| 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|| |
Hypertension (HTN) is known to be one of the most common chronic health problems that affects about one-quarter of the adult Saudi population. , However, few studies showed that HTN patients received inadequate health care. , 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. ,,, 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|| |
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.  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.  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|| |
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).|
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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.
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|| |
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. , 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.  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. , 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.  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. , 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. ,
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. ,,, 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,  but were higher than that reported from Oman (34% and 25%, respectively)  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.  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%)  and Al-Khaldi (35%),  Al-Menawar (32%) from Aseer region,  USA study (31%)  and Riyadh region (25%),  but similar to that found by Al-Tuwijri et al in Riyadh (40%)  and that reported from Oman (41%) and lower than figures from South Africa (57%)  and Kuwait (44.4-58.4%). 
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%),  but less than that reported by Al-Homrani et al (25%)  and similar to that reported by Al-Khaldi (22%). 
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. ,,,,,, 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. ,, 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|| |
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|| |
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
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Dr. Safar A Al-Saleem
Department of Public Health, General Directorate of Health Affairs, Aseer Region, Khamis Mushayt
[Table 1], [Table 2]