|Year : 2018 | Volume
| Issue : 1 | Page : 81-86
Failure to achieve goal blood pressure and its associated factors among hypertensive patients registered in a primary health centre in South India
Bharathnag Nagappa1, Pruthu Thekkur2, Marie Gilbert Majella3, Divya Nair3, Gomathi Ramaswamy3, Palanivel Chinnakali1
1 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Monitoring and Evaluation Officer, Centre for Operational Research, The Union, Puducherry, India
3 Department of Community Medicine, Sri Venkateshwaraa Medical College Hospital and Research Centre, Puducherry, India
|Date of Web Publication||30-Apr-2018|
Dr. Palanivel Chinnakali
Department of Preventive and Social Medicine, JIPMER, Puducherry
Source of Support: None, Conflict of Interest: None
Introduction: Uncontrolled blood pressure (BP) among hypertensive patients leads to life-threatening complications, hospitalization, and premature mortality. Knowledge on the burden of uncontrolled BP and its correlates will help in devising strategies to achieve goal BP. We aimed to determine the proportion who have not achieved goal BP and its associated factors among hypertensive patients in a Primary Health Centre (PHC). Materials and Methods: A facility-based cross-sectional analytical study was conducted among the hypertensive patients attending chronic disease clinic of PHC at Ramanathapuram, Puducherry. BP was measured and goal BP was defined based on Joint National Committee-8 criteria. The interview was conducted using semi-structured questionnaire capturing sociodemographic details, behavioral characteristics, physical activity with the International Physical Activity Questionnaire (IPAQ), medication adherence with Morisky Medication adherence scale-8 (MMAS-8), and stress with perceived stress scale. The data were entered and analyzed using EpiData software. The proportion “not achieved goal BP” was expressed as percentage and association were measured using prevalence ratios (PRs) with 95% confidence interval (CI). Results: Of total 259 hypertensives studied, 140 (54.1%) were aged above 60 years, and 161 (62.2%) were females. Overall, 63 (24.3%) participants had not achieved goal BP. On univariate analysis, individuals aged 45–59 years (PR-2.1 [95% CI: 1.4–3.4]), being male (PR-1.6 [95% CI: 1.1–2.4]) and employed (PR-2.0 [95% CI: 1.1–3.5]) were associated with not achieving goal BP. Conclusion: One-fourth of patients treated for hypertension in PHC failed to achieve goal BP. Considering the consequences of uncontrolled BP, cost-effective, context-specific interventions at the primary health-care level are needed.
Keywords: Disease management, hypertension, Joint National Committee-8 guidelines, primary health care, uncontrolled blood pressure
|How to cite this article:|
Nagappa B, Thekkur P, Majella MG, Nair D, Ramaswamy G, Chinnakali P. Failure to achieve goal blood pressure and its associated factors among hypertensive patients registered in a primary health centre in South India. J Family Med Prim Care 2018;7:81-6
|How to cite this URL:|
Nagappa B, Thekkur P, Majella MG, Nair D, Ramaswamy G, Chinnakali P. Failure to achieve goal blood pressure and its associated factors among hypertensive patients registered in a primary health centre in South India. J Family Med Prim Care [serial online] 2018 [cited 2021 Feb 28];7:81-6. Available from: https://www.jfmpc.com/text.asp?2018/7/1/81/231542
| Introduction|| |
The World Health Organization in its Global Health Risks (2009) report, estimated high blood pressure (BP) to be the leading risk factor for mortality accounting for 9.4 million deaths every year. Raised BP is the most prevalent and important treatable cardiovascular risk factor. It contributes to 45% of deaths due to heart disease and 51% of deaths due to stroke., Globally, about 45% of adults aged 25 years and above are estimated to be hypertensive. Over the years, the prevalence of hypertension has shown an upward trend as it rose from 600 million in 1980 to 1 billion in 2008. India with an estimated prevalence of 29.8% among the adults, accounts for about 20% of the global burden of hypertension.
According to rule of halves, only 50% of the hypertensive patients are diagnosed, of the diagnosed only 50% are put on treatment and of this only 50% have their BP controlled. Achieving BP control is essential to avert the complications such as hemorrhagic stroke, kidney failure, hypertensive retinopathy, and cardiac failure. The management of hypertension focus on reducing the untoward life-threatening complication through appropriate BP control. Well-controlled BP in hypertensive leads to 40% reduction in risk of stroke and 15% in risk of myocardial infarction. In spite of these benefits, the studies have reported high prevalence (42%–89%) of uncontrolled BP among the treated hypertensive patients., There is need to explore the burden of uncontrolled hypertension and also determine the factors contributing to failure in achieving the target BP.
