Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 865 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 

Table of Contents   
RENAL DATA FROM THE ARAB WORLD  
Year : 2014  |  Volume : 25  |  Issue : 6  |  Page : 1328-1333
Hypertension care in Aseer region, Saudi Arabia: Barriers and solutions


1 Department of Public Health, General Directorate of Health Affairs, Aseer Region, Saudi Arabia
2 Department of Family Medicine and Research, General Directorate of Health Affairs, Aseer Region, Saudi Arabia

Click here for correspondence address and email

Date of Web Publication10-Nov-2014
 

   Abstract 

The aim of this study is to assess the current situation of hypertension (HTN) care, to explore the barriers and to suggest the practical solutions to improve the quality of HTN care in primary health care centers (PHCC) in the Aseer region, KSA. This cross-sectional study was conducted in PHCCs in this region in 2010. Data collection sheets used to achieve the aims of this study consisted of three checklists, the first one derived from the quality assurance manual and HTN records used at the PHCCs giving details of the structural base of HTN care. Satisfaction with HTN care was assessed by using a five-point Likert scale questionnaire, while the third part was assessed by a checklist designed for the HTN care processes. Data were coded, entered and analyzed using SPSS version 16. The total number of HTN patients registered at PHCCs in Aseer region was 23,156 patients. Of them, 15,942 (69%) had files at PHCCs. Most of the essential infrastructures were acceptable, except training of doctors and nurses on HTN, which were 75% and 89%, respectively. About 40% of patients were on Beta blockers or ACE inhibitors and 30% were being given Aspirin in addition. HTN was uncontrolled among 45% of patients, while the defaulter rate was 22%. The rates of complications ranged from 0.7% for stroke to 7% for ischemic heart diseases. It was found that more than one-third of the patients had obesity and diabetes, while 10% suffered from dyslipidemia. Health teams were unsatisfied with the community participation (43%), patient compliance with appointment (32%) and coordination with hospitals (20%). They were satisfied with the health team (85%), while satisfaction with other items ranged from 60% to 75%. This study revealed that HTN patients received insufficient care, which could be attributed to many different barriers. In order to improve the quality of HTN care for HTN, these barriers should be overcome by implementation of the recommendations.

How to cite this article:
Al-Saleem SA, Al-Shahrani A, Al-Khaldi YM. Hypertension care in Aseer region, Saudi Arabia: Barriers and solutions. Saudi J Kidney Dis Transpl 2014;25:1328-33

How to cite this URL:
Al-Saleem SA, Al-Shahrani A, Al-Khaldi YM. Hypertension care in Aseer region, Saudi Arabia: Barriers and solutions. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2020 May 31];25:1328-33. Available from: http://www.sjkdt.org/text.asp?2014/25/6/1328/144313

   Introduction Top


Hypertension (HTN) is known to be one of the most common chronic health problems that affects about one-quarter of the adult Saudi population. [1],[2] However, few studies showed that HTN patients received inadequate health care. [3],[4] Lack of essential infrastructure for HTN care, poor compliance of patients to medical advice and non-adherence of phy­sicians with clinical guidelines may contribute to poor HTN control. [5],[6],[7],[8] In order to have a clear and comprehensive picture about HTN care, it is vital to assess the current situation of HTN care from different angles.

The objectives of this study were to assess the current situation of HTN care, to explore the barriers and to suggest the practical solu­tions to improve the quality of HTN care in primary health care centers (PHCCs) in the Aseer region, Saudi Arabia.


   Materials and Methods Top


This study was conducted by the end of the year 2010 in Aseer region, southwest of Saudi Arabia. The Aseer region is divided into 20 health sectors. Each sector consists of five to 12 PHCCs. Each center provides primary health care services, including preventive and curative services. HTN care in PHCC was introduced by primary health care physicians and nurses who were given special training courses in HTN. In order to attain the objec­tives of this study, the researchers designed checklists derived from the quality assurance manual and HTN records used at PHCCs. [9] The first checklist contained data related to the total population of the PHCC, number of HTN patients and gender in addition to items of infrastructures, namely availability of mini-clinic, well-trained doctor/nurse, specific day for HTN, records, formats, appointment sys­tem, defaulter system, glucometer, reagents for urine and blood, health education materials and viability of essential drugs.

Satisfaction of health care providers regar­ding HTN care was assessed by using a five-point Likert scale for the following items: Patient cooperation, compliance of patients with appointment system, cooperation of health team to care for HTN, availability of reagents at laboratory, availability of essential drugs for HTN, availability of health education mate­rials, coordination with hospitals, recall sys­tem, appointment system, training of health team and community participation.

