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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2008  |  Volume : 19  |  Issue : 6  |  Page : 990-996
Hypertension care at primary health care centers: A report from Abha, Saudi Arabia


1 Department of Internal Medicine, King Khalid University, Aseer Region, Saudi Arabia
2 Department of Family and Community Medicine, King Khalid University, Aseer Region, Saudi Arabia
3 Joint Programme of Family Medicine, King Khalid University, Aseer Region, Saudi Arabia

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   Abstract 

It is well known that effective management of hypertension reduces the incidence of myo­cardial infarction, stroke and vascular complications. The Ministry of Health, Kingdom of Saudi Arabia, introduced the Quality Assurance Guidelines with the hope to improve the management of hypertension in its centers. We conducted an audit of two Primary Health Care Centers namely, Al-Manhal (MPHCC) and Al-Numais (NPHCC), to evaluate how well hypertension was managened at these centers. A check list was derived from the Quality Assurance Manual to audit the process and to assess the health outcome. A retrospective study on a chosen sample of 120 files of hypertensive patients, out of 256 from both the Primary Health Care Centers was performed, during the last three months of the year 2000. Results showed that 61% of the patients were between 45-64 years of age, 56% were females, 85% were married, 54% were illiterate and 7.5% were smokers. A total of 92% of the patients had primary hypertension and 25% had a positive family history of hypertension. Beta-blockers were the most commonly used drugs in both the centers. Although the recording of the information was not perfect, there was no statistical difference in the socio-demongraphic data and also the means of the total score in both the centres. On the other hand, carrying out the important procedures for hypertensive patients was found to be better at MPHCC in com­parison to NPHCC (p < 0.05). The commonly missed procedures were chest x-rays, electrolytes and ECG. Hypertension was well controlled in 63% of the patients, 58% were found to have obesity, 9% suffered from hypertension-related complications while almost 50% had good compliance to appointment in both the centers. Our study reveals that the process of hypertension care at the two Primary Health Care Centres in Aseer region was not in accordance with the recommended national standards. The reasons include lack of updating systems, recall system and provision of laboratory services and all these factors need to be addressed to improve care.

How to cite this article:
Al-Homrany MA, Khan MY, Al-Khaldi YM, Al-Gelban KS, Al-Amri HS. Hypertension care at primary health care centers: A report from Abha, Saudi Arabia. Saudi J Kidney Dis Transpl 2008;19:990-6

How to cite this URL:
Al-Homrany MA, Khan MY, Al-Khaldi YM, Al-Gelban KS, Al-Amri HS. Hypertension care at primary health care centers: A report from Abha, Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Sep 15];19:990-6. Available from: http://www.sjkdt.org/text.asp?2008/19/6/990/43482

   Introduction Top


Hypertension (HTN) is a chronic condition of concern due to its role in the causation of coronary artery disease, stroke and other vas­cular complications. It is the commonest car­diovascular disorder, posing a major public health challenge to the population at large.

The prevalence of arterial HTN is increasing globally. In developed countries like the United Kingdom and the United States of America, 37% and 25% of their adults had hypertension respectively [1],[2] while the reported prevalence was 28.5% in Kuwait [3] and 26.3% in Egypt. [4] Studies have revealed that the prevalence of HTN is increasing in Saudi Arabia. [5],[6],[7],[8],[9] The highest prevalence of HTN in Saudi Arabia has been reported by Kalantan et al from the Al-Qasim region (30%) [10] while Al-Nozha et al reported a prevalence in the age-group of 30­70 years in both sexes was 26.1%. [11] In the Aseer region, the prevalence of HTN ranged from 2.6 to 11.1%. [5],[6],[12]

Wilber and Barrow in 1972, pointed out that only half of the hypertensive subjects in the general population of most of the developed countries were aware of the condition, aware of the problem, were being treated, and only about half of those treated were considered adequately treated/controlled. The situation may be even worse in developing countries. [13] Several studies have reported that most of the known hypertensives were poorly controlled, [14],[15],[16] and that physicians and nurses who care for the hypertensive patients did not have ade­quate knowledge regarding the management of HTN. [17],[18] In order to introduce good quality health care, the Ministry of Health in Saudi Arabia, in co-operation with WHO- Regional office issued a practical manual in Primary Health Care (PHC) which specified details of HTN care. [19] There are few audit studies concerned with the process, outcome and struc­tures for HTN care in the Kingdom of Saudi Arabia. [20],[21] The objective of this study was to audit and compare the process and outcome of HTN care at primary Health Care Centers (PHCCs) in Abha, Saudi Arabia, using the guidelines of Quality Assurance.


