Self-rated health and its determinants in patients with hypertension in Isfahan in 2019

doi:10.21203/rs.3.rs-3223425/v1

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Self-rated health and its determinants in patients with hypertension in Isfahan in 2019

https://doi.org/10.21203/rs.3.rs-3223425/v1

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published 15 Feb, 2024

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Background and Objectives:

This article examines the self-rated health (SRH) and its determinants in Iranian patients with hypertension (HTN). SRH is a measure of satisfaction with social, mental, and physical health and has been widely used in public health research. The study aims to identify the factors that influence SRH among hypertensive patients in Iran.

Material and Methods

The data were obtained from a project evaluating the impact of hypertension guidelines on patient care. A total of 886 patients with essential HTN were included in the study. The patients' demographic and clinical characteristics, including education, income, comorbidities, and HTN control, were assessed.

Results

The results showed that higher education level and income were associated with better SRH. Patients without diabetes had higher SRH scores.

Conclusion

This study highlights the importance of socioeconomic factors and comorbidities in determining SRH among hypertensive patients in Iran. The findings can contribute to the development of interventions and strategies for improving HTN treatment and prevention in Middle Eastern countries.

Self-rated health

Blood pressure

Hypertension

Socioeconomic status

Chronic disease

Iran

A person's level of satisfaction with various aspects of their social, mental, and physical health is known as their "self-rated health" (SRH)(1). As a result of SRH's simplicity, reliability, validity, and putative biological basis, it has been frequently employed in public health research (2–4). Large-scale studies have highlighted that SRH is closely correlated to cardiovascular health outcomes(5), morbidity, and mortality in people(4). SRH’s results indicate a wide range of variability across different ethnicities, countries, and also genders, which is partly due to the impact of demographic variables (e.g., age and sex), lifestyle, physical activity, income, and education of individuals(6). Additionally, another important factor affecting SRH and patients’ quality of life is the presence of chronic disease(7). One of the most significant chronic diseases is hypertension (HTN), which not only has significance as a standalone condition but also considerably influences the likelihood of developing other noncommunicable diseases, such as cardiovascular disease, cerebrovascular disease, and chronic kidney disease (CKD) (8). This disease is considered the first priority in cardiovascular research in Iran (9). Moreover, HTN enormously has influenced the economy around the world, especially in Middle East countries enormously (10, 11). The estimated prevalence of HTN in the Middle East and North Africa is 26.2% according to a recent meta-analysis of 147 studies with an increasing trend over the past decades(12). However, awareness and treatment have not improved notably (10, 13). Therefore, early interventions are essential to reduce the deleterious effects of HTN and its accompanying complications.

Several recent endeavors have evaluated the relationship between blood pressure (BP), SRH, and overall quality of life. For instance, in a study conducted on Chinese people, there was a substantial link between controlled blood pressure (BP) and excellent SRH (8). Furthermore, poor control of HTN and suboptimal SRH score in Australian patients were associated with a higher frequency of visiting general practitioners monthly (14). Although SRH’s determinants have been evaluated in some nations; studies are scarce regarding SRH and its determinants in hypertensive patients in Iran. As a result, we aimed to determine SRH and its determinants in Iranian patients with diagnosed HTN. This research has the potential to pave the way for significant improvements in HTN treatment and prevention in Middle Eastern countries.

Study participants

We used the data from our previous project entitled “Assessing the Impact of Training general practitioners the latest hypertension international and National Guidelines on Controlling their Under-Treatment Hypertensive Patients” that was approved with the ethical code IR.MUI.MED.REC.1398.311.

The study population consisted of men and women with essential HTN who were registered in Isfahan's Comprehensive Health Service Centers (CHSCs). Eight hundred eighty-six patients were selected using a multistage sampling procedure. Inclusion criteria included an age between 30 and 70 years old, a diagnosis of essential HTN, and taking at least one anti-hypertensive medication. Our exclusion criteria included being over 70 or under 30, suffering from an incurable illness (such as cancer in an advanced stage), having mental retardation, or lack of agreement to participate in the study. Informed consent was obtained from all patients participating in the study. The current study was approved by the Ethics Committee of Isfahan University of Medical Sciences (ethical code: IR.MUI.MED.REC.1399.1165).

Assessments and measurements

Through the use of a checklist, trained interviewers gathered patients’ sociodemographic data (e.g., age, gender, educational level, employment, monthly income and marital status), comorbidities (including dyslipidemia, diabetes, and pulmonary disease), controlled HTN, taking antihypertensive medicines and compliance to treatment.

