BLOOD PRESSURE CONTROL AND ITS CONTRIBUTING FACTOR AMONG AMBULATORY HYPERTENSIVE PATIENTS IN ADAMA HOSPITAL MEDICAL COLLEGE, EAST SHOA, ADAMA, ETHIOPIA

1-15| P a g e International Standard Serial Number (ISSN): 2347-4785

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IJPBSRD, Vol.2 Issue 5: July 2014

INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND BIOLOGICAL SCIENCES RESEARCH AND DEVLOPMENT

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ICV 3.00*** Pharmaceutical Sciences RESEARCH ARTICLE……!!!

BLOOD PRESSURE CONTROL AND ITS CONTRIBUTING FACTOR

AMONG AMBULATORY HYPERTENSIVE PATIENTS IN ADAMA

HOSPITAL MEDICAL COLLEGE, EAST SHOA, ADAMA, ETHIOPIA

Gete Chemeda Lichisa1*

, Gobezie Temesgen Tegegne1 ,Belayneh Kefale Gelaw

1 ,Amsalu Degu

Defersha1, Minyahil Alebachew

1, Woldu, Jimma Likisa Linjesa

1

1Department of Pharmacy, College of Medicine and Health Science, Ambo University, Ambo,

Ethiopia.

KEYWORDS:

Hypertension, Systolic

Blood Pressure, Diastolic

Blood Pressure.

For Correspondence:

Gete Chemeda Lichisa *

Address:

Department of Pharmacy,

College of Medicine and

Health Science, Ambo

University, Ambo,

Ethiopia.

E- mail:

[email protected]

ABSTRACT

Background: Hypertension is a common medical condition

worldwide. It is an important public health challenge because of the

associated morbidity, mortality, and the cost to the society. BP was

poorly controlled in hypertensive patients and hypertensive patients

with diabetes. Objective: to asses extent of blood pressure control and

to determine factors that affect blood pressure control among

attendants of outpatient departments at Adama hospital medical college

in east Ethiopia. Methods: A hospital-based retrospective cross-

sectional study was conducted on 160 participants aged 17 years or

older from March 2014 to April 2014. Simple random sampling was

used. Results: The mean age of the participants was 52.4+11.4 years.

The average mean of BP in 12 months was 140.58/80.92mmHg; the

overall control rate was 43.6%. most of the patients had uncontrolled

BP. There was mean BP difference among eight months. Age, sex,

area, diagnosis, presence of co morbidity and number of drug had no

effect on blood pressure control. Conclusions: The average mean SBP

and DBP obtained in 12 month were above the goal of BP needed.

Greater than half of the participants had uncontrolled BP in data

collection time (April 2014. Age, sex, area, diagnosis, presence of co

morbidity and number of drug were not associated with BP control.

mailto:[email protected]



INTRODUCTION:

Hypertension was defined as a persistent systolic blood pressure reading (SBP) of 140mmHg or

greater and or a diastolic blood pressure reading (DBP) of 90mmHg or greater and or taking of

antihypertensive medication.(1)

The exact causes of high blood pressure are not known, but several factors and conditions may

play a role in its development, including Smoking, Being overweight or obese, Lack of physical

activity, Too much salt in the diet, Too much alcohol consumption (more than 1 to 2 drinks per

day), Stress, Older age, Genetics, Family history of high blood pressure, Chronic kidney disease

and Adrenal and thyroid disorders(2). According to the Eighth Joint National Committee on the

management and the goal of hypertension there was strong evidence to support treating

hypertensive persons aged 60 years or older to a BP goal of less than 150/90mmHg and

hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90mmHg;

however, there was insufficient evidence in hypertensive persons younger than 60 years for a

systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a

BP of less than 140/90mmHg for those groups based on expert opinion. