The inspiration for writing this piece was to commemorate World Hypertension Day Saturday, May 17, 2025 with the intention to share the importance of being disciplined with hypertensive treatment.
Firstly I want the readership to imagine this scenario before delving into the article. We will use this as an icebreaker.
Imagine your blood vessels are like a garden hose that carries water (blood) from a tap (your heart) to the garden (the organs in your body). When everything is working properly, the water flows smoothly through the hose at just the right pressure, watering the garden gently and evenly.
Now, let’s suppose the nozzle at the end of the hose is partially blocked, or the hose gets a kink. The water pressure builds up inside the hose because the same amount of water is being forced through a narrower space. Over time, that high pressure can strain the hose, causing leaks, or even burst it. We all know the saying “pressure buss pipe.” Now there are parts of your garden that are accustomed to a certain supply of water (blood) that now are not receiving this vital life sustaining liquid to keep your plants (cells that make up your organs) alive.
Similarly, if your arteries become narrow or stiff due to certain health conditions your heart has to pump harder to push blood through them. This increased force against the walls of your blood vessels is what we call high blood pressure or hypertension.
Just like a hose under too much pressure can be damaged, high blood pressure can hurt your vital and sensitive organs such as your heart, kidneys, eyes, and brain if it is not controlled.
Stroke is among the top causes of death and long-term disability in the Caribbean, including Antigua and Barbuda. The majority of strokes in the region are attributable to poorly controlled hypertension a condition that often goes undetected or untreated until complications arise, contributing to long-term disability and premature mortality.
While antihypertensive medications are proven to reduce the risk of stroke, non-compliance remains alarmingly common due to cultural, economic, and systemic factors.
Hypertension is one of the most prevalent chronic conditions in Antigua and Barbuda and one of the key if not the principal contributor to the high incidence of Cerebrovascular Disease otherwise know as stroke. Despite the availability of effective medications, non-compliance with hypertension treatment (hypertensive patients not being disciplined with their treatment regimen) remains a significant challenge, across the population.
This article serves to explore the relationship between hypertension and stroke, the local barriers to treatment adherence and possible public health strategies to improve compliance, with a hope to shed some light, educate and strengthen adherence to antihypertensive therapy.
In Antigua and Barbuda, a high proportion of adults over 40 are hypertensive, with many unaware of their condition. The Caribbean Public Health Agency (CARPHA) has repeatedly emphasized hypertension as the most significant risk factor for stroke in the region. Chronically elevated blood pressure (high levels of blood pressure for a sustained period of time) exerts excessive force against arterial walls, leading to thickening, narrowing, and eventual weakening of blood vessels – like in our garden hose example.
This gradual damage to the blood vessels within the brain makes them prone to rupture or blockage, which can lead to one of these 3 variations of cerebrovascular disease.
An ischemic stroke is the most common type of stroke. It usually happens when the brain’s blood vessels become narrowed or blocked. This causes reduced blood flow, known as ischemia. Blocked or narrowed blood vessels can be caused by fatty deposits that build up in blood vessels. Or they can be caused by blood clots or other debris that travel through the bloodstream, most often from the heart.
A hemorrhagic stroke occurs when a blood vessel in the brain leaks or ruptures. Bleeding inside the brain, known as a brain hemorrhage, can result from many conditions that affect the blood vessels.
Transient ischemic attack, also known as a TIA is a temporary disruption of blood flow to the brain. A TIA doesn’t cause lasting symptoms and the person usually recovers completely. Usually recovery can be expected to be seen within an hour while some literature extends the period for complete recovery from a transient attack to be within 24hours.
Although the 3 types may have different mechanisms in how they lead to stroke what they do have in common is poor management of high blood pressure being a major risk factor.
Diet plays a pivotal role in the development and progression of Chronic Non-Communicable Diseases (CNCDs) such as hypertension. In Antigua and Barbuda, there has been a marked shift from traditional, plant-based diets to Western-style diets rich in processed foods, sugars, and saturated fats. High sodium intake has been directly linked to hypertension, while high glycemic diets contribute to poor glycemic control in diabetic patients. These nutritional patterns significantly increase the risk of ischemic and hemorrhagic strokes.
Notably, the burden of stroke disproportionately affects older adults, many of whom have multiple chronic conditions such as Hypertension, Type 2 Diabetes, Heart Disease, Vascular Disease and Renal Disfunction and face difficulties adhering to their medication regimens which may seem arduous or complex.
Non-compliance with antihypertensive medication defined as skipping doses, taking medication inconsistently, or stopping treatment altogether leads to poorly controlled blood pressure and increased stroke risk.
Possible Barriers to Compliance in Antigua & Barbuda
Several local factors contribute to poor compliance with hypertension treatment:
Limited Access: In rural and underserved areas, consistent access to medications and regular follow-up can be challenging especially in communities where clinics are not easily accessible to certain parts of the population. Thankfully in recent years there have been measures put in place with the opening and revitalization of various community policlinics which will widen the net and hopefully make primary care more accessible for the treatment and control of chronic non-communicable diseases within our population.
Lack of Symptoms: Sadly we have this tendency in Caribbean Culture of not believing in what we can’t see, touch or feel. An old adage I would hear my mother tell me as a child instantly comes to mind, “Wah eye nah see, heart na grieve.” Many hypertensive patients stop taking their medication once they feel “well,” not realizing that hypertension remains dangerous even without symptoms. Once diagnosed, patients need to be conscious that this is a chronic condition which they will have for life and needs constant management. The symptoms that one usually feels or manifests from chronic hypertension are more often as a result of the complications due to damage to various organs in the body mainly our heart, kidneys, eyes, and brain.