   Materials and Methods Top


Aseer is one of the thirteen administrative regions of Saudi Arabia with a total population of 1.2 million. The health services in this region are provided through a network of PHCCs and general hospitals and one central hospital. In order to make health services accessible to every one, the region is divided into 16 health sectors. Each sector consists of a group of PHCCs and one general hospital. Those patients who need secondary care are referred to general hospitals. Hypertension care in Aseer Region is provided by the governmental agencies (Ministry of Health, Ministry of Defence and Aviation, Ministry of Interior) and by private hospitals and poly­clinics.

This audit study was conducted by students of the sixth level in the medical school at the King Khalid University, under the direct su­pervision of the staff of the department of Family and Community Medicine, in the year 2000. Two out of six urban PHCCs in Abha city, Al-Manhal PHCC and Al-Numais PHCC, were randomly selected for this study. Half of the hypertension files at each PHCC were ran­domly selected by simple randomization me­thod. Assessment of the process of HTN care was carried out by using a check list derived from Quality Assurance Manual. [19] The check list included the following data: age, marital status, education status, employment, duration of HTN, family history of HTN, smoking his­tory, treatment received, recorded weight, re­corded blood pressure, and laboratory tests including urine analysis, fasting blood sugar, kidney function test, lipid profile, electrolytes, ECG, chest X-ray and optic fundus exami­nation. Presence or recording of each item was given one point on two point scale (0 and 1). Process of care was considered as good if the total score was > 6 out of 10 points. Blood pressure was considered well controlled if the last reading was < 140/90 mmHg and poorly controlled if it was above 140/90 mmHg.

Data of the selected files were entered and analyzed by using SPSS. Statistical analysis was carried out by using the appropriate tests and p value, 0.05 was considered significant.


   Results Top


The total population of MPHCC and NPHCC were 13464 and 16769 while the total number of the hypertensive patients at MPHCC and NPHCC were 140 and 116, respectively. Cha­racteristics of the selected patient are shown in [Table 1]. Sixty-one percent of patients were between 45 and 64 years old, 56% were fe­males, 85% were married, 54% were illiterate and 7.5% were smokers; 92%.of patients had primary hypertension and more than three­quarters of the patients had negative family history for HTN. Beta-blockers were the most commonly used drugs in both centers.

[Table 2] compares the process of care in the two centers. Educational status was the most commonly missed socio-demographic data in NPHCC while recording the names of drugs was the most common missed item in MPHCC. Generally, there was no statistical difference regarding the recording of all the socio-demographic data and also the mean of the total score in both centers. However, carrying out the important relevant procedures for hypertensive patients was found to be better at MPHCC in comparison to NPHCC (P < 0.05). The most common missed procedures were chest x-rays, electrolytes and ECG.

[Table 3] depicts some hypertension-related outcomes. HTN was well controlled in 63% of patients, 58% were found to have obesity, 9% suffered from HTN-related complications while almost 50% had good compliance to appoint­ments in both centers.


   Discussion Top


Auditing of common and chronic health pro­blems such as diabetes and hypertension is essential in order to identify the obstacles and to suggest the practical solutions. To our cu­rrent knowledge, this is the first audit of hyper­tension care at PHCC level in Aseer region, located in the southwest of Saudi Arabia.

This study showed that many socio-demo­graphic data were not recorded which reflected that updating of the hypertensive files was not working. Revising all files and completing all missed information can be carried out by the nurse responsible for hypertension care in this PHCCs. Process of care is integration between human and non-human resources to get good outcome. Auditing of hypertension care in both centers was less than acceptable as the total score was lower than six out of a maximum of ten points. However, the Manhal PHCC got better score (5.9) compared to Numais PHCC (4.7), a difference which was significant (p< 0.05).

It was obvious that most of the items that could be carried out at PHCC level such as blood sugar and urine analysis were better in both centers in comparison to the items which were supposed to be done at hospital level such as electrolytes, lipids, ECG and fundos­copy. These figures were similar to those reported for diabetics who also need the same investigations. [22] In a study conducted in Riyadh, it was found out that most of these investigations were carried out smoothly be­cause these resources were available and accessible for hypertensive patients at that setting. [20]

In order to introduce a good quality of care for hypertensives in PHCCs, it is vital to provide them with a well equipped laboratory which can do the essential investigations such as kidney function tests, lipid profile and electrolytes.

