Tabinda Ashfaq ( Department of Family Medicine, Ziauddin University, Karachi. )
Qudsia Anjum ( Department of Family Medicine, Ziauddin University, Karachi. )
Hemna Siddiqui ( Department of Family Medicine, Ziauddin University, Karachi. )
Shazia Shaikh, ( Department of Family Medicine, Ziauddin University, Karachi. )
E. A Vohra ( Department of Family Medicine, Ziauddin University, Karachi )
Objective: To compare awareness of hypertension among patients attending Primary Health Care Centre (PHC) and outpatient department (OPD) of a tertiary care hospital of Karachi.
Methods: Cross sectional survey of patients more than 18 years of age without any complication of hypertension in a squatter settlement of Karachi through non-probability convenient sampling.
Results: A total 202 patients were approached, 49 (24%) were males and 153 (76%) were females. Majority of the patients attending tertiary care OPD (80%) and 56% from PHC group believed that hypertension could lead to cardiovascular disease (CVD). On inquiring the duration of taking antihypertensive drugs, 61 % from tertiary care OPD group and 31 % of PHC group said they are taken only for few months (p<0.001). Over two-third (77%) of patient of tertiary OPD were not doing exercise and not avoiding oily and heavy food to keep their weight under control. Large number of OPD patients (91 %) used oil for cooking in comparison to PHC group (78%) who utilized ghee (p<0.001).
Conclusion: This study showed a marked difference in awareness regarding hypertension in urban slum and middle class community, which can be attributed to the level of education. This outcome reveals need for more awareness campaigns especially in the squatter settlement with special emphasis on lifestyle modifications along with pharmacological therapy for the better control of hypertension (JPMA 57:396:2007).
Hypertension is one of the major risk factors for cardiovascular diseases and an important cause of morbidity and mortality accounting for a large proportion of coronary heart diseases.' It is one of the non-communicable diseases imposing a double burden on the developing countries already combating the challenges of existing problems with infectious diseases.2-4Pakistan is also one of such countries where one in three individuals over the age of 45 years is hypertensive as revealed by the National Health Survey (NHS).5 A further analysis of NHS revealed 17% prevalence of risk factors for cardiovascular diseases in Pakistani population.6 This alarming situation calls for a shift from curative to preventive cardiology for reducing cardiovascular events. Therefore early detection, adequate treatment and control of hypertension are the key components of the integrated management of cardiovascular risk.
Patient's knowledge regarding hypertension and its complications is an important factor in achieving better compliance and control as shown in an Arabian study.? Compliance involves not only taking the prescribed medications but also adherence to follow up appointments and maintaining the recommended lifestyle modifications. In addition, the patient should be an active participant in the plan of care.
This study was conducted with the objective to compare awareness regarding hypertension among patients attending OPD in a tertiary care unit and Primary Health Care Center.
This was a cross-sectional study conducted at Primary Health Care (PHC) center in Gulshan-eSikandarabad, a squatter settlement situated near Ziauddin University (ZU) Clifton campus and the Internal Medicine Clinic at Ziauddin Hospital (ZH), North Nazimabad campus, Karachi. The PHC center is situated in a low socioeconomic area with a population of approximately 20,000. Majority of the inhabitants are labourers or transporters with a poor literacy level. The PHC center is a low cost OPD running under supervision of ZU. The North Nazimabad campus of ZH is a 250 bed tertiary care hospital, the patients attending OPD in this hospital mostly belong to the middle socioeconomic class.
The faculty members interviewed patients using a pretested structured questionnaire through non-probability convenient sampling method. Patients aged more than 18 years without any complications of hypertension were included in the study. Exclusion criteria were patients presenting with complications of hypertension like stroke, cerebrovascular accidents (CVA), etc, and patients presenting with comorbidities like diabetes mellitus, renal failure and ischemic heart disease (M). The interviewer also measured and recorded the blood pressure in the right arm with the patient sitting quietly using a calibrated aneroid sphygmomanometer. The patients were classified as hypertensive on the basis of Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines.8 Weight was measured in kilograms (kg) using a bathroom scale and standing height was measured in centimeters (cm) using a measuring tape. Body mass index (BMI) was calculated as weight in kg divided by height in meters squared. Patients having BMI of less than 18.5 were classified as underweight, from 18.5 to 25 were considered normal, from 25 to less than 30 were overweight, whereas those more than 30 were considered obese.
Data obtained comprised of age, sex, marital status, educational level, family history of hypertension, smoking status, physical exercise, drug compliance, knowledge regarding complications of hypertension, duration of antihypertensives for control of hypertension, symptoms of hypertension, knowledge regarding blood sugar, cholesterol and ECG. Their attitude was assessed by regular visits to the doctor for BP monitoring. Inquiry was also made regarding decrease in salt intake, weight reduction, regular exercise and use of cooking oil.