National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke in India emphasize on managing individuals with hypertension at primary health-care (PHC) level. In India, the majority of the hypertensive patients are being currently managed at PHCs. Only those with comorbid conditions requiring specialist care are referred and managed at higher levels. Knowledge on the burden and determinants of the not achieving target BP will help in devising the feasible strategies at PHC level. This would eventually reduce the untoward complications, the need for referral and financial burden on the patient. Hence, we conducted a study to determine the proportion who have not achieved goal BP and its associated factors among hypertensive patients in a Primary Health Centre (PHC).
| Materials and Methods|| |
Study design and setting
During April 2016, a facility-based cross-sectional study was conducted among patients with hypertension seeking healthcare from chronic disease clinic, Rural Health Centre (RHC), Ramanathapuram. The RHC is a PHC located in Puducherry, India and is 16 kilometers away from the Puducherry main town. It is attached to a tertiary care research institute and involved in delivering PHC in close coordination with the Government of Puducherry. It caters to the health needs of 9852 individuals residing in four sociodemographically and economically similar villages, namely, Ramanathapuram, Thondamanatham, Thuthipet, and Pillayarkuppam. Majority of people are dependent on agriculture for living as is the scenario in most of the Indian villages. People here mainly depend on RHC for their health needs. RHC, Ramanathapuram provides round the clock health services which include outpatient department services from 9 am to 4.30 pm and emergency services in remaining hours. Special clinics for chronic diseases Antenatal care and Well Babycare are scheduled on Wednesday, Thursday, and Friday, respectively. The study was carried out among patients attending chronic disease clinic at RHC, Ramanathapuram. Patients with at least one chronic disease condition such as hypertension, diabetes mellitus, coronary heart disease, rheumatic heart disease, asthma, thyroid disorders, epilepsy, and psychiatric disorders are registered in chronic disease clinic. A total of 537 patients with chronic diseases are divided into batches of around 130, and each batch visits RHC for consultation and follow-up once in a month. Consultation, drugs for 28 days and necessary laboratory services are provided free of cost during this monthly follow-up visits. Patients are reviewed every Wednesday by trainee doctors under the supervision of medical officer in charge of RHC. During each monthly visit, the details on management are updated in the comprehensive patient case sheets by attending medical doctor. The patients are advised regarding the need for regular follow-up visits and lifestyle modifications to combat noncommunicable disease. The pharmacist educates patients regarding dose and regimen of the prescribed medication to be followed during the next 4 weeks.
We included all the patients with hypertension who are registered and attending chronic disease clinic at RHC, Ramanathapuram during April 2016 and had received drugs for at least past 4 weeks. The patients were interviewed after obtaining an informed consent during their visit to chronic disease clinic.
Study tool and Study variables
Pretested, semi-structured interview schedule was used to collect information. The interview schedule had three components sociodemographic details, details of treatment received, comorbidities, adherence to medication, physical activity, and stress. The component of socio-demographic details included age, gender, education, occupation, marital status, family type, and also lifestyle behaviors such as added salt intake, alcohol use, and tobacco use. The treatment details had variables such as type of morbidity, duration of treatment, number and dosage of drugs received, and regularity in attending health facility. The details of treatment received were extracted from patient case sheets. Adherence to medication was captured with the eight-item Morisky MMAS-8 which has eight questions and was graded as low adherence, moderate adherence, and good adherence. MMAS-8 is validated in India and other parts of the world in different languages with reliability value (α) of 0.83.,, Psychological stress was captured with perceived stress score (PSS) which has ten questions, and each question has score ranging from 0 to 4. Physical activity was captured with the IPAQ short form which has seven questions and metabolic equivalent of task (MET)-minutes will be calculated using the formula given with IPAQ.,
The questions were translated and back-translated to Tamil and English respectively by two separate bi-linguistic persons for content verification. The interview schedule was administered by trained MBBS interns who were well versed in the local language (Tamil). BP was measured twice with a minimum gap of 2 min using sphygmomanometer and mean of two readings was recorded.
Failure to achieve goal BP: This was defined as per Joint National Committee-8 (JNC-8) guidelines. The individuals aged >60 years with BP ≥150/90 and individuals aged <60 years or with coexisting diabetes with BP ≥140/90 were considered to have failed to achieve goal BP.
Adherence to medication: Patients having a score of 8 were considered to have good adherence. Patients with scores of 6–7 were considered to have moderate adherence. Patients with scores of <6 were considered to have low adherence.