Controlled HTN was defined as systolic and diastolic blood pressure lower than 130 and 80 mmHg, respectively, despite taking antihypertensive medicines (15). SRH was asked based on a 5-point scaled question recommended by the World Health Organization (16) “In general, how would you describe your current state of health?”. We dichotomized SRH into 2 categories good (comprising of the answers intermediate, good, and very good) and poor (comprising the answers bad and very bad) in line with other studies (17, 18).

Statistical analysis

We used IBM SPSS 25 software for data analysis. Quantitative and qualitative variables were described using mean (standard deviation (SD)) and number (%), respectively A comparison of quantitative and qualitative variables between patients with good or poor SRH was performed using the independent sample test and chi-square test, respectively. To identify predictors of SRH in patients with HTN we used logistic regression. We applied the forward strategy, recommended by Hosmer and Lemeshow (19) to determine SRH predictors. In the first step, we ran a univariate logistic regression for age, sex, education, employment, marital status, income, diabetes, dyslipidemia, pulmonary disease, HTN control, taking antihypertensive medicines and compliance with treatment, one by one. Then, we entered all variables with a P value below 0.2 in the first step in a multivariable logistic regression. Variables with a P value below 0.05 remained in the final model.

Sample characteristics

Eight hundred eighty-six subjects attended the study, of which 71.9% were female. The mean age of the participants was 57.8 ± 8.8 (range 32–84). Among the whole sample, 571 (87.4%) were married, and 82 (12.6%) were unmarried. Most of the patients had nonacademic education (71.9%) and a monthly income below < 20,000,000 IRR (84.7%). Three hundred eighty-one (43.7%) patients had diabetes. Further details are presented in Table 1.

Table 1

– characteristics of Participants in total and by self-rated health status
Variable		n (%)
Age		57.8 (8.8)
Gender (male)		249 (28.2)
Education	Illiterate	164 (18.6)
	Non-academic education	636 (71.9)
	Academic education	84 (9.5)
Employment	Employed	122 (13.8)
Employment	Unemployed	762 (86.2)
Marital status	Married	571 (87.4)
Marital status	Unmarried	82 (12.6)
Monthly income	< 20,000,000 IRR	749 (84.7)
Monthly income	≥ 20,000,000 IRR	135 (15.3)
Diabetes (yes)		381 (43.7)
Dyslipidemia (yes)		516 (59.9)
Pulmonary disease (yes)		70 (8.0)
Systolic blood pressure		133.2 (16.6)
Diastolic blood pressure		78.7 (10.5)
HTN control (yes)		338 (38.5)
Taking anti-hypertensive medicine	Regular	831 (94.1)
	Irregular	48 (5.4)
	No treatment	4 (0.5)
Compliance to treatment	Low	224 (25.5)
	Intermediate	315 (35.9)
	High	339 (38.6)
IRR: Iranian Rial

Description of SRH by exploratory variables

Seven hundred ninety-four patients (89.6%) rated their health as good, and 90 (10.2%) patients reported poor SRH. Two subjects did not answer this question. The comparison of participants with good and poor SRH in terms of demographic and clinical characteristics is displayed in Table 2. The SRH distribution was significantly different among different levels of education (p = 0.005), as the illiterate participants rated their health lower than the educated group. Additionally, monthly income had a significant association with SRH (p = 0.003), with high-income patients reporting higher levels of SRH. Good SRH was more prevalent in older, male, married, and employed patients; however, these differences were not statistically significant (p = 0.116 to 0.647). Diabetes mellitus, hyperlipidemia, and pulmonary diseases had significant associations with poor SRH (p < 0.001, P = 0.008, and P = 0.041, respectively).