Data entry and analysis was done using SPSS version 10, frequencies of different variables were determined. Chi-square test was applied to measure association between different variables in two groups and test of proportions was used to compare knowledge between patients at the two different clinics at p-value <0.05.
A total of 202 hypertensive adults were interviewed with 106 from tertiary care OPD and 96 from PHC center. The majority of patients were more than 49 years of age with male to female ratio of 1:3 in both groups. Seventy five percent of the OPD patients were Urdu speaking whereas 81% from PHC group belonged to the Pathan community. Over half of the tertiary group patients (56%) were matriculate or above, whereas most of the patients (85%) from PHC group were uneducated (p<0.001). The characteristics of the patients are presented in Table 1. The mean systolic and diastolic blood pressure of patients was 143.7+15.7 mmHg and 91.3+8.5 mmHg respectively. The mean BMI of patients from both groups was 28.05 +4.32 kg/m2
. On the basis of JNC 7, 34.7% had normal (controlled) systolic blood pressure and 29.7% had normal (controlled) diastolic blood pressure.
Knowledge and attitude of the patients regarding hypertension is shown in Table 2. Majority of patients
| || ||OPD n=106 (%) || ||PHC n=96 (%) || ||p-value |
|Age Gruoup |
|20-39 Years || ||12 ||(11) ||17 ||(18) ||<0.001|
|40-59 Years || ||56 ||(53) ||72 ||(75) |
|60-79 Years || ||38 ||(36) ||7 ||(7) |
|Male || ||28 ||(26) ||21 ||(22) ||0.452|
|Female || ||78 ||(74) ||75 ||(78) |
|Urdu Speaking || ||79 ||(75) ||7 ||(7) ||<0.001|
|Other || ||27 ||(25) ||89 ||(93) |
|Education Of Patient |
|No Education || ||29 ||(27) ||82 ||(85) ||<0.001|
|Primary & Secondary || ||18 ||(17) ||11 ||(11) |
|Primary & Secondary || ||59 ||(56) ||3 ||(3) |
|Employement Status |
|Lobourer/driver || ||59 ||(56) ||3 ||(3) ||<0.001|
|House Wife || ||61 ||(58) ||72 ||(75) |
|Retired || ||13 ||(12) ||2 ||(2) |
|Private Job / Professional || ||29 ||(27) ||5 ||(5) |
|Marital Status |
|Married || ||98 ||(93) ||87 ||(91) ||0.64|
|Unmarried / divorced / separated /widow || ||8 ||(8) ||9 ||(9) |
|BMI Of Patient |
|18.5-24.9 || ||23 ||(22) ||14 ||(15) ||0.142|
|25-29.9 || ||36 ||(34) ||45 ||(47) |
|>30 || ||47 ||(44) ||37 ||(39) |
|Smoking Status |
|Current/Ex-Smoker || ||16 ||(15) ||17 ||(18) ||0.61|
|Non-Smoker || ||90 ||(85) ||79 ||(82) |
|Family History of Hypertension |
|Yes || ||57 ||(54) ||56 ||(58) ||0.514|
|No/Don't Know || ||49 ||(46) ||40 ||(42) |
|Sedentary || ||84 ||(79) ||90 ||(94) ||0.002|
|Mild/Moderate || ||22 ||(21) ||6 ||(6) |
attending tertiary care OPD were well aware of the complications of hypertension. Eighty percent patients believed that hypertension could lead to cardiovascular disease (CVS), whereas 58% from PHC group considered hypertension as a risk factor for cardiovascular disease. In relation to cerebrovascular accident (CVA), 80% from tertiary OPD and 55% from PHC group supposed that hypertension could lead to CVA (p<0.001).Seventy one percent from OPD group and 76% from
| || ||OPD n=106 (%) || ||PHC n=96 (%) || ||p-value |
|Antihypertensives taken regularly || ||75 ||(71) ||33 ||(34) ||<0.001|
|Taking antihypertensive life long || ||65 ||(61) ||30 ||(31) ||<0.001|
|Hypertension causes CVD || ||85 ||(80) ||56 ||(58) ||0.003|
|Salt intake increases BP || ||91 ||(86) ||70 ||(73) ||0.067|
|Obesity increases BP || ||58 ||(55) ||47 ||(49) ||0.072|
|Smoking increases BP || ||30 ||(28) ||23 ||(24) ||0.01|
|Exercise decreases BP || ||51 ||(48) ||28 ||(29) ||0.01|
|Awareness of symptoms || ||31 ||(29) ||13 ||(14) ||0.02|
|Patient knows the BP value || ||57 ||(54) ||20 ||(21) ||<0.001|
|Gets cholesterol checked regularly || ||66 ||(62) ||20 ||(21) ||<0.001|
|Gets blood glucose checked regularly || ||69 ||(65) ||25 ||(26) ||<0.001|
|Gets ECG regularly || ||70 ||(66) ||28 ||(29) ||<0.001|
|Visit doctor 4 times / year || ||74 ||(70) ||59 ||(62) ||0.211|
|Visit doctor annually || ||24 ||(23) ||18 ||(19) ||0.496|
|BP checked every month || ||83 ||(78) ||58 ||(60) ||0.005|
|Eat less salt || ||86 ||(81) ||50 ||(52) ||<0.001|
|Do exercise || ||29 ||(27) ||9 ||(9) ||<0.001|
|Reduce weight || ||41 ||(39) ||14 ||(15) ||<0.001|
|Use oil for cooking || ||96 ||(91) ||21 ||(30) ||<0.001|