Hypertensive patients may develop retino­pathy especially if the control of hypertension is poor. As a result, it is recommended that hypertensive patients should undergo annual fundoscopy by an ophthalmologist. [20] This is achievable by either referring the patients to a general hospital or by training the PHCC phy­sicians to perform fundoscopy. The first choice may face many difficulties including shortage of staff and increased load as the number of patients increase each year. To make this option successful, good co-ordination between PHCCs and hospital should be implemented properly, as suggested by many workers in this regard. [23],[24],[25] The second choice is practical but needs good training of PHCC physicians to perform proper fundoscopy so that early cha­nges in the retina can be detected.

Good control of HTN is essential to minimize the long-term complications. In this study, we found that 63% of patients were having well controlled blood pressure (BP < 140/90 mm Hg). These findings were better than reported from other regions of Saudi Arabia (24.4%; 48.8%), USA (20%), UK (49%) but similar to the report from New Zealand (63%) and lower than that reported from Canada (90%). [15],[20],[26],[27],[28]

Hypertension is known to be associated with other co-morbidities such as diabetes and obe­sity. We found that 29% of the hypertensive patients in both centers were suffering from overweight and 58% were obese. These high figures should make the physicians working in PHCCs aware of the importance of life style changes (exercise and diet therapy) in the management of HTN through intensive health education programs.

Our study revealed that nine percent of the patients had complications directly attributable to HTN (stroke, CHD, retinopathy, nephro­pathy). These figures were similar to those reported by Al-Owayyed from Riyadh city. [20]

Compliance to appointment is very crucial to impart good care to any patient in general and to patients with chronic disorders in parti­cular. [28] This study showed that 25% of patient did not attend the PHCCs for a period longer than six months. However, defaulter rate at Manhal PHCC was lower than that in Numais PHCC (20% vs 32%). These figures were higher than those recommended by Quality Assurance Manual. [19] Solution to this problem could be easily done by activation of the recall system in the centers through the nurse in charge and by providing PHCCS with the necessary lab facilities and drugs, the lack of which may be contributing to the high de­faulter rate. Similar observations were made by other authors. [28]


   Conclusion Top


This study showed that the quality of HTN care at two large PHCCs in Aseer region was not acceptable and was not in accordance with the recommended national standards. The rea­sons for this include lack of updating system, recall system and essential lab investigations.

To overcome these obstacles, provision of well-equipped lab is strongly recommended activation of updating, recall.

