Comprehensive Primary Health Care Services Research Articles

IJCM_252A: An Assessment of Functioning of Health and Wellness Centres - Sub Health Centres (HWC-SHC) in Raipur District.

Background: The National Health Policy 2017 has envisioned the integration of Health and Wellness Centers (HWCs) into India’s healthcare system as part of Ayushman Bharat. In February 2018, the Indian Government declared the transformation of 1,50,000 existing Sub Health Centers and Primary Health Centers into Health and Wellness Centers (HWCs) to provide Comprehensive Primary Health Care (CPHC). Health and Wellness Centres have an important role in the prevention of several diseases and health promotion and in undertaking public health functions in the community to strengthen the frontline workers and community platforms. Objective: To assess the availability of Infrastructure and 12 comprehensive primary health care services in study centres (HWC-SHC) in Raipur district Methodology: This is a cross-sectional observational study conducted in the 32 Health and wellness centre-sub centres of Raipur district, Chhattisgarh. In the Raipur district, there are 4 blocks and from each block, 25% of the study centres (HWC-SHC) are selected by simple random sampling. Semi- structured assessment tool with the reference of Government of India Operational Guidelines was used which consisted of checklist regarding Physical Infrastructure, Human Resource, Medicine, Diagnostic, IT component and 12 comprehensive primary health care services. The data was collected and analysis is being done by using SPSS software. Results: Out of 32 HWC-SHCs, 6 (18.75% ) were catering the services for the population as per the norms i.e. 3000- 5000. In the present study, 19 (59.4%) boundary wall, and 21 (65.6%) of SCs had wellness space. There were 31 (96.9%) of SCs had labor room, and 14 (43.8 %) had newborn care corner (NBCC). In this study, 21.9% Grievance board and 100% of IEC were present at the studied subcentres. It was observed that 31(96.9%) SCs had water, 27 (84.4%) had electricity supply and 1 (3.1%) of SCs had power backup. Separate public utilities for males and females were available in 2(6.3%) of the study centres. Out of the study sub-centre, 28 (87.5%) residential facilities were available, out of which 24 (85%) were occupied. For diagnostic services, 53.1 % of study centres have sickle- cell rapid tests and none of the centres have VIA for Screening of cervical cancer. Conclusion: The finding of the study shows that there is a scarcity in the physical infrastructure, Human resource and lab-diagnostic services at the studied centres. The major factor contributing to the non-utilization of health services at the SCs was the lack of adequate infrastructure, and logistics available at these centres.

Logic modelling as hermeneutic praxis: Bringing knowledge systems into view during comprehensive primary health care planning for homelessness in Australia.

Logic modelling is used widely in health promotion planning for complex health and social problems. It is often undertaken collaboratively with stakeholders across sectors that hold and enact different institutional approaches. We use hermeneutic philosophy to explore how knowledge is 'lived' by - and unfolds differently for - cross-sectoral stakeholders during comprehensive primary healthcare service planning. An Organisational Action Research partnership was established with a non-government organisation designing comprehensive primary health care for individuals experiencing homelessness in Adelaide, Australia. Grey literature, stakeholder input, academic feedback, a targeted literature review and evidence synthesis were integrated in iterative cycles to inform and refine the logic model. Diverse knowledge systems are active when cross-sectoral stakeholders collaborate on logic models for comprehensive primary health care planning. Considering logic modelling as a hermeneutic praxis helps to foreground and explore these differences. In our case, divergent ideas emerged in how health/wellbeing and trust were conceptualised; language had different meanings across sectors; and the outcomes and data sought were nuanced for various collaborators. We explicate these methodological insights and also contribute our evidence-informed, collaboratively-derived model for design of a comprehensive primary health care service with populations experiencing homelessness. We outline the value of considering cross-sectoral logic modelling as hermeneutic praxis. Engaging with points of difference in cross-sectoral knowledge systems can strengthen logic modelling processes, partnerships and potential outcomes for complex and comprehensive primary health care services.

