Comparing the knowledge and management of hypertensive individuals

doi:10.21203/rs.3.rs-2817107/v1

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Comparing the knowledge and management of hypertensive individuals

https://doi.org/10.21203/rs.3.rs-2817107/v1

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Background

Aim

To determine the knowledge and management of hypertension in private and public health care sectors in an African population.

Method

One hundred and thirty-seven sample population was taken from black ethnic community. The cross-sectional study was used as a convenience sampling of participants. Interview-led questionnaires were also used to assess participants’ demographic information, hypertension management and lifestyle factors.

Results

Data analysis yielded the group’s overall blood pressure 124.7/79.6mm Hg with public health care sector (125.9/80.3mm Hg) and the private health care sector (123.3/78.8mm Hg) (p = 0.4). The participants showed significant differences within the groups on all the ‘Medication and adherence’ and ‘Management of hypertension’ categories.

Conclusion

Both the participants of the private health care sector and public health care sector had the same understanding of the knowledge and management of hypertension, as well as its risk factors.

Contribution:

The objectives of the study were met through the clinical application understanding the knowledge and management of hypertension and its risk factors to help identify the differences between the patients utilising public and private health care providers.

Hypertension

Knowledge

Management

South Africa

Lifestyle modification

Hypertension is one of leading risk factors for death and disability globally, and accounts for 22% of the adult population [1]. In South Africa and other sub-Saharan African countries, the presence of hypertension has increased significantly more than 80% [2] and is a driver of cardiovascular disease [3] accounting for 17.3 million deaths [4]. Low- and middle-income countries bear the greatest burden of cardiovascular disease-related disease [5], with an estimated prevalence of hypertension ranging from 39%-49% [6]. South Africa has one of the highest prevalence rates of hypertension worldwide reaching 77.9% in those above 50 years [7]. Hypertension is the fastest growing non-communicable disease in South Africa, with hypertension the major cause of death among patients with non-communicable disease [8].

The high prevalence of hypertension in South Africa can be attributed to poor community assessment, limited protocols for treatment and management of the disease and the relatively asymptomatic characteristic of the disease such that individuals are only diagnosed at later stages of disease progression with comorbidities accounting to about 53 men and 78 women dying daily from hypertension [4]. The South African health care system has the necessary infrastructure, but mismanagement and lack of medical care staff present are additional challenges that have led to poor patient management [9]. Likewise, knowledge of hypertension, including prevention and disease management such as self-monitory are important for obtaining community reduction [10]. Evidence from an intervention study to educate hypertensives on the diseases demonstrated a reduction of ≥5mm Hg [10]. Amongst hypertensive patients, improved hypertension knowledge is also linked with adherence to blood pressure lowering medication [11].

The management of hypertensives in South Africa is also challenging [12]. In South Africa and other low- and middle-income countries, achieving blood pressure control can be complicated by several factors such as commodities, compliance, lifestyle behaviour modification and access to health care [12]. The poor are generally exposed to limited care, whilst the rich receive better treatment and management due to established control measures aligned with premium health care models [13]. The latter have access to well-resourced facilities and trained staff employed in private health care, while the former is faced with a disparate public health system ripe with financial constraints and corruption [13]. The long waiting times and mismanagement of chronic disease in the public health system can also have dire consequences for patient care [9]. There are limited studies on the management of hypertension and knowledge of the disease from the patients’ perspective in South Africa. The aim of the study was to determine the knowledge and management of hypertension in private and public health care sectors in an African population. This sample was based on the known presence of elevated blood pressure, 33% in KwaZulu-Natal [12], and therefore increased risk of hypertension.

Study population

The sample population was taken from black ethnic community, Umlazi Townships in KwaZulu-Natal. Participants who met the inclusion criteria (as described below in study design) and who utilized strictly public or strictly private health care sectors to manage their hypertension were invited to participate. Umlazi Township is facilitated by 1 primary hospital (Prince Mshiyeni Memorial Hospital) which caters for more than five other townships in the south of Durban, other than Umlazi Township, KwaZulu-Natal.

Study design

This cross-sectional study was used a convenience sampling of participants in a form of printed advertisements placed on clinics advertisement walls, the doctor’s rooms and community halls followed by snowball sampling of participants through word of mouth, in and around the area of Umlazi Townships. The inclusion criteria of participants were if (i) diagnosed with hypertension by a medical professional; (ii) taking antihypertensive medication prescribed by a medical doctor, (iii) utilising sole public or sole private health care sector to manage hypertension and (iv) living in the Umlazi area. Participants suffering and/or recovering from stroke or any other co-morbidity that may affect their physical abilities, and those diagnosed with hypertension but are not currently taking hypertensive medication were excluded from the study.

