INTRODUCTION

Hypertension is a crucial global health challenge because it is associated with a high risk of cardiovascular (CV) and kidney disease.¹ Hypertension is one of the top contributors to the global burden of disease, causing 9.4 million deaths annually.² Many published studies have shown a high prevalence of hypertension in West African communities.^3-5 Nigeria is the most populous African country, and the prevalence of hypertension contributes to the continent’s disease burden. A higher prevalence was found in urban areas compared to rural settlements.⁶ The study conducted among African Americans⁷ and the study done by Pirasath et al,⁸ in Northern Sri Lanka reported female predominance among hypertensive patients. Recent studies in Nigeria have reported the prevalence of hypertension in adults ranging from 26.8% to as high as 51.3%.^9-12

Modifiable risk factors include unhealthy diet, physical inactivity, tobacco and alcohol use and being overweight or obese, while a family history of hypertension, age and co-morbidities such as diabetes or kidney disease are non-modifiable risk factors that contribute to high blood pressure.^13-19 The tertiary care approach to hypertension therapy, based on regular hospital visits, needs to be complemented to effectively address the burden of hypertension. One of these avenues is the task-shifting strategy, which is a meaningful transfer of tasks in tertiary health care from physicians to non-physician health professionals.^20-24 The study assessed patients’ knowledge, attitude and adherence regarding hypertension and its management, and physicians’ practice with reference to the standard treatment guidelines (STGs).

METHODS

Study design

The study was a cross-sectional descriptive study that included hypertensive participants who received treatment within the past six months and utilized medical records for background information on inclusion and exclusion criteria.

Study setting

The study took place in the Cardiology Unit (Special Outpatient Department) of Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH), Awka.

Inclusion criteria

All patients diagnosed of hypertension, who have been receiving hypertensive care for the past six months, 18 years and above, who had given their informed consent to participate in the study. Physicians who gave their informed consent to participate in the study.

Sample size determination

Yamane²⁵ provided a simplified formula to calculate sample sizes. This formula was used to calculate the sample size as shown below:

  n = N/1+N(e)² 

n= Sample size (unknown)

N= Population size

E= margin of error = 0.05

The value 171 was population size of hypertensive patients and 44 was the population size of physicians.

n (hypertensive patients) = 171/1+171/(0.05)² = 171/1.4275 = 119.789 + 10 (attrition) = 130

n = 130 hypertensive patients

n (physicians) =  44/1+44/(0.05)2    = 44/1.11 = 40

n = 40 physicians

Data collection tool and sampling procedure

A pilot study was conducted in COOUTH using 10 hypertensive patients to ensure that the data collection tool passes both face and content validation tests and amendments was made accordingly. The respondents who participated in the pilot study were excluded from the main study to avoid bias after ethical approval was obtained from the Research and Ethics Committee of COOUTH Awka. Previously identified patients and physicians who were eligible and gave their informed consent were consecutively recruited for the study.

Questionnaire design

The Section A contained the social demographics. Eight questions in the Section B for knowledge assessment and 6 questions in the Section C for assessment of patients’ attitude were adapted from Bollampally et al.²⁶ The Section D of the questionnaire used for assessment of adherence was adapted from Pirasath et al.⁸

Physicians’ hypertension management pattern with reference to a standard treatment guideline-based questionnaire

Questionnaire on physicians’ hypertension management pattern was developed with reference to a standard treatment guideline incorporated from the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8, and JNC 7) and the American College of Cardiology Foundation and the American Heart Association (ACCF/ AHA), American College of Obstetrician and Gynecologist and Lifestyle Work Group.²⁷

Data analysis

The data was analyzed with IBM SPSS Statistics version 23. Descriptive statistics such as frequency, mean, standard deviations and percentages was used to present the data. A cut-off above the mean score was used to assess “good” knowledge and “positive” attitude, while adherence was assessed using Morisky Medication Adherence Scale of 8-point questions. Scores for the scale range within low adherence (<6), medium adherence (6 to 8), and high adherence (=8). The therapeutic Adherence Scale for Hypertensive patients was used to assess physicians’ hypertension management. A 5 points Likert scale was used to score the therapeutic adherence scale for hypertensive patients with the least value 1 (never) to 5 points (all the time) assigned, respectively, and reverse scores are assigned for reverse questions. The scores ranged from 25 to 125 in which the highest scores indicated greater adherence. A cut-off score of 109 was used to distinguish satisfactory and low adherence behaviors. Scores were obtained, divided by 125 and multiplied by 100 to convert them to percentage.^27,28,29

RESULTS

Table 1: Sociodemographic characteristics of the patients

Table 2:  Patients’ responses to the knowledge of hypertension

Table 3: Patients’ attitude towards hypertension management

Table 4: Patients’ adherence to medication use in hypertension management

 Table 5: Patients’ knowledge, attitude and adherence Levels in hypertension management

Table 6:  Socio-Demographic characteristics of the doctors

Table 7:  Correct answers by doctors to questions on hypertension classification, management goal and drug combination

Abbreviations: HTN = Hypertension, BP = Blood pressure

Table 8:  Correct answers by doctors to questions on hypertensive patients with compelling indications

Abbreviations: HF = Heart failure, CKD = Chronic Kidney disease, CVA = cerebrovascular accident, DM = Diabetics Mellitus, MI = Myocardial infarction.

Table 9: Correct answers by doctors to questions on lifestyle modifications in hypertension management

Abbreviations: DASH = Dietary approach to stop hypertension

Table 10: Correct answers by doctors to questions on ACEI and ARB combination as well as β blockers without compelling indication (n=40)

Abbreviations: ACEs = Angiotensin converting enzyme inhibitors; Arbs = Angiotensin receptor blocker.