Assessment of Functioning of Health and Wellness Centers of Western Odisha: A Cross-Sectional Study.

Background The National Health Policy (NHP) 2017 of India recommends strengthening the delivery system of Primary Health Care through the establishment of Health & Wellness Centres (HWC) as the platform to deliver comprehensive primary health care services.HWCs are being set up as an upgraded version of existing sub-centers, primary health care centers, and urban primary health centers. This study was conducted to evaluate the functioning of health and wellness centers in Western Odisha. Objective To assess the availability of human resources, health care services, drug availability, lab services, and IT services at the health and wellness centers of Western Odisha. Methods Out of 10 districts of Western Odisha, two districts (Sambalpur and Deogarh) were selected for convenience, and a cross-sectional study was conducted from January 2021 to December 2022. All 43 health and wellness centers (35 rural primary health centers (PHCs) and eight urban PHCs) of the above two districts were included in the study. All relevant data were collected using a predesigned, pretested, and semi-structured questionnaire. Results The study showed that all 43 HWCs had good availability of pharmacists and lab technicians but less availability of medical officers, AYUSH medical officers, and staff nurses. Maternal and childhood services, family planning, and non-communicable disease (NCD) services were conducted regularly in all health and wellness centers, but basic oral health services and palliative care services were inadequate. All laboratory services like blood grouping, differential count/total leucocyte count, rapid test for pregnancy, urine albumin, urine routine examination/microscopic examination along with culture/sensitivity and water quality testing were done at urban PHC HWCs, whereas these lab services were less available at rural PHC HWCs.Drug groups like antipyretics, antihistaminic, antifungal, antihypertensive, oral hypoglycemic agent (OHA), antispasmodics, and antiseptic ointments were adequately available (>80%) at all urban and rural PHC HWCs. For IT support, appliances like desktops, internet facilities, and telephone facilitieswerefound to be present at all HWCs. Teleconsultation services were found to be available at 88% of urban PHC HWCs and 60% of rural PHC HWCs. ​Conclusion The study showed that infrastructure, human resources, and 12 service packages of health care and drugs should be addressed on a priority basis to achieve desired goals as envisaged by Ayushman Bharat to achieve the full potential of the health and wellness centers.

Urban health in India: from smaller steps to a big leap

The focus on urban health in India was majorly lagging in the initial years post-independence except in some specific areas like family planning during the 1st and 2nd Five Year Plans (FYPs). The subsequent FYPs too for the next ten to fifteen years did not witness any shift in focus to the diverse health-related problems in urban areas. The National Rural Health Mission in 2005 had a primary focus on rural health, with some initiatives taken up to expand health services in urban areas. However, the major milestone in urban health was the launch of the National Urban Health Mission (NUHM) in 2013, wherein urban health in India got centre stage. The COVID-19 pandemic led to an accelerated response in strengthening the health systems across the country including health infrastructure in urban areas. Overall, it can be said that urban health in the country is currently undergoing major transitions. Despite there being several issues, the reforms for assured comprehensive primary health care services seem promising in improving the status of health in urban India. Convergence with key stakeholders and other sectors beyond health would be the key to bridging the gap in addressing social determinants of health, social protection for migrants and floating population and focusing on environmental protection. Such actions would leverage enhanced health access of urban poor to quality and equitable healthcare services. The paper focuses on government policies that began prioritising urban health, the limitations of present health systems, and the roadmap to construct a much-needed future foundation for improved health outcomes in urban India.