Table 2

Description of self-rated health by exploratory variables
Variable		SRH (%)		p-value
Variable		Good SRH	Poor SRH	p-value
Age	≤ 60 years	465 (90.6)	48 (9.4)	0.341†
Age	> 60 years	329 (88.7)	42 (11.3)	0.341†
Gender	Male	230 (92.4)	19 (7.6)	0.116†
Gender	Female	564 (88.8)	71 (11.2)	0.116†
Education	Illiterate	136 (82.9)	28 (17.1)	0.005†
	Non-academic education	581 (91.4)	55 (8.6)
	Academic education	77 (91.7)	7 (8.3)
Employment	Employed	111 (91.0)	11 (9.0)	0.647†
Employment	Unemployed	683 (89.6)	79 (10.4)	0.647†
Marital status	Married	512 (89.7)	59 (10.3)	0.136†
Marital status	Unmarried	69 (84.1)	13 (15.9)	0.136†
Monthly income	< 20,000,000 IRR	663 (88.5)	86 (11.5)	0.003†
Monthly income	≥ 20,000,000 IRR	131 (97.0)	4 (3.0)	0.003†
Diabetes	Yes	327 (85.8)	54 (14.2)	< 0.001†
Diabetes	No	456 (93.1)	34 (6.9)	< 0.001†
Dyslipidemia	Yes	453 (87.8)	63 (12.2)	0.008†
Dyslipidemia	No	322 (93.3)	23 (6.7)	0.008†
Pulmonary disease	Yes	58 (82.9)	12 (17.1)	0.041†
Pulmonary disease	No	727 (90.5)	76 (9.5)	0.041†
hypertension control	Yes	490 (90.7)	50 (9.3)	0.221†
hypertension control	No	298 (88.2)	40 (11.8)	0.221†
Taking anti-hypertensive medicine	Regular	746 (89.8)	85 (10.2)	0.597‡
	Irregular	44 (91.7)	4 (8.3)
	No treatment	3 (75.0)	1 (25.0)
Compliance to treatment	Low	199 (88.8)	25 (11.2)	0.551†
	Intermediate	288 (91.4)	27 (8.6)
	High	303 (89.4)	36 (10.6)
IRR: Iranian Rial † Chi-square Test ‡ Fisher Exact Test

Determinants of SRH

We used forward logistic regression to identify SRH determinants in patients with hypertension. In the primary analysis, we tested all variables, including age, sex, education, employment, marital status, income, diabetes, dyslipidemia, pulmonary disease, HTN control, taking antihypertensive medicines and compliance with treatment, in univariate models and selected those with a p value < 0.2 for the next analysis. In the second step, we constructed a multivariate model from the variables selected in the first step and analyzed and modified this model to obtain the final model. As revealed in Table 3, among demographic variables, education level and income had significant associations with SRH, i.e., educated patients without university degrees (OR = 1.88, 95% CI = 1.13–3.11, p = 0.015) and patients earning more than twenty million Rials per month (OR = 4.34, 95% CI = 1.43–13.18, p = 0.010) were more likely to report good SRH. Among the comorbidity variables, not having diabetes was associated with higher SRH (OR = 2.12, 95% CI = 1.34–3.35, p = 0.001).

Table 3

Predictors of good SRH
variable		95% confidence interval	P-value
comorbidities
Having diabetes	1	-	-
No diabetes	2.12	1.34, 3.35	0.001
education level
Illiterate	1	-	-
Non-academic education	1.88	1.13, 3.11	0.015
Academic education	1.01	0.38, 2.68	0.98
monthly income
≤ 20,000,000 IRR	1	-	-
> 20,000,000 IRR	4.34	1.43, 13.18	0.01

In the present study of 886 hypertensive patients, we investigated the association of demographic variables and comorbidities with good and poor SRH. In terms of demographic variables, higher income, and education level were associated with a good rating of SRH, whereas such associations were not observed for age, sex, marital status, and employment status. Among comorbidities, diabetes, dyslipidemia, and pulmonary diseases were associated with poor SRH. We also observed that preuniversity education and high income increased the odds of good SRH by roughly two and four times, respectively.

The observed association between SRH and socioeconomic factors (income and education level) corroborates previous studies (20–22). The presence of higher education levels in patients with good SRH could be due to both causal effects of education level on good health and vice versa. There are articles that support the latter hypothesis. These articles suggest that healthier people are more likely to attain higher levels of education due to certain confounding factors that affect both health and education levels such as suitable parental care (23). However, a stronger body of evidence supports the causal effect of education level on health (24). An explanation for this hypothesis is the good effect of high education on income, lifestyle, access to social assets and health care, cognitive ability, and skills related to health (24).

Our findings about the association between income and SRH match those of previous literature (25–27). Former studies reported that low-income patients had less access to health care, performed less physical activity, paid less attention to other elements of health-related lifestyle, and subsequently were less healthy than the high-income group (28–31). On the other hand, some studies attributed the negative-rated health in low-income people to their perception of deprivation, which negatively changed their judgment of their health status (32–34).