Data collection procedures

All data was collected by the researcher according to standardised procedures (ACSM’s Guideline for Exercise Testing and Prescription, 2013) [10]. Resting blood pressure was measured using a HI-CAREINT cuff and HI-CAREINT, KT-102 stethoscope, with an adult cut-off point of ≥ 160/100mm Hg. Weight (kg) was measured using a Pure Pleasure Glass, BSG01 scale and height (m) using a Topline measuring tape mounted on the wall. Waist circumference measurements were made with a flexible yet inelastic tape measure. Hypertension defined as a persistent elevation of office blood pressure ≥ 140/90 mm Hg. The optimal blood pressure is a value < 130/85 mm Hg. high normal is blood pressure levels from 130–139mm Hg systolic and 85–89mm Hg diastolic [14]. Interview-led questionnaires were also used to assess participants’ demographic information, hypertension management and lifestyle factors. Diagnosis, knowledge, and current treatment of hypertension was measured using an adapted version of the World Health Organisation’s patient questionnaire: Developing Integrated Response of Health Care System to Rapid Population Ageing, a widely used questionnaire to track patient’s hypertension diagnosis, management, complications, medication adherence and knowledge of self-care. Reliability was confirmed before starting the submission, the interviewer had to check the inclusion criteria. The respect of the inclusion criteria was crucial to avoid any bias. Thus, the interviewer had to pay particular attention to the procedure. Validity the questionnaire numbers had to correspond to the question number in the questionnaire. Only questions that need additional comments were taken into consideration. In general, interviewer can rely on specific instruction given to the single question. This manual was only a support in preparation of the submission. Physical activity levels were measured using the Global Physical Activity Questionnaire [15]. The Global Physical Activity Questionnaire provides reproducible data and showed a moderate-strong positive correlation with International Physical Activity Questionnaire, a previously validated and accepted measure of physical activity [16]. Overall, the results indicated that Global Physical Activity Questionnaire is a suitable and acceptable instrument for monitoring physical activity in population health surveillance systems [16]. The Global Physical Activity Questionnaire was used to quantify moderate-to-vigorous-intensity physical activity as Metabolic Equivalents minutes per week (Metabolic Equivalents minutes per week (mins/wk)). Time min/wk spent in each domain (work, travel and recreation) is calculated, as well as the total physical activity Metabolic Equivalents mins/wk, according to the World Health Organisation STEPwise method (http://www.who.int/chp/steps/resources/GPAQ_Analysis_Guide.pdf).

Ethical Considerations

Ethical permission for conducting the study was obtained by the Human Research Ethics Committee (Medical), University of the Witwatersrand (ethics certificate number M161034). Permission to invite participants from a provisional hospital was obtained from the KwaZulu-Natal National Department of Health (HRKM117/17 KZ_2017RP1_590). The Informed Consent form was included before confirmation of participation, to ensure that appropriate safety procedures were taken regarding the well-being during testing of participants.

Data Analysis

Data analysis was conducted using Statistic version 14 (TIBCO Software Inc. (2020). Data Science Workbench, version 14. http://tibco.com.). Results are expressed as means ± standard deviation. For normally, distributed continuous data (anthropometry, blood pressure), an independent by variables t-test was used to determine any significant differences between the two groups: public and private health care sectors. For non-normally distributed or categorical data (marital status, level of education, knowledge, and management outcomes). We calculated descriptive statistics to characterize the distribution of the study results and t-test, independence, by groups was used to determine any significant differences between the two groups: public and private health care sectors. Statistical significance was set at p-value ≤ 0.05.

Participant Characteristics

The sample of N = 137 included 91 (66.4%) females and 46 (33.6%) males. Participants managed by public health care were older, had a higher proportion with employment, but lower percentage of participants having completed high school than participants managed by private health care (p < 0.05). Both groups reported similar blood pressures, and both systolic blood pressure and diastolic blood pressure reflected good blood pressure management (Table 1). The participants being managed by private health care had a higher proportion of individuals in favour of lifestyle modification as suggested by the lower number of participants consuming alcohol and tobacco.