VOICE–Validating Outcomes by Including Consumer Experience: A Study Protocol to Develop a Patient Reported Experience Measure for Aboriginal and Torres Strait Islander Peoples Accessing Primary Health Care

Aboriginal and Torres Strait Islander peoples' (hereafter respectfully referred to as Indigenous Australians) experiences of health care are shaped by historical, social and cultural factors, with cultural security critical to effective care provision and engagement between services and community. Positive patient experiences are associated with better health outcomes. Consequently, it is an accreditation requirement that primary health care (PHC) services must formally gather and respond to patient feedback. However, currently available patient feedback tools were not developed with Indigenous Australians, and do not reflect their values and world views. Existing tools do not capture important experiences of care of Indigenous Australians in PHC settings, nor return information that assists services to improve care. Consistent with the principles of Indigenous Data Sovereignty, we will co-design and validate an Indigenous-specific Patient Reported Experience Measure (PREM) that produces data by and for community, suitable for use in quality improvement in comprehensive PHC services. This paper presents the protocol of the study, outlining the rationale, methodologies and associated activities that are being applied in developing the PREM. Briefly, guided by an Aboriginal and Torres Strait Islander Advisory Group, our team of Indigenous and non-Indigenous researchers, service providers and policy makers will use a combination of Indigenous methodologies, participatory, and traditional western techniques for scale development. We will engage PHC service staff and communities in eight selected sites across remote, regional, and metropolitan communities in Australia for iterative cycles of data collection and feedback throughout the research process. Yarning Circles with community members will identify core concepts to develop an "Experience of Care Framework", which will be used to develop items for the PREM. Staff members will be interviewed regarding desirable characteristics and feasibility considerations for the PREM. The PREM will undergo cognitive and psychometric testing.

The First Year of the COVID-19 Pandemic: Changes in Preventive Services in Community Health Centers

IntroductionCommunity Health Centers provide comprehensive primary healthcare services to many underserved populations. It is unknown how routine preventive and chronic care services in Community Health Centers may have changed nationwide during the COVID-19 pandemic.MethodsThe 2014–2020 Health Resources and Services Administration Uniform Data System of Community Health Centers was used, and data analysis was conducted from November 2021 to May 2022. Data for clinical quality measures in 2020 were treated as during the pandemic, whereas receipt of care in 2019 and before were treated as before the pandemic. Outcomes included 6 clinical quality measures of being up to date for colorectal cancer screening, cervical cancer screening, tobacco screening and cessation counseling, BMI screening and follow-up, depression screening and follow-up, and aspirin use for ischemic vascular disease. A mixed effects regression model was used to estimate changes in measures by year.ResultsBetween 2019 and 2020, receipt of preventive services declined for each of the 6 clinical quality measures: from 40.8% to 37.7% for colorectal cancer screening, from 48.8% to 44.9% for cervical cancer screening, from 85.8% to 83.4% for tobacco screening and cessation counseling, from 70.7% to 65.4% for BMI screening and follow-up, from 71.1% to 64.9% for depression screening and follow-up, and from 81.5% to 79.4% for aspirin use for ischemic vascular disease.ConclusionsReceipt of preventive services in Community Health Centers declined during the COVID-19 pandemic for each of the 6 clinical quality measures considered in the study. Immediate action is required to support ongoing high-quality, primary healthcare services in Community Health Centers across the nation.

Changing roles of frontline workers (FLWs) at health and wellness centres of south-west Bihar

Background: Ayushman Bharat Program was announced by Government of India in February 2018 with a vision, which is supposed to deliver comprehensive primary health care services to the entire population. Objectives: To obtain views of FLWs about their changing role at health & wellness centre and the challenges being faced by them in service delivery. Methods: A qualitative study done in 10 Health and wellness centres selected nearby Narayan Medical College & Hospital of Rohtas District of Bihar. The frontline workers posted in the selected HWCs were the study participants. Total duration of the study was 10 months. IDI of FLWs were done and the analysis of the verbatims was done using ATLAS-Ti (Free trial version) software. Results: After analysis of the verbatims two broad themes were made and there were several domains & codes under which the result was stated. It was observed that the frontline workers posted at the selected health & wellness centres were aware of the expanded range of services like yoga, school health, geriatric & palliative care being provided but they were also facing some challenges like manpower, equipment, working hour in service delivery.

BPSS Award

BPSS Award

Role of family physicians in providing primary healthcare during COVID-19 pandemic.