DISCUSSION

Majority of the patients were females and similar to the study conducted among African Americans ⁷ and the study done by Pirasath, et al,⁸ in Northern Sri Lanka whom in their studies reported female predominance among hypertensive patients. These findings may be attributed to the loss of estrogen during menopause and the fact that women have good health seeking behavior and are likely to be more diagnosed of the condition. The finding is contrary to the study by Akinlua et al,³⁰ who recorded a higher prevalence level in male. Most of the participants fell within the age range of 46-64 years. This agrees with the findings by Chimberengwa and Naidoo³¹ who reported the mean age of hypertensive patients to be 59 years. Most of the participants in this study were married and self-employed.

The knowledge of hypertension among hypertensive patients was low with about 56.9% of them having poor knowledge of hypertension. This agrees with the findings of most studies irrespective of the place it was carried out and may be due to inadequate educational programs.^13,31-33 This study also recorded a high level of negative attitude towards hypertension management among the participants (83.8%) which is in line with the study conducted by Das et al in Kolkata, India.¹³ The study showed low level of adherence to medication use in hypertension management which is in line with the study done by Pirasath et al⁸ in Northern Sri Lanka who reported low adherence level. The results of this study showed that most of the physicians have heard about the guidelines of JNC 8 without necessarily reflecting on their utilization in practice. Regarding hypertension classification, management goal, and drug combinations, most of the participants knew the correct definition of the prehypertension stages. The outcome was higher compared to the study that was conducted in Jordan by Al-Azzam and his colleagues.³⁴ It is higher than the study conducted in Saudi Arabia by Al-Gelban, et al.³⁵

In hypertension with compelling indications, such as chronic kidney disease, diabetes mellitus, heart failure, ischemic heart disease, and cerebrovascular accident, specific antihypertensive medications classes are recommended to ameliorate disease progression and improve patient’s outcome.^36,37 However, in COOUTH, lesser proportion of the physicians agreed to use Angiotensin converting enzyme (ACE) inhibitors or Angiotensin receptor blocker (ArBs) as the first line therapy for the management of hypertension with renal impairment in cases without renal artery stenosis. Physicians’ management pattern in this study was similar to that of Jordanian physicians and lower than that of Saudi physicians.^34,35 Again, the variation in the awareness between studies may be attributed, in part, to the time of releasing JNC 7 guidelines. In this study, the guidelines have been disseminated and adopted by COOUTH physicians since the JNC 7 report was released in 2003 compared with the Jordanian study, which was conducted two years after the release of the JNC 7 guidelines.

 Most of the physicians (85%) agreed to use ACE inhibitors, ArBs, thiazide diuretics or calcium channel blockers as the first line therapy for this group of patients. Most physicians (74.3%) in Saudi Arabia agreed to use any of the above medications as first line in a hypertensive patient with diabetes, meaning that the recommendations of JNC 8 guidelines were well adopted by COOUTH physicians.³⁵ The use of ACE inhibitor, β-blockers, diuretics, and spironolactone as a standard combination for patients with heart failure in stage C has advantages such as slowing the progression of heart failure and remodeling, decreased mortality, and improved patient’s quality of life.³⁸ Most of the physicians agreed to use this standard therapy in hypertensive patients with stage C heart failure. Previous studies showed that 40.1% of Jordanian physicians and 43% of Kuwaiti physicians correctly selected ACE inhibitors and ArBs, respectively, as the first line in a hypertensive patient with heart failure.^34,39 Majority of the physicians agreed to use β-blockers with ACE inhibitors as a first line therapy in a patient who has myocardial infarction and hypertension. Only, 59.3% of the Jordanian physicians correctly selected β-blockers as a first line in a hypertensive patient with ischemic heart disease.³⁴

Labetalol is recommended as a first line agent in pregnant women with severe hypertension.⁴⁰ Several studies revealed that labetalol is a preferred antihypertensive agent in chronic hypertension during pregnancy, especially in severe cases since methyldopa has a mild effect on hypertension with slow onset and nifedipine has many adverse effects.^40,41 β-blockers, according to JNC 8, are no longer recommended as first line agents to treat hypertension in patients without compelling indication owing to their association with greater risk of cardiovascular death when compared with amlodipine-based regimen.^42,43

This study suggested that the adherence of physicians to the STGs was moderate  in COOUTH. Combination therapy of ACE inhibitors and ArBs during the management of hypertension patients should be avoided according to JNC 8. However, less than a half of the COOUTH physicians agreed not to combine ACE inhibitors with ArBs in a patient with hypertension, which is low compared to the result obtained from the Family and Internal Medicine Residents in Saudi Arabia, where most of them agreed not to use ACE inhibitors and ArBs together.⁴⁴ Majority of the participants recommended weight loss, moderate physical exercise, Dietary approach to stop hypertension (DASH), and reduction of sodium intake, respectively, as parts of lifestyle modifications for a patient with hypertension. Similar findings were obtained from another study conducted in Saudi Arabia.³⁵

CONCLUSION

The study indicated lack of strict adherence to the standard treatment guidelines by physicians. Majority of the patients had poor knowledge of hypertension and attitude towards hypertension management. Majority of the patients showed poor adherence to medication use in hypertension management due to forgetfulness, inability to stick to medication plan and stopping of medication when they feel okay. There is need for continuous medical education programs for physicians so that their practice will follow the National Standard Treatment guidelines always.

CONFLICT OF INTEREST

The authors have none to declare

FUNDING

The study did not receive funding from any organization.

ETHICAL APPROVAL

Ethical approval was obtained from the Research and Ethics Committee of Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Awka