Table 1

Demographic Characteristics
Characteristics	Total	Public Health care Sector (n = 77)	Private Health care Sector (n = 60)
Age (years)	62.8 ± 10.3	64.6 ± 10.8	60.4 ± 9.2^*
Sex
Female, n (%)	91 (66.4)	51 (66.2)	40 (66.7)
Male, n (%)	46 (33.6)	26 (33.8)	20 (33.3)
Marital Status
Single/Separated/ Divorced/ Widowed, n (%)	66 (48.2)	40 (52.0)	26 (43.3)
Married/ Cohabiting, n (%)	71 (51.8)	37 (48.1)	34 (56.7)
Highest level of Education
No school attended, n (%)	9 (6.6)	9 (11.7)	0 (0.0)^*
Primary completed, n (%)	18 (13.1)	17 (22.1)	1 (1.7) ^*
Incomplete Secondary, n (%)	26 (19.0)	22 (28.6)	4 (6.7) ^*
Completed high school, n (%)	84 (61.3)	29 (37.7)	55 (91.7)^*
Occupation
Unemployed, n (%)	83 (60.6)	35 (45.5)	48 (80.0)^*
Employed (Skilled and Unskilled), n (%)	54 (39.4)	42 (54.6)	12 (20.0)^*
Household Income
<$3651pa, n (%)	34 (24.8)	32 (41.6)	2 (3.3)^*
$3652-$7301pa, n (%)	35 (25.5)	20 (26.0)	15 (25.0)
>$7302pa, n (%)	68 (49.6)	25 (32.5)	43 (71.7)^*
Anthropometry and blood pressure
Body mass (kg)	76.8 ± 15.1	75.4 ± 14.6	78.7 ± 15.6
BMI (kg·m²)	30.4 ± 6.2	29.8 ± 6.1	31.1 ± 6.3
Waist circumference (cm)	102.2 ± 17.0	100.4 ± 17.0	104.5 ± 16.8
Systolic BP (mm Hg)	124.7 ± 16.0	125.9 ± 15.9	123.3 ± 16.1
Diastolic BP (mm Hg)	79.6 ± 12.1	80.3 ± 12.3	78.8 ± 12.1
Lifestyle behaviours
Meeting physical activity guidelines, n (%)	63 (46.0)	32 (41.6)	31 (51.7)
Sedentary behaviour (min/day)	287.6 ± 119.0	293.8 ± 125.2	279.9 ± 111.2
Smoking/tobacco cessation	66 ± 48.2	30 ± 39.0	36 ± 60.0^*
Not drinking alcohol	58 ± 42.3	27 ± 35.1	31 ± 51.7^*

Data presented as n (%) for categorical data and mean ± SD for continuous data; ^*p < 0.05 private versus public health care.

Knowledge of Hypertension

Of the 77 participants in the public health care sector, 84.4% (n = 65) with controlled blood pressure reported they regularly take all their prescribed medication, when comparing to the 15.6% (n = 12) with the uncontrolled blood pressure. Similar trend is seen in the private health care sector, 91.7% (n = 55) with controlled blood pressure compared to 3.3% (n = 2) uncontrolled blood pressure, with a significant different within the groups (p = 0.001*) and between the groups (p = 0.05^) (Table 2).

Management of Hypertension

In the public health care sector, 67.5% (n = 52) of the controlled group stated that they were informed by a health care provider to control their blood pressure, comparing to 13% (n = 10) of the uncontrolled that did not indicate they were informed. A similar trend was also seen in the private health care sector where 95% (57) of the controlled blood pressure group were informed to control their blood pressure comparing to 5% (n = 3) of the uncontrolled group. A significant difference was seen within the group (p = 0.004*) and between groups (p = 0.0004^). Again, when compared to 12 months ago, the public health care sector had 54.5% (n = 42) of controlled blood pressure mentioned their blood pressure was better, where 4.0% (n = 3) with uncontrolled blood pressure also felt their blood pressure was better. When looking at the same effect in the private health care sector 58.3% (n = 35) with controlled blood pressure felt their blood pressure was better and 0% of those had uncontrolled blood pressure. A significant difference was seen within the groups (p = 0.01*) and between the groups (p = 0.007^).

