should be taught to healthcare providers on a regular basis. (e) By collaborating with other Asian societies of HTN [74–75] and sharing knowledge with international committees working on HTN, it is essential to develop a HTN treatment specifically tailored to suit the Chinese race.

Conclusion

This study evaluated the community-based Chinese BPHS program for effectively managing male and female hypertensive patients with comorbidities and found that almost two-thirds of the hypertensive patients have comorbidity in Yunnan Province. The BPHS program also successfully encouraged healthy lifestyle changes, lowered DBP and SBP, and improved BP control in HTN patients with various comorbidities. However, we also observed that male patients with HTN seemed to benefit more from BPHS than women. For the first time in China, this study results call for better management strategies and allocation of health care resources for chronic diseases, especially to women in older age group.