According to the World Health Organization, over 41 million cases of COVID-19 and 1 million deaths have been reported globally. More than 7 million cases of coronavirus have been reported in India alone. The growing number of cases of coronavirus worldwide poses numerous challenges to the country's current healthcare delivery system, especially in developing nations such as India. In such a situation, the task of maintaining continuity in the provision of comprehensive primary healthcare services in the community becomes a big challenge. This article discusses how family physicians can help to augment the healthcare system at the time of pandemic by providing easily accessible, holistic healthcare and by use of telemedicine. It also talks about the need to mainstream family medicine into the undergraduate and postgraduate medical curriculum and establish a robust network of family physicians trained in outbreak response and disease preparedness. For this study we looked for all papers with the terms 'Family physician', 'COVID-19', 'pandemic', and 'Primary health care'. Databases searched include PubMed, Google Scholar and DOAJ, using key words - family physician, family medicine, primary healthcare, COVID-19, and pandemic in different combinations.

Study Protocol for Process Evaluation of Health and Wellness Center Programme in Bhandara District of Maharashtra

Background: Ayushman Bharat programme, which was started by Government of India in 2018-19, has two components. First component is up gradation of existing primary health centres and sub centres in to Health and Wellness centers (HWCs), which will deliver comprehensive primary health care services at government facility level in rural area within no more than 30 minutes. Non-Communicable disease services is the integral part of comprehensive primary care. This study aims to assess availability and readiness of Health and Wellness centres at sub centres for provision of Non communicable disease Services in rural area of Bhandara district and to assess utilization of Non communicable disease Services in rural area of Bhandara district.
 Methodology: This implementation research will be conducted in Health and Wellness Sub centers from rural areas of Bhandara district. It will include the facility assessment of Sub centers. Household survey will be conducted by a stratified multi-stage sampling design using Digital questionnaire Standardized and validated Facility survey Tool, Service delivery Tool and Household survey Tools. Data will be analyzed using STATA-14 software.
 Expected Results: Increase in coverage and utilization of Non communicable disease Services in Health and Wellness Centre Subcenters in rural area and reduction in out of pocket expenditure of villagers is expected.
 Conclusion: The proposed component of NCD services matches well with health and wellness programme targets in district and is helpful in delivery of non-communicable disease services in rural areas.

Steps towards Universal Health Coverage through Health and Wellness Center under Ayushman Bharat Programme Delivering Comprehensive Primary Health Care in Bhandara District

Background: In 2018-19 as recommended by National Health Policy an Ambitious health care scheme as Ayushman Bharat programme was started by Government of India steps toward the Universal health coverage. Ayushman Bharat is also known as Healthy India having two major component. Creation of Health and Wellness Centres and Pradhan Mantri Jan Arogya Yojana (PM-JAY). Comprehensive primary health care services will be delivered up gradation of existing health facility in various 10 core area and 13 different types of health services will be delivered at HWC health facility.
 Progress in Health and Wellness under Ayushman Bharat Programme: First HWC was inaugurated by GOI in state of Chhattisgarh within Bijapur district at jangla village of Bhairamgarh Taluka on On 18th April 2018. Till 06th Feb 2021 total 58961 Health and wellness cneters are operational in India and In Maharashtra total 8423 Health and wellness cneters are operational where in Bhandara district total 177 Health and wellness cneters are operational which include 143 SHC Health and wellness center, 33 PHC Health and wellness center and 1 UPHC Health and wellness center.
 Achievements in Health and Wellness Center: In Bhandara district 98% of Medical Officer, 90% of Staff Nurse, 93% of MPW Female, 88% of MPW Male and 99% of ASHA trained NPCDCS Programme. Where 10,69,219 screening test for Hypertension and 10,81,901 screening test for Diabetes conducted in HWC health facility. Total 4097 Yoga sessions conducted at HWC health facility.
 Conclusion: 13 different types of health services which are delivered at Health and Wellness Centres health facility under Ayushman Bharat is step towards the Unvarsal health coverage provision in rural area of bhandara district.