Table 2

Factors related to hypertension management and knowledge
Characteristics	Public Health care Sector (n = 77)			Private Health care Sector (n = 60)
	Controlled	Uncontrolled	P Value	Controlled	Uncontrolled	P Value
Medications and adherence
Have you been prescribed any medications to lower your blood pressure?	65 (84.4)	12 (15.58)	1.00	57 (95.0)	3 (5.0)	1.00
Do you regularly take all your prescribed medications?	65 (84.4)	12 (15.6)	0.001*	55 (91.7)	2 (3.3)	0.05^
Number of medications/day	4.0 ± 1.1	4.8 ± 1.1	0.35	4.2 ± 1.4	5.3 ± 1.5	0.23
I don’t like the side effects	1 (1.3)	1 (1.3)		2 (3.3)	0 (0)
I prefer alternate medicines	16 (20.8)	2 (2.6)		20 (33.3)	1 (1.7)
I forget to take my medicines	15 (19.5)	5 (6.5)		12 (20.0)	2 (3.3)
Knowledge and Self-care
Aware of hypertension complication?	55 (71.4)	12 (15.6)	0.46	49 (81.7)	3 (5.0)	0.21
If yes, informed by the doctor/ nurses about these complications?	48 (62.3)	10 (13.0)	0.20	50 (83.3)	3 (5.0)	0.16
Have been told that stroke is related to hypertension?	51 (66.2)	11 (14.3)	0.36	50 (83.3)	3 (5.0)	0.30
Knowledge of Risk Factors
Unhealthy diet	49 (63.6)	9 (11.7)	0.17	51 (85.0)	3 (5.0)	0.12
Alcohol	56 (72.7)	11 (14.3)	0.87	50 (83.3)	3 (5.0)	0.77
Smoking	54 (70.1)	9 (11.7)	0.72	45 (75.0)	3 (5.0)	0.60
Physical inactivity	49 (63.6)	8 (10.4)	0.54	46 (76.7)	3 (5.0)	0.43
Management
Informed by a doctor/ nurse to control your blood pressure?	52 (67.5)	10 (13.0)	0.004*	57 (95.0)	3 (5.0)	0.0004^
When do you go for your routine blood pressure check as advised by the doctor?	25 (32.5)	2 (2.6)	0.14	28 (46.6)	2 (3.33)	1.22
Do you and/or a family member/neighbour regularly check your blood pressure?	9 (11.7)	0 (0)		9 (15)	0 (0)
Compared to 12 months ago, do you think that your blood pressure is better?	42 (54.5)	3 (4.0)	0.01*	35 (58.3)	0 (0)	0.007^
Family member with hypertension	45 (58.4)	10 (13.0)		42 (70)	2 (3.33)
Complications and Hospitalisations	65 (84.4)	12 (15.6)		57 (95.0)	3 (5.0)

Data presented as n (%); ^*p < 0.05 for Chi square model comparing within group; ^ p < 0.05 for Chi square model comparing between groups.

The purpose of the study was to determine the knowledge and management of hypertension in private and public health care sectors in an African population. Findings from this study yield important insight of the knowledge and management of hypertension to understand trends of the current study population to be able to find ways to improve their management. This study found that the average blood pressure for its participants was classified as normal blood pressure for both the public health care sector (125.9/80.3mm Hg) and the private health care sector (123/78.8mm Hg), respectively. Both the groups had an average blood pressure classified as normal, which suggests that most of the participants in both groups do manage their blood pressure according to the guidelines given to them by their health care provider. similar findings were seen in the study by Rampamba [17] where most patients knew hypertension is dangerous to their health and that taking antihypertensive medication as prescribed or advised is necessary to control their blood pressure. This suggests that patients are likely to comply with their medicines with increasing knowledge about the benefits of taking their medication [17], increasing patients’ knowledge can improve hypertension management [18]. This will in turn result in the participants yielding lower risks for stroke, symptomatic cardiovascular disease, and premature mortality [19].

Although low adherence levels of hypertension have been documented in South Africa for several long-term treatment regimens [20]. Monakali [2], found that of those participants who were aware of their hypertension 38.1% status and were on treatment, only had their blood pressure well controlled. Among those who reported use of blood pressure medication, only 52.0% had controlled blood pressure which may be due to poor adherence to antihypertensive medications or possibly ineffective medication [20]. This study also showed that when compared to 12 months ago both the private and public health care sector participants, had similar control of blood pressure which suggests that neither participant had better management of hypertension as compared to the other. However, the majority of the participants of the private health care sector were aware of hypertension complications when compared to those of the public health care sector of those participants that had controlled blood pressure, co-morbidities may be contributing factors to these differentials. It is also worth noting that very few patients were aware as to how blood pressure readings are recorded in their files and understood the meaning of the blood pressure reading numbers, as well as what normal blood pressure readings should be, indicating that patients did not know their treatment target [17].