 
   References Top

1.Primatesta P, Brookes M, Poulter NR. Improved hypertension management and control: Results from the Health Survey for England 1998. Hypertension 2001;38(4):827-32.  Back to cited text no. 1    
2.Mackenzie J, Pinger RR, Kotecki JE. An introduction to community health. 5th edition. Boston. Jones and Bartlett Publisher, 2005.  Back to cited text no. 2    
3.Zobaid M, Suresh CG, Thalib L, Rashed W. Differential distribution of risk factors and outcome of acute coronary syndrome in Kuwait: Three years experience Med Princ Pract 2004;13(2):63-8.  Back to cited text no. 3    
4.Ibrahim MM, Rizk H, Appel LJ, et al. Hypertension prevalence, awareness, treatment and control in Egypt, result from the National Hypertension Project (NHP). Hypertension 1995;26(6.1):886-90.  Back to cited text no. 4    
5.El-Hazmi MA, Warsy AS, Al-Swailem A, Al­Swailem AM. Prevalence of hypertension in adult Saudi population. Saudi Med J 1998; 19(2):117-22.  Back to cited text no. 5    
6.Al-Nozha MM, Osman AK. The prevalence of hypertension in different geographical regions of Saudi Arabia. Ann Saudi Med 1998; 18(5):401-7.  Back to cited text no. 6    
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8.Al-Nozha MM, El-Shabrawy M, Karrar A. A community-based study of hypertension in Riyadh region. J Saudi Heart Assoc 1993;5(1):25-30.  Back to cited text no. 8    
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10.Kalantan KA, Ashry GM, Al-Taweel AA, Ghani HM. Hypertension among attendants of Primary Health Care Centers in Al-Qasim region, Saudi Arabia. Saudi Med J 2001;22 (11):960-3.  Back to cited text no. 10    
11.Al-Nozha MM, Moheeb A, Arafah MR, et al. Hypertension in Saudi Arabia. Saudi Med J 2007;28(1):77-84.  Back to cited text no. 11    
12.Abolfotouh MA, Abu-Zeid HA, AbdelAziz M Alakija W, Mahfouz AA, Bassuni WA. Prevalence of hypertension in south-western Saudi Arabia. East Mediteranean Health J 1996;2(2):211-8.  Back to cited text no. 12    
13.Wilber JA, Barrow JG. Hypertension: a community problem. Am J Med 1972;52(5): 653-63.  Back to cited text no. 13    
14.Siddique S, Ogbeide DO, Karim A, Al-Khalifa I. Hypertension control in a community health centre at Riyadh, Saudi Arabia. Saudi Med J 2001;22(1):49-52.  Back to cited text no. 14    
15.Akbar DH, Al-Ghamdi AA. Is hypertension well controlled in hypertensive diabeties. Saudi Med J 2003;24(4):356-60.  Back to cited text no. 15    
16.Al-Rukban MO, Al-Sughair AM, Al-Baer BO. Management of hypertensive patients in pri­mary health care setting, auditing the practice. Saudi Med J 2007;28(1):85-90.  Back to cited text no. 16    
17.Elzubier AG, Al-Shahri MA. Drug control of hypertension in primary health care centers­registered patients, Al-Khobar, Saudi Arabia. J Fam Com Med 1997:4(2):47-53.  Back to cited text no. 17    
18.Al-Dharrab SA, Mangoud AM, Mohsen MF. Knowledge, attitude and practice(KAP) of pri­mary health care physicians and nurses towards hypertension: A study from Dammam, Saudi Arabia. J Fam Com Med 1996;3(2):57-63.  Back to cited text no. 18    
19.The Scientific Committee of quality assurance in primary health care. Quality Assurance in Primary Health Care Manual, Riyadh, 1994; 143-164.  Back to cited text no. 19    
20.Al-Owayyed A . Hypertension care in a family and community medicine department: An audit of process and outcome. Saudi Med J 1996; 17(1):18-25.  Back to cited text no. 20    
21.Al-Sharif AI, Al-Khaldi YM. Resource availa­bility for care of hypertensives at primary health care settings in Southwestren Saudi Arabia. Saudi Med J 2003;24(5):466-71.  Back to cited text no. 21    
22.Khattab MS, Al-Khaldi YM, Abolfotouh MA, Khan MY, Alakija W, Al-Tokhy M. Impact of diabetic program in a family practice setting in Asir region, Saudi Arabia. Diabetes Res 1998;33:115-27.  Back to cited text no. 22    
23.Khattab MS, Abolfotouh MA, Al-Khaldi YM, Khan MY. Studying the referral system in one family practice center in Saudi Arabia. Ann Saudi Med 1999;19(2):167-70.  Back to cited text no. 23    
24.Al-Khaldi YM, Khan MY, Khairallah SM. Audit of referral of diabetic patients to eye clinic from primary health care setting to Abha General Hospital in Aseer Region. Saudi Med J 2002;23(2):177-81.  Back to cited text no. 24    
25.Khattab M, Abolfotouh M, Alakija W, Humaidi M, Al-Tokhy M, Al-Khaldi YM. Audit of diabetic care in an academic family practice in Asir Region, Saudi Arabia. Diabetes Res 1996;31:243-54.  Back to cited text no. 25    
26.Ahmed ME, El-Awad IB. Blood Pressure Control and target organ complications among hypertensive patients in southern Saudi Arabia. East Med Hlth J 2001;(4/5)7:689-69.  Back to cited text no. 26    
27.Fahey T, Peters TJ. Clinical guidelines and the management of hypertension: a between - practice and guideline comparison. Br J Gen Pract 1997;47(424):729-30.  Back to cited text no. 27    
28.Al-Khaldi YM, Al-Jaser AM, Al-Gelban KS. Barriers to compliance among diabetics in Asir region. Saudi Med J 1999;20(12):951-3.  Back to cited text no. 28    

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Correspondence Address:
Mohd Yunus Khan
Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha
Saudi Arabia
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    Tables

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