the PHC group did not know that smoking has any relationship with hypertension (p=0.01). On the other hand, 48% patients from OPD group and 29% from PHC group considered exercise having significant role in controlling hypertension (p<0.01). Forty seven percent in the OPD group and 79% in PHC group did not know about the values at which blood pressure is considered high (p<0.001). On inquiring the duration of taking antihypertensive drugs, 61% from tertiary care OPD group and 31% of PHC group said they are taken only for few months (p<0.001). One third of patients (34%) from OPD and 71% from PHC group were unaware about electrocardiogram (ECG), 38% from OPD and 79% from PHC group did not know about blood cholesterol and 35% from OPD and 74% from PHC group did not get their blood sugar level checked regularly. The attitude of patients regarding control of hypertension is shown in table 2. Majority of patients from tertiary OPD and PHC group visited the doctor at least four times per year. Seventy eight percent patients from tertiary group and 60% patients from PHC group had blood pressure checked less than a month ago (p<0.001). Almost 80% of patients from tertiary OPD group had reduced salt intake in contrast 48% from the PHC group who did not reduce salt intake during hypertension (p<0.001). Over two-thirds (77%) of tertiary OPD patients were not doing exercise as compared to 91% of PHC group. Large number of OPD patients (91%) used oil for cooking in comparison to PHC group (78%) who utilized ghee (P-value<0.001).
According to this study, a small number of patients had controlled blood pressure. The tertiary OPD patients had a better knowledge of regular medication use for hypertension as compared to patients coming to the PHC center. The patients studied were predominantly above 40 years females in both the groups which are consistent to the studies done in Saudi Arabia and America.7,9 A large number of studied patients were either overweight or obese which is similar to other community studies in Pakistan.10-11 Excess salt intake was correctly thought to be associated with high blood pressure in the present study, which has been proven in a study done on British Population. 12
The tertiary OPD patients were taking antihypertensives regularly as compared to the PHC group, which took medicines for hypertension occasionally. Literature supports that although lifestyle modifications are essential for controlling hypertension, but adequate control of patients require appropriate medicines and compliance. 13 The percentage of patients regarding lifelong intake of antihypertensive medications was higher among the tertiary OPD patients and this was probably due to higher educational level. Most of the tertiary OPD patients were of the opinion that hypertension leads to cardiovascular and cerebrovascular diseases which is similar to the study done by Line Aubert and Susan.14,15 Most of the patients were unaware of the relationship of smoking with hypertension, which is similar to other studies done in Pakistan. 16 Half of the patients in the tertiary OPD group knew that exercise decreases blood pressure as compared to the PHC group, this observation is consistent with the finding of another study done on patients attending tertiary care hospitals in Pakistan.16
On questioning about frequency of checking cholesterol level, more than half in the tertiary OPD group had the correct information but it was less in the PHC group. Interesting finding in this study was that greater proportion in the tertiary OPD group were of the opinion of getting their ECG regularly done but the case was opposite in the PHC group. The reason might be due to the difference in the education level in both the groups. Majority of the tertiary OPD patients had their blood sugar level assessed regularly, while a large number of OPD patients did not get blood sugar checked regularly. Analysis of the National Health Survey showed that identification of those at risk of
hypertension and diabetes should be made as obesity is a leading factor for these non-communicable diseases.17
The patients' regularity of visiting the doctor for the care of hypertension was not different in both the groups. The attitude of patients towards hypertension care by means of regularly checking blood pressure, adopting life style changes, that is, weight reduction and exercise was found to be significantly different in both the groups. This might be because of the misconception that these lifestyle changes have no influences on better control of BP as is shown by Aubert.14 Patients in both the tertiary OPD and PHC group had reduced salt intake, which is proven in a study that the DASH (Dietary Approach to Stop Hypertension) diet and reduced sodium intake improves blood pressure control.l8 The tertiary OPD patients also knew that cooking oil is good for health whereas PHC patients were unaware about this.