The need to prioritise childhood tuberculosis case detection

The need to prioritise childhood tuberculosis case detection

Assessment of functioning of Health and Wellness Centers in a district of Western Gujarat

Introduction: Ayushman Bharat is an attempt to move from a selective approach to health care to deliver comprehensive range of services spanning preventive, promotive, curative, rehabilitative and palliative care. To ensure delivery of Comprehensive Primary Health Care services, existing Sub Health Centers and Primary Health Centers are converted to Health and Wellness Centers (HWC).Objective: The main objective of our study is to assess functionality of HWCs in various blocks of Jamnagar district and to determine prevalence of non-communicable diseases in the community. It is a cross sectional study conducted between August-December 2019. A semi-structured proforma containing questionnaires was used for data collection. Data were entered and analyzed in Microsoft Excel version 2007.There are 58 health and wellness centers in Jamnagar, of which, we randomly select 50% of centers from each taluka, so total of 29 HWCs selected, four among them could not be assessed, so our final sample size would be 25. Result: Our study observed satisfactory performance of health and wellness centres except barring a few indicators. Community health officers and multipurpose workers are available in about majority of centers. The study found that the prevalence of hypertension, diabetes mellitus, oral Cancer, breast cancer, and cervical Cancer was 20.44%, 11.03%, 0.73% 0.45% and 1.02% respectively. Staff at the centers was in need of vital training like Techo, refresher training etc. Conclusion: Majority of health and wellness centers are functioning as per the guidelines laid down by the Government barring a few services like laughing club, music therapy, meditation etc.

“Living long in India”– India’s progress towards Universal Health Coverage

Abstract Issue There are multiple small health insurance schemes throughout India. However, high out-of-pocket (OOP) expenditures, unaffordable and inequitable access to healthcare services still persist. In an attempt to address these issues and achieve Universal Health Coverage (UHC), India launched the healthcare scheme ‘Ayushman Bharat’ (“long live India”) in 2018. Description The Ayushman Bharat (AB) scheme has two components which include 1) transforming the existing primary healthcare centers (PHC) under the control of State Governments and 2) the National Health Protection Scheme (NHPS) also known as “ModiCare” - a health insurance. The scheme aims to transform nearly 150.000 PHCs to deliver comprehensive primary healthcare services across the country by 2022. NHPS covers the costs of almost all secondary and many tertiary care procedures of about 40% of the total Indian population. The coverage will be approximately €6.400 per year per beneficiary family; 60% of the costs are borne by the Centre and 40% by the States. Results Approximately €127 million have already been allocated by the Centre towards the AB scheme for the fiscal year 2018-19. Till date, around 29 million health insurance cards have been issued, approximately 1,8 million beneficiaries have been admitted and around 15.291 hospitals have been empaneled under NHPS. However, there is no data available validating the usage of the health services yet. Few Indian states are yet to implement the AB scheme. Lessons For the first time, attempts have been made to provide affordable healthcare services to the Indian population under a single common initiative. However, the AB scheme fails to cover outpatient health services, which are an important part of OOP expenses in India. Main message The effort to launch Ayushman Bharat in a big, democratic and diverse country like India has to be lauded, which not only aims to make healthcare services affordable but also aligns itself to the concept of UHC.

The impact of the introduction of a point-of-care haematology analyser in a New Zealand rural hospital with no onsite laboratory.

Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital. This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost-benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted. Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to 'make it work'. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost-benefit analysis showed a clear cost saving to the health system as a whole. This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