This part of the questionnaire was completed by doctors working at HTN mini-clinics at PHCCs. In order to conduct this study, the investigators invited all the technical super­visors of the health sectors and trained them on "how to fill the questionnaire." The tech­nical supervisors invited the doctors and nur­ses who work in chronic diseases' mini-clinic and explained for them on how to complete the questionnaire.

Regarding the process of care, each indivi­dual HTN file was reviewed by the nurse and the doctor working in mini-clinics using ano­ther checklist that contained the following items: Demographic data, co-morbidities, num­ber of visits in the previous 3, 6 and 12 months, results of clinical examination if performed, results of the relevant investigations if per­formed and the last three readings of blood pressure. Outcomes were assessed using the following indicators: Degree of HTN control, which was considered as good if the last available reading was less than 140/90 mm Hg, rate of different complications and rate of defaulters for more than six months. [9] Data of the questionnaire were coded and entered into a personal computer provided with the statis­tical package for social sciences (SPSS) pro­gram, which was used for statistical analysis. Appropriate statistical tests were used accor­dingly and considered significant if the P-value was less than 0.05.

Two months later, a PHCCs club was con­ducted and the results were presented and discussed with the technical supervisors of the health sectors and PHCC doctors in order to show the current situation and to suggest practical solutions.


   Results Top


The total HTN patients registered at PHCCs in Aseer region was 23,156 patients. Of them, 15,942 (69%) patients had files at PHCC. More than half of the HTN patients were female, And most of them were Saudi and married while less than 2% were smokers, as shown in [Table 1].
Table 1: Profile of hypertension patients at the PHCC, Aseer region, KSA, 2010 (N = 23156).

Click here to view


The availability of infrastructure was as fol­lows: 75% of doctors and 89% of nurses were trained on HTN care, mini-clinics were avai­lable in 95% of the centers, appointment sys­tem in 99% of centers, 98% of PHCC had a HTN register while 97% had a recall system; HTN files, glucometer, and urine sticks were available in all centers.

Items of process of care were as follows: Face to face health education were documen­ted in 80-83% of patients' file for the follo­wing items: basic concepts of HTN, diet, exer­cise, drugs and important of compliance with appointment. Measuring weight and calcula­ting body mass index was performed for 72%, conducting clinical examination in 53%, measuring blood glucose in 65%, checking lipid in 41%, checking urea/creatinine in 33%, urine analysis in 34%, ECG on 30% and fundoscopy on 25% patients. Regarding prescribing, about 40% of the patients were on beta blockers or ACE inhibitors and 30% were given aspirin.

[Table 2] displays the outcomes of HTN care. HTN was uncontrolled among 45% of the pa­tients, while the defaulter rate was 22%. Rates of complications ranged from 0.7% for stroke to 7% for IHD. Regarding associated co-mor­bidities, it was found that more than one-third of the patients had obesity and diabetes, while 10% had dyslipidemia.
Table 2: Outcomes of hypertension care, PHCC, Aseer region, KSA, 2010.

Click here to view


Regarding satisfaction of health care pro­viders, it was found that they were unsatisfied with the community participation (43%), pa­tient compliance with appointment (32%) and coordination with hospitals (20%). It was found to be very satisfactory with the health team (85%), while satisfaction with other items ranged from 60% to 75%.


   Discussion Top


Optimal HTN care is based on three impor­tant pillars: Patients, physicians and health care system. Patients should comply with diffe­rent medical advices, doctors should manage patients depending on the best available know­ledge and health care system should ensure the availability of all essential infrastructures and training of health care providers. This study was the first comprehensive one that included most of PHCCs in Aseer region and involved the health care providers and decision makers to make practical and focused recommen­dations. In this study, it is obvious that about 31% of HTN patients did not have an HTN file at the PHCC. This defect was due to the fact that many patients received medical care from different medical sectors such as military and private hospitals. In this regard, the impor­tance of effective coordination with all medi­cal sectors to ensure that those patients comply with appointments regularly was emphasized.

The second issue discussed by the partici­pants was recording in patients' files. In this aspect, it was found that most of the demo­graphic data were not completely recorded. Such findings have been noticed in previous studies. [3],[4] Discussing these defects showed no definite reason, and they recommended that the demographic data should be completed by the nurses at mini-clinics while recording the smoking status, and a list of health problems should be carried out by doctors.

The third important issue regarding HTN care was training; it was found that one-quarter of the doctors and 11% of the nurses did not have training on "HTN care." This fin­ding is in agreement with the study conducted by Al-Gelban et al, which concluded that PHCCs should receive training on HTN guidelines. [8] In this regard, it was agreed to conduct a training course on HTN care for all those health care providers who did not attend a training course.