The limitation of this study was that it mainly comprised of females, as it was conducted in morning hours when most of the male members are supposedly at their work places.
This comparative study of an urban middle class and a squatter settlement has shown that education may be associated with a better understanding of the disease. A relatively better knowledge regarding hypertension and its management was found in the tertiary OPD group as compared to the PHC group. More awareness campaigns and counseling sessions are required in tertiary OPD as well as in the squatter settlement.
We highly appreciate the supervision and guidance of Dr Jawaid Usman and Dr Amir Omair in the study. We are also grateful to Dr Rahila Ali for assisting in data collection and Mr Ejaz Alam for data analysis.
1. Padwal R, Straus SE, McAlister FA. Evidence based management of hypertension. Cardiovascular risk factors and their effects on the decision to treat hypertension: evidence based review. BMJ 2001;322:977-80.
2. Marshall SJ. Developing countries face double burden of disease. Bull World Health Organ 2004; 82:556.
3. Reid CM Thrift AG Hypertension 2020: Confronting tomorrow's problem today. Clin Exp Pharmacol Physio12005; 32:374-6.
4. Ghaffar A, Reddy KS, Singh M. Burden of noncomunicable diseases in South Asia. BMJ 2004; 328:807-10.
5. Nishtar S, Faruqui AM, Mattu MA, Mohamud KB, Ahmed A. The National Action Plan for the prevention and control of noncommunicable diseases and health promotion in Pakistan- Cardiovascular Diseases. J Pak Med Assoc 2004; 54:14-25.
6. Jafar TH. Women in Pakistan have a greater burden of clinical cardiovascular risk factors than men. Int J Cardio12006;106:348-54.
7. Al Sowielem L S, Elzubier AG Compliance and knowledge of hypertensive patients attending PHC centers in Al Khobar, Saudi Arabia. East Mod J 1998; 4:301-7.
8. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The JNC 7 Report. JAMA 2003;289; 2534-73.
9. Haajar I, Kotchen TA. Trends in Prevalence, Awareness, Treatment, and Control of Hypertension in the United States, 1988-2000. JAMA 2003; 290:199-206.
10. Dennis B, Aziz K, She L, Faruqui AM, Davis CE, Manolio TA et al. High rates of obesity and cardiovascular disease risk factors in lower middle class community in Pakistan: the Metroville Health Study. J Pak Mod Assoc 2006; 56:267-72.
11. Dodani S, Mistry R, Farooqi M, Khwaja A, Qureshi R, Kazmi K. Prevalence and awareness of risk factors and behaviours of coronary heart disease in an urban population of Karachi, the largest city of Pakistan: a community survey. J Public Health 2004;26:245-9.
12. Beard TC, Blizzard L, O'Brien DJ, Dwyer T. Association between blood pressure and dietary factors in the dietary and nutritional survey of British adults. Arch Intern Mod 1997:157;234-8.
13. Israili ZH, Hernandez-Hernandez R, Valasco M. The future of antihypertensive treatment. Am J Ther 2007;14:121-34.
14. Aubert L, Bovet P, Gervasoni GP, Rwebogora A, Waeber B, Paccaud F. Knowledge, Attitudes, and Practices on Hypertension in a Country in Epidemiological Transition. Hypertension 1998; 31:1136-45.
15. Oliveria SA, Chen RS, Mccarthy BD, Davis CC, Hill MN. Hypertension knowledge, awareness and attitudes in a hypertensives population. J Gen Intern Mod 2005;20:219-25.
16. Jafary FH , Aslam F, Mahmud H, Waheed A, Shakir M Afzal A et al. Cardiovascular health knowledge and behavior in patient attendants at four tertiary care hospitals in Pakistan - a cause for concern. BMC Public Health 2005, 5:124
17. Jafar TH, Chaturvedi N, Pappas G Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo-Asian population. CMAJ2006;175:1071-7.
18. Svetkey LP, Simons-Morton DQ Proschan MA, Sacks FM Conlin PR, Harsha D et al. Effect of the Dietary Approaches to Stop Hypertension Diet and Reduced Sodium Intake on Blood Pressure Control. J Clin Hypertens 2004;6:373-81.