Number of drugs: Total number of different drugs that the patient has been prescribed by attending medical doctor to consume per day.
Physical activity: Physical activity was considered as adequate if MET-minute >3000 and inadequate if MET-minute is ≤3000.
Stress: If PSS score >20, it considered as “patient having stress” and if <20 then it considered has not having stress.
High salt intake: Any added salt intake in the form of pickle, papad, or table salt.
Regularity: Patient was irregular who missed chronic disease clinic for 2 or more times in the last 6 months.
Data were entered into EpiData version 3.1 and was analyzed using EpiData analysis version 184.108.40.206. Continuous data such as age, duration of disease, number of drugs received and scores of MMAS, PSS, and IPAQ were converted into categorical data. All the categorical data were presented as percentages. Association between BP control and categorical variables such as age group, gender, education status, occupation, duration of disease, dosage and number of drugs, physical activity, stress, salt intake, and medication adherence was tested using prevalence ratios (PRs) with 95% confidence interval (CI).
| Results|| |
There were 302 hypertensive patients registered in chronic disease clinic. Of these, 32 patients had not attended the clinic for >6 months, and information of 11 patients was incomplete. Hence, 259 patients were included for analysis. Among 259 patients, 140 (54.1%) were aged >60 years and mean (standard deviation) age was 60 (12) years. Of the total, 161 (62.2%) were women, 146 (56.4%) participants had no formal education, and 97 (37.5%) were employed. Sociodemographic characteristics of study participants are described in [Table 1].
|Table 1: Sociodemographic and clinical characteristics of hypertensive patients registered at a rural primary health centre, south India, 2016 (n=259)|
Click here to view
The median duration of hypertension was 4 (IQR–2–7) years, and 87 (33.6%) patients had hypertension for >5 years. Of the 259 participants, 109 (41.2%) had concurrent diabetes. Of the total, 139 (53.7%) patients were on single-drug therapy. Of the total participants, 163 (62.9%) had good adherence to treatment, and 73 (28.2%) were attending clinic irregularly. Around 120 (46.3%) had stress, and 80 (30.9%) reported adequate physical activity. The participant's lifestyle characteristics and medication adherence are described in [Table 2].
|Table 2: Lifestyle characteristics and medication adherence among hypertensive patients registered at a rural primary health centre, south India, 2016 (n=259)|
Click here to view
Overall, 63 (24.3%. 95% CI = 19.3%–30.1%) participants had not achieved goal BP. On univariate analysis, individuals aged 45–59 years (PR-2.1 [95% CI: 1.4–3.4]), being male (PR-1.6 [95% CI: 1.1–2.4]) and employed (PR-2.0 [95% CI: 1.1–3.5]) were associated with not achieving goal BP. The association between the individual characteristics and not achieving target BP is depicted in [Table 3] and [Table 4].
|Table 3: Association of sociodemographic and clinical characteristics with uncontrolled blood pressure status among hypertensive patients registered at a rural primary health centre, south India, 2016 (n=259)|
Click here to view
|Table 4: Association lifestyle characteristics and medication adherence with uncontrolled BP status among hypertensive patients registered at a rural primary health centre, south India, 2016 (n=259)|
Click here to view
| Discussion|| |
The current study conducted among hypertensive patients registered in chronic disease clinic of PHC showed that one out of four had failed to achieve goal BP. Male gender, age between 45 and 59 years and being employed were found to be associated with not achieving target BP.
Previous studies from different settings have reported the proportion of uncontrolled hypertension ranging from 42% to 89%.,,,, However, in the current study, we found relatively lower proportion (23.4%) of hypertensive patients with uncontrolled BP. The difference in the estimate from the previous studies may be due to the difference in study settings. All the previous studies were either community based or conducted among hypertensive patients seeking care from tertiary healthcare facilities. While community-based studies may include hypertensive patients seeking care from different healthcare providers, tertiary care hospitals mainly cater to patients with complications and other comorbidities. In both these scenarios, the proportion of uncontrolled hypertensive may turn out to be high. In contrast, the current study setting is one of the well-performing PHCs functioning under a teaching medical institute. The patients receive individualized care from doctors trained in standard operating procedures developed as per contemporary JNC guidelines. Furthermore, the majority of the patients seek care regularly and are adherent to medications as assessed in the current study.