Informing NCD control efforts in India on the eve of Ayushman Bharat

Informing NCD control efforts in India on the eve of Ayushman Bharat

Ayushman Bharat Yojana: a memorable health initiative for Indians

India in a state of epidemiological health transition i.e shifting from communicable to non-communicable diseases. The annually 3.2% Indians falling below the poverty line and three forth Indians spending their entire income on health care and purchasing drugs. The government of India announced a Ayushman Bharat Yojana- National Health Protection Scheme (AB-NHPM) in the year 2018. The aim of this programme is to providing a service to create a healthy, capable and content new India and two goals are to creating a network of health and wellness infrastructure across the nation to deliver comprehensive primary healthcare services and to provide health insurance cover to at least 40% of India's population which is deprived of secondary and tertiary care services. This Yojana will be implemented through Health and Wellness Centres that are to be developed in the primary health centre or sub-centre in the village and that will provide preventive, promotive, and curative care for non-communicable diseases, dental, mental, geriatric care, palliative care, etc. These centres would be equipped with basic medical tests for hypertension, diabetic and cancer and they are connected to the district hospital for advanced tele-medical consultations. The government has aims to set up 1,50,000 health and wellness centres across the country by the year 2022.

Interprofessional teamwork in comprehensive primary healthcare services: Findings from a mixed methods study

ABSTRACTThis article draws on data from a 5-year project that examined the effectiveness of Comprehensive primary healthcare (CPHC) in local communities. A hallmark of CPHC services is interprofessional teamwork. Drawing from this study, our article presents factors that enabled, or hindered, healthcare teams working interprofessionally in Australian primary healthcare (PHC) services. The article reports on the experiences of teams working in six Australian PHC services (four managed by state governments, one non-government sexual health organisation, and one Aboriginal community-controlled health service) during a time of significant health sector restructure. Findings are drawn from two key methods: an online survey of practitioners and managers (n = 154), and interviews with managers and practitioners (n = 60) from the six study sites. The majority of survey respondents worked with other health professionals in their service to provide interprofessional care to clients. Processes included formal team meetings, case conferencing, referring clients to other health professionals if needed, informal communication with other health professionals about clients, and team-based delivery of care. A range of interrelated factors affected interprofessional work at the services, from contextual, organisational, processual, and relational domains. Funding cuts and policy changes that saw a reorientation and re-medicalisation of South Australian services undermined interprofessional work, while a shared CPHC culture and commitment among some staff was helpful in resisting some of these effects. The co-location of services was a factor in PHC teams working interprofessionally and not only enabled some PHC teams to work more interprofessionally but also created barriers to interprofessional teamwork through disruption resulting from restructuring of services. Our study indicates the importance of decision makers taking into account the potential effects of policy and structural changes on interprofessional teamwork. Decision makers should strive to minimise unintended negative effects of changes on the functioning of interprofessional teams.

Exploring the Role of the Public and Private Funded Primary Health Care Facilities for Children in a Pluralistic Health Care Setting of Barbados: One of the English Caribbean Countries.

Background:The major objectives of this study were to evaluate the existing primary health care service provisions in the public and private sector and utilization of the services, and to assess the existing manpower and material resources.Methods:Data were collected through interviews with the primary health care providers. Data were also collected from the records maintained at the polyclinics and the Ministry of Health Statistics. An analysis and discussion of all the available data was conducted to develop a comprehensive primary health care service utilization and resources inventory at the polyclinics. Similar data were collected from the primary care providers in the private sector.Results:In the public sector, there are 8 polyclinics that provide primary health care to the children. All the polyclinics have immunization services and curative acute care. Some of the polyclinics have a range of services, including dental care, eye care, and rehabilitative care services that common to both adults and children. In the private sector, primary health care is delivered through the 76 private office and of the individual physicians and 11 grouped private practices. All of the private offices and group practices have curative acute care for children and some of the offices have immunization services. Over all 87.5% of all the immunizations were done at the polyclinics. Over all 60.1% of acute care visits were to the private sector and 39.9% to the public sector. In the public sector, 59.5% were under 5 years children while 40.5% were 5 years or older. The corresponding figures in the private care settings were 80.9% and 11.9%.Conclusions:The findings demonstrate the complimentary role of the public and the private sector in the primary health care of children in this country. While the private sector has a major role in the curative acute care of children, the public sector plays a pivotal role in the immunization services.

The World Hypertension League challenges hypertension and cardiovascular organizations to develop strategic plans for the prevention and control of hypertension.

The World Hypertension League challenges hypertension and cardiovascular organizations to develop strategic plans for the prevention and control of hypertension.