The fourth subject that was discussed was the availability of infrastructure. It was obvious that most of the items were available com­pared with the studies by Al-Sharif and Al-Khaldi in 2001. [5],[6] This improvement could be explained by the fact that the Ministry of Health was giving priority for caring of chronic di­seases during the last few years.

The process of care is the second pillar of quality of care, as mentioned in the manual of quality assurance in the PHCC. [9] In this study, the process of care was divided into educa­tional, physical examination, investigations and prescribing. More than 80% of the patients received health education about the main elements of HTN and more than 50% were had their physical examination performed. In spite of that, all patients should be educated and examined annually; these defects could be due to a lack of recording in the patients' files either because of overflow of patients or inade­quate care by doctors. Whatever the reasons, it was agreed that documentation is mandatory and those health care providers who are reluc­tant to do this properly should be accounted.

Checking for lipid, urine analysis and kidney function tests was performed for less than 50% of the total patients, while checking for glu­cose was performed for 65% of the patients. These low figures are similar to previous studies. [3],[4] Regarding fundus examination and ECG, only 25% and 30% of patients had such procedures performed on them, which is compa­rable to previous studies from Aseer region. [3],[4]

The reasons of such low figures were ex­plored, and it was because most of PHCCs in the region lack laboratories. In addition to that, the concerned hospitals were uncooperative to allow for direct access to laboratory facilities and no priority is given for hypertensive pa­tients for fundoscopy. These difficulties have been reported since a long time by many investigators. [3],[4],[5],[6] In order to overcome these barriers, it was suggested to conduct urgent meetings between the directors of PHCC affairs and directors of hospitals in the Asser region to discuss this issue and to take the appropriate action. For a long-term solution to manage these challenges, large PHCCs should be provided with facilities such as laboratories and other relevant diagnostic facilities.

In spite of the efficacy of diuretics and cal­cium channel blockers in the management of HTN, the study showed that they were pres­cribed for less than 10% of patients compared with ACE inhibitors and beta blockers (40% of patients). These findings did not differ from those found by Al-Menawar, [7] but were higher than that reported from Oman (34% and 25%, respectively) [10] but differed from those noticed in a study from South Africa, which revealed that 81%, 72%, 55% and 4% received diu­retics, ACE inhibitors, CCB and beta blockers, respectively. [11] These big differences could be explained by many factors such as availability of drugs as well as preference of physicians and patients. Whatever the reason, PHCC doc­tors should be alert regarding the current recommendations regarding the drugs of first choice, particularly in those patients who suffer from multiple problems and use mul­tiple drugs.

The main goal of HTN care is to get good control in order to prevent complications. In this study, 40% had good HTN control, which is slightly higher than that reported by Al-Homrani et al (37%) [3] and Al-Khaldi (35%), [4] Al-Menawar (32%) from Aseer region, [7] USA study (31%) [12] and Riyadh region (25%), [13] but similar to that found by Al-Tuwijri et al in Riyadh (40%) [14] and that reported from Oman (41%) and lower than figures from South Africa (57%) [11] and Kuwait (44.4-58.4%). [15]

HTN control is affected by many factors related to patients, physicians, diseases and drug efficacy. Whatever the reason, physicians should assess the compliance with lifestyles, drugs to determine the underlying causes and to deal with it accordingly either by reinfor­cing compliance to adjust the dose or to add another medication.

More than one-fifth of HTN patients (22%) did not show up for longer than six months, which is higher than the national standard (less than 20%), [9] but less than that reported by Al-Homrani et al (25%) [3] and similar to that reported by Al-Khaldi (22%). [4]

To reduce the defaulter rate, the recall system at all PHCCs could use Short Message Service (SMS) messages for reminding patients, as most of the people in the region have mobile telephones.

It was noticed that, in this study, the rates of co-morbidities and complications were low compared with the findings of national and international studies. [2],[10],[13],[14],[15],[16],[17] This could be due to the lack of diagnostic facilities and weak documentation rather than the true picture and, therefore, priority should be given to improve the quality of HTN care and recording process.

Satisfaction of health care providers is an important issue. In this regard, they showed a different degree of satisfaction with HTN care. They showed good satisfaction with coope­ration of the health team and availability of most of infrastructures items, which were avai­lable in most of the PHCCs. However, their satisfaction with community participation, co­operation of patients, compliance of patients with appointment system, recall system and coordination with hospital was lower than that expected. In previous studies, most of these findings were reported. [3],[5],[6] To overcome these barriers, the following recommendations were agreed on: (1) activation of the recall system using SMS and (2) conducting urgent meeting with the representatives of hospitals to discuss how to improve the weak referral system in the region.

Concerning community participation and co­operation of patients, the participants empha­sized the role of community leaders and activa­tion of community health friends' committees.