In the current study, we attempted to identify the factors associated with not achieving goal BP. Previous studies had reported male gender, elderly age group, employed, coexisting diabetes, tobacco use, and poor adherence to treatment to be associated with uncontrolled BP.,,, Similar associations were found in the current study with respect to gender and employment status. In the current study, age between 45 and 59 years was associated with uncontrolled BP in contrast to previous studies. This difference may be due to confounding by employment status and gender. There was no association between coexisting diabetes, tobacco use, and poor adherence to treatment. Although the proportion of people with uncontrolled BP was relatively higher among those with poor adherence and those having diabetes, it was not statistically significant. This may be due to lower sample size in the current study.
This study has few strengths:First, the study had high response rate (93%). Second, we used standard guidelines for assessing BP and also defined the failure to achieve goal BP as per JNC-8 guidelines. Third, we included all the independent variables with relevance to BP control and followed standard definitions and instruments (IPAQ 7, MMAS-8, PSS scale) to define these variables. Finally, quality-assured data entry was done using the EpiData software. The study had few limitations. The study had a low sample size because of which multivariate analysis could not be carried out. Quantitative measurement of salt intake which is an important factor in BP control was not done. As this study was carried out in a PHC functioning under a tertiary medical hospital and college, the results may not be generalized to the other PHCs.
Since the proportion of hypertensive patients without adequate BP control may differ based on the treatment setting, the proportion of patients with poor BP control should be included as an indicator to monitor the performance of chronic disease clinics. This will help in identifying specific groups at risk of uncontrolled BP and providing specific interventions to them. This study also highlights the need to explore the reasons due to which the male gender was predisposed to poor BP control. Higher proportion of employed individuals had uncontrolled BP in this study; it is imperative to target this group through workplace interventions such as stress reduction activities, healthy workplace environment, periodic health camps, and health education sessions.
| Conclusion|| |
One-fourth of patients treated for hypertension in PHC failed to achieve goal BP. Considering the consequences of uncontrolled BP, cost-effective, context-specific interventions at PHC level are needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al.
Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens 2014;32:1170-7.
Lawlor DA, Kim L, Morris R, Amuzu A, Whincup P, Ebrahim S, et al.
Survival with treated and well-controlled blood pressure: Findings from a prospective cohort study. PLoS One 2011;6:e17792.
Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, et al.
Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 2013;310:959-68.
Hypertension Study Group. Prevalence, awareness, treatment and control of hypertension among the elderly in Bangladesh and India: A multicentre study. Bull World Health Organ 2001;79:490-500.
Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976) 2000;25:3186-91.
Voils CI, Hoyle RH, Thorpe CT, Maciejewski ML, Yancy WS Jr. Improving the measurement of self-reported medication nonadherence. J Clin Epidemiol 2011;64:250-4.
Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, et al.
Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: Report of the ISPOR task force for translation and cultural adaptation. Value Health 2005;8:94-104.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
Smith A. Exploration of the Benefits of Exercise on the Physical and Mental Well-Being in a Population of Young Adult Survivors of Adolescent and Young Adult Cancer. Texas Christian University; 2015. Available from: https://www.repository.tcu.edu/handle/116099117/10442
. [Last accessed on 2017 Feb 08].
Gupta R, Guptha S, Sharma KK, Gupta A, Deedwania P. Regional variations in cardiovascular risk factors in India: India heart watch. World J Cardiol 2012;4:112-20.
Tamhane AR, Westfall AO, Burkholder GA, Cutter GR. Prevalence odds ratio versus prevalence ratio: Choice comes with consequences. Stat Med 2016;35:5730-5.
Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18:73-8.
Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005;366:1744-9.
Sumit B, Umesh S, Mamta S, Jyoti K, Prakash B. Prevalence, awareness, treatment and control of hypertension among the people above 15 years in rural area Nagpur Maharashtra – A cross sectional study. Natl J Commun Med 2012;3:213-7.
Babiker FA, Elkhalifa LA, Moukhyer ME. Awareness of hypertension and factors associated with uncontrolled hypertension in Sudanese adults : Cardiovascular topic. Cardiovasc J Afr 2013;24:208-12.
Shanthirani CS, Pradeepa R, Deepa R, Premalatha G, Saroja R, Mohan V, et al.
Prevalence and risk factors of hypertension in a selected South Indian population – the Chennai Urban Population Study. J Assoc Physicians India 2003;51:20-7.
Mohan V, Deepa M, Farooq S, Datta M, Deepa R. Prevalence, awareness and control of hypertension in Chennai – The Chennai Urban Rural Epidemiology Study (CURES-52). J Assoc Physicians India 2007;55:326-32.
[Table 1], [Table 2], [Table 3], [Table 4]