Supporting the previous literature, our results demonstrated an association between chronic comorbid conditions and a low rating of SRH (35). In addition to the direct effect of chronic diseases on health status, this association might be partly mediated by psychological factors such as self-esteem, self-worth, and self-mastery (control over life). Self-mastery is considered a resource in coping with stressful situations (36) and was a significant predictor of low SRH in people with chronic diseases in a study by Cott et al. (37) The association between having diabetes and reporting poor SRH observed in this study, is consistent with previous literature (35). This association has been justified by impaired daily activities caused by diabetes complications (38). Daily activity impairment was observed to be higher in patients with higher age, longer duration of diabetes, more elevated fasting glucose, more severe obesity, insulin use, and concurrent hypertension (39). Moreover, in another investigation of 1837 adults with type 2 diabetes, disability, and depression were predictors of poor SRH (40).

Similar to diabetes, the association between pulmonary disease and poor SRH is supported in previous studies; In a study on 8200 adults, after controlling for confounders, having asthma was associated with poor SRH. There are some explanations for this association, including poor asthma control, anxiety about exacerbation of the disease, and the influence of inflammatory cytokines (41). The same associations with poor SRH have been reported for other pulmonary diseases like chronic obstructive pulmonary disease (COPD) and interstitial lung disease (42, 43). On the other hand, poor SRH was a predictor of exacerbation and hospitalization in patients suffering from COPD (44).

In line with previous studies, we demonstrated an association between an impaired lipid profile and poor SRH, as a study of 3744 showed the same relationship (45).

Our main limitation is the cross-sectional design of this study, which disables us from reaching any causal conclusions. Furthermore, the insignificance of the statistical tests of hypertension control characteristics might be due to an inadequate sample size. On the other hand, the sampling method was one of the study’s strengths, as it was well-designed to recruit a sample sufficiently representative of the Iranian population.

SRH in hypertensive patients was associated with education level, income, and comorbid conditions, including diabetes, hyperlipidemia, and pulmonary disease. However, prospective studies are needed to establish the causative effect of these factors on SRH. Additionally, a longitudinal approach could be taken to detect the changes in SRH over time. In this study, we could not achieve statistically significant results regarding the association between hypertension control characteristics and SRH rating. However, the SRH distribution pattern in our sample was different from previous studies (46). We observed that the patients with intermediate adherence to medical treatment who would irregularly take their medicine had a higher percentage of good SRH. Subsequently, we recommend performing studies with larger sample sizes to illuminate the relationship between SRH and hypertension control.

Previous studies have established SRH as a multidimensional inclusive index, reflecting current health status and aspects of psychological and social well-being (47, 48). The present study could expand healthcare providers’ and managers’ understanding of SRH and its determinants in patients with hypertension. As SRH is reported to be an independent predictor of survival (49), this study’s findings also recommend paying particular attention to low socioeconomic hypertensive patients and those with chronic comorbid diseases.

SRH: self-rated health

HTN: hypertension

BP: blood pressure

SD: standard deviation

COPD: chronic obstructive pulmonary disease

Ethics approval and consent to participate

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the by Ethics Committee of the Isfahan University of Medical Sciences ethical code: IR.MUI.MED.REC.1399.1165). Informed consent was obtained from all patients, including Legally Authorized Representatives of illiterate participants in the study.

Consent for publication

Not Applicable

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Availability of data and materials

The data that support the findings of this study are available from [Asieh Mansouri] but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of [Asieh Mansouri].

Competing interests

Non declared.

Funding

This study was performed using data from a primary study with registration code IR.MUI.MED.REC.1398.311. All costs of the mentioned study were supported by the COBEL DAROU company.

Author Contributions

AM, AK, and NM conceived and designed the study. AM, AK, NM, and MJ contributed to data collection. FN performed statistical analyses. AM, GA, RS, and HR interpreted the results and drafted the manuscript. All authors have reviewed and accepted the final manuscript.

Acknowledgment

The data of this study were derived from a research project of the Isfahan Cardiovascular Research Institute with registration code IR.MUI.MED.REC.1398.311. The authors would like to thank the COBEL DAROU company that supported data collection costs in the mentioned study.

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Self-rated health and its determinants in patients with hypertension in Isfahan in 2019

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Abstract

Background and Objectives:

Material and Methods

Results

Conclusion

Introduction

Methods

Study participants

Assessments and measurements

Statistical analysis

Results

Sample characteristics

Description of SRH by exploratory variables

Determinants of SRH

Discussion

Conclusion and recommendations

Abbreviations

Declarations

References

Additional Declarations

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Journal Publication

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