Cultural Beliefs: Some amongst us may be enticed by the belief that natural remedies or prayer alone are a sufficient and superior alternative to medical treatment. Although both may contribute towards overall health and well being in their own specific way we cannot deny or turn our backs on the advances in science that we take advantage of and exploit on a daily basis. Why not also apply this to our health and use the medications that are scientifically proven to combat and manage our chronic health conditions? We turn our light switches on daily without any skepticism towards science. We drive our cars and sit in plane seats and blindly trust the same science, laws of science, the scientific method and it’s application that engineers have used to create the finished product. Chances are you are reading this very article from a mobile device or computer that was generated using years of compounding technology and innovation to become a reality birthed to you by the same science that some of us shun when it comes to our own health. Treatments for chronic non-communicable diseases like hypertension were and are developed in the same fashion proven by years of research to decrease the incidence and prevalence of complications due to these diseases and leading to an increase in life expectancy amongst patiences who are compliant with their treatment regimen.
Medication Side Effects: Fear of or actual side effects may lead patients to discontinue use without consulting a doctor. This sometimes only requires an adjustment in dosage or change in the type of medication that the patient is currently taking. Certain types of treatments are not compatible with certain patients due to multiple factors and hypertensive treatment shouldn’t be treated as a one size fits all glove. A tailored approach can be achieved overtime which hits the sweet spot between benefit & adverse effects on a patient to patient basis. This also shows the importance of regular follow ups with your primary care provider to inform them of the possible side effects or lifestyle inconveniences your current treatment is causing. This would allow reevaluation to see if another regimen or combination of anti-hypertensives can achieve controlling one’s hypertension and is still manageable for the patient.
Low Health Literacy: How many of us have that one relative or family member that would claim in our beautiful Antiguan twang “Doctah sey meh blood pressure high & meh haffu watch meh sugar!” Yet in-between both declarations would pause for a munch of a succulent bun butter and cheese washed down by a very generous swallow of punch soda.
Some patients may not fully understand their diagnosis or the importance of lifelong treatment and the lifestyle changes that accompany these treatments. In most instances taking the medication is only a fraction of the battle and lifestyle adjustments such as dietary changes and exercise have a tremendous impact when treating hypertension. A lot of the time patients have little information or are poorly informed about their conditions. Some who may be more curious may seek information from sources that may not be credible or qualified to be disseminating healthcare information based on factual evidence based practices. Not all of us are aware of the dangers of entering a prompt into a web browser and thinking that whatever comes out on the other end is 100% factual. To many google is akin to the bible, which truly isn’t the case. Patients understanding what their diagnosis is and what complications could arise is essential because treatment of any problem first begins with the awareness that there is a problem and that consciousness is gained as a result of education and enlightenment via channels that are qualified to disseminate healthcare advice/education/information.
In recent years thankfully there has been an increase in healthcare literacy and the amount of campaigns have increased eg. Walks & Marathons organized by MBS, numerous non-profit healthcare societies and various community groups. Efforts like these need to continue and increase and are definitely a step in the right direction.
Tackling non-compliance and arming our population with the necessary knowledge to instill discipline is crucial in reducing stroke-related disability and mortality in Antigua and Barbuda.
Possible Strategies to Improve Compliance
Improving compliance with hypertension treatment in Antigua and Barbuda requires a culturally tailored, multi-level approach:
1. Health Education Campaigns: Targeted messaging through radio, churches, and community events in partnership with qualified healthcare professionals can raise awareness of hypertension and its risks.
2. Community Leaders & Health Workers: Trained community members can follow up with patients, assist with medication routines, and encourage clinic attendance. Imagine large mobilization of door to door campaigning to ensure that granny is taking her anti-hypertensive medications is eating healthy and is attending the clinic regularly. This in the long run may be more beneficial to community leaders also maybe more politically and economically sustainable than the usual door to door with the turkey and ham loaded with sodium. Let’s think about it if granny lives longer she may be around next election cycle to cast her vote as a show of appreciation.
3. Integrated Care Programs: Public health clinics should adopt patient tracking systems and mobile outreach to improve continuity of care. This to some extent is done in limited capacity but a more efficient approach possibly could be developed overtime. Use of Technology such as Mobile apps, SMS reminders can be used to help patients stay on track with their medications.
4. Affordable Medication Access: Ensuring regular availability of essential antihypertensives through national insurance or government supply chains is critical. The Medical Benefits Scheme has been the staple of this effort for the past few decades assuring that persons who contribute towards the scheme have access to heavily subsidized treatment for their chronic conditions such as hypertension. There have been recent talks of the implementation of a new National Health Insurance hopefully this opportunity would be taken to assess in an objective way the flaws of our current model to create a more efficient, affordable and most importantly accessible one.
5. Family Engagement: Our environment plays a big role in who we are.
Encouraging family members to participate in managing a relative’s blood pressure improves accountability and support. Whether it be helping or accommodating with the adjustment to lifestyle changes like diet and exercise or simply ensuring that medication is being taken regularly and at the right dosages. These small things contribute in a large way. “Likkle likkle fill bucket.”
To conclude, in Antigua and Barbuda, non-compliance with hypertension treatment is a major driver of preventable stroke. Enhancing treatment adherence through education, system-wide improvements, and community involvement is essential. By addressing the unique cultural and structural barriers to compliance, the nation can make significant strides in reducing stroke incidence and improving population health outcomes.