   Conclusion Top


This study revealed that hypertensive patients in Aseer region received insufficient care, which was contributed to many and different barriers. In order to improve the quality of care for HTN patients, these barriers should be overcome through implementation of the re­commendations by investigators and partici­pants as soon as possible.


   Acknowledgment Top


The authors extend their thanks to Dr. Ibraheem Al-Asmari, Dr. Abu-Al-Kaiser Shoudri and Dr. Mohammed Tasneem from the Department of Public Health, General Directorate of Health Affairs for their valuable help in conducting meetings with technical supervisors of health sectors and for their participation in formu­lating and suggesting practical solutions.

Conflict of interest: None

 
   References Top

1.
Al-Nozha MM, Abdullah M, Arafah MR, et al. Hypertension in Saudi Arabia. Saudi Med J 2007;28:77-84.  Back to cited text no. 1
    
2.
Saeed AA, Al-Hamdan NA, Bahnassy AA, Abdalla AM, Abbas MA, Abuzaid LZ. Preva­lence, awareness, treatment, and control of hypertension among Saudi adult population: A National Survey. Int J Hypertens 2011;2011: 174135.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Al-Khaldi YM. Quality of hypertension care in the family practice center, Aseer Region, Saudi Arabia. J Family Community Med 2011:8:45-8.  Back to cited text no. 4
    
5.
Al-Khaldi YM, Al-Sharif AI. Health education resources availability for diabetes and hyper­tension at primary care settings, Aseer region, Saudi Arabia. J Family Community Med 2005;12:75-7.  Back to cited text no. 5
    
6.
Al-Sharif AI, Al-Khaldi YM. Resources avai­lability for care of hypertensives at primary health care settings in southwestern Saudi Arabia. Saudi Med J 2003;24:466-71.  Back to cited text no. 6
    
7.
Al-Menawar HA. Non-compliance among hypertensive patients. Med J Cairo Univ 2007;75: Suppl 3:387-93.  Back to cited text no. 7
    
8.
Al-Gelban KS, Khan MY, Al-Khaldi YM, et al. Adherence of primary health care physicians to hypertension management guidelines in the Aseer region of Saudi Arabia. Saudi J Kidney Dis Transpl 2011;22:941-8.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
The scientific committee of quality assurancein primary health care. Quality assurance in primary health care manual. WHO/ EM/PHC/81-A/G/93:145-164.  Back to cited text no. 9
    
10.
Almahreezi A, Al-Zakwani I, Al-Aamri A, et al. Control and management of hypertension at a university health center in Oman. Sultan Qaboos Univ Med J 2008;8:179-84.  Back to cited text no. 10
    
11.
Onwukwe SC, Omole OB. Drug therapy, lifestyle modification and blood pressure control in a primary care facility, South of Johannesburg, South Africa: An Audit of hypertension management. S Afr Fam Pract 2012;54:156-61.  Back to cited text no. 11
    
12.
Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hyper­tension in the United States. JAMA 2003; 290:199-206.  Back to cited text no. 12
    
13.
Al-Rukban MO, Al-Sughair AM, Al-Bader BO, Al-Tolaihi BA. Management of hyper­tensive patients in Primary Health Care setting: Auditing the practice. Saudi Med J 2007; 28:85-90.  Back to cited text no. 13
    
14.
Al-Tuwijri AA, Al-Rukban MO. Hypertension control and co-morbidities in primary health care centers in Riyadh. Ann Saudi Med 2006;26:266-71.  Back to cited text no. 14
    
15.
Al-Awadhi NM, Majbour TK, Al-Orbany MI. Improving hypertension management in primary health care. Kuwait Med J 2007;3 9:26-30.  Back to cited text no. 15
    
16.
Al-Hamdan N, Saeed A, Kutbi A, Choudhry AJ, Nooh R. Characteristics, risk Factors, and treatment practice of Known adult hyper­tensive patients in Saudi Arabia. Int J Hypertens 2010;2010:168739.  Back to cited text no. 16
    
17.
Bani IA. Prevalence and related risk factors of essential hypertension in Jazan region, Saudi Arabia. Sudan J Public Health 2011;6:45-50.  Back to cited text no. 17
    

Top
Correspondence Address:
Dr. Safar A Al-Saleem
Department of Public Health, General Directorate of Health Affairs, Aseer Region, Khamis Mushayt
Saudi Arabia
Login to access the Email id


DOI: 10.4103/1319-2442.144313

PMID: 25394461

Rights and Permissions



 
 
    Tables

  [Table 1], [Table 2]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
   Acknowledgment
    References
    Article Tables
 

 Article Access Statistics
    Viewed1913    
    Printed17    
    Emailed0    
    PDF Downloaded392    
    Comments [Add]    

Recommend this journal