Majority of the private health care sector stopped smoking and consuming alcohol when compared to those of the public health care sector (Table 1). Similar findings were seen in other studies were most of the patients were also not consuming alcohol and were not smoking, and half of the patients indicated reducing or stopping salt intake has assisted in reducing high blood pressure [17]. If not, consuming alcohol is maintained in the long term, results in improved blood pressure management and increases life expectancy. There is strong and consistent evidence that reducing sodium intake reduces blood pressure [21]. Significant findings were seen in the public health care sector where majority of the uncontrolled participants did not take their medication regularly and were informed by a health care provider to control their blood pressure (Table 2). Indicating that there is a need for public health care participants to be continuously given hypertension information and be empowered with specific knowledge on hypertension in order to improve their management.

Although respondents in the General Household Survey also reported higher levels of problems in public hospitals than in private hospitals, other than in care being too expensive [9], this was not the case in the current study’s findings. The true differential in the burden of non-communicable diseases between the public and private sectors is unknown and will vary by disease due to differences in the underlying risk factors [9]. Africa has a clear commitment to address social determinants that are associated with health; the challenge is to move into action [22]. To providing guidance for a healthy lifestyle, physicians and nurses should also encourage their patients to measure and understand blood pressure at home by themselves [1]. Patients’ education about hypertension, together with guidance for self-measurement of blood pressure and routine assessment of whether home blood pressure measurement took place, might be among the responsibilities of primary clinic nurses [1]. It is also important for all health care providers in health facilities to continuously assess hypertensive patients understanding and knowledge of their disease, as well as the type of information they received [17].

Strengths and Limitations

We are aware of the limitations of this study, which include the subjectively measurements of the trends of hypertension management and knowledge between the public and private health care sector and is the first study conducted in such a population, which does not represent all the townships in the country. It also used self-reported data and did not take into consideration the accuracy of the subjective nature of the questionnaires and objective observation - the clinical records might have given more precise outcomes of the differences between the two groups.

The differences in the management of hypertension between public and private health care sector in South Africa goes beyond the type of health care provider the participates utilise to manage their hypertension – their socioeconomic status, level of school and the type of occupation they have, just to name a few, can also have a major significance in type of health care provider they utilise. Both the private and public health care sector groups had moderate management of hypertension, regardless of the knowledge they had in managing hypertension.

Ethics approval and consent to participate: The research design and procedures of the research study was submitted to the Human Research Ethics Committee (Medical), of the University of the Witwatersrand (M161034). Permission to invite participants from a provisional hospital was obtained from the KwaZulu-Natal National Department of Health (HRKM117/17 KZ_2017RP1_590). The authors can confirm that all experimental protocols were approved by both the above mentioned human research Ethics Committees. The Informed Consent form was included before confirmation of participation of all participants, to ensure that appropriate safety procedures were taken regarding the well-being during testing of participants. To ensure that appropriate safety procedures were taken regarding the well-being during testing of human participants: right to privacy or nonparticipation, right to remain anonymous, right to confidentiality, right to withdraw from the study without any negative consequences were informed and communicated to the participants (N.B. The absence of formal education did not constitute illiteracy of understanding the study procedure for any of the participants). All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication: Not Applicable.

Acknowledgements: No acknowledgements.

Competing interests: The authors declare that no competing interests exist. The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced in writing this article. The funders played no role in the design, conduct, or reporting of this study.

Author contributions: Conceptual design: Mandisa Simamane and Philippe Gradidge; Data collection and curation: MS; Data analysis and interpretation: MS and PG; Writing of the manuscript: MS and PG; Supervision of the postgraduate research project: Demitri Constantinou and Estelle Watson.

Funding: This study was funded by the National Research Foundation (NRF) of South Africa, Postgraduate Funding, Innovation (Reference Number SFH150728132039).

Data availability: The primary researcher had the identifying responses of individual participants, and every effort was made to prevent anyone outside the study from connecting the participants by having code numbers for participants raw data. Records identifying information, were kept in a separate document that links the study code to subjects’ identifying information. Raw data is accessible by the researchers and can be made available upon request to Ethics committee and DHET journal intended to publish in.

Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

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No competing interests reported.

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Comparing the knowledge and management of hypertensive individuals

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Abstract

Introduction

Methods

Study population

Study design

Data collection procedures

Ethical Considerations

Data Analysis

Results

Participant Characteristics

Knowledge of Hypertension

Management of Hypertension

Discussion

Strengths and Limitations

Conclusion

Declarations

References

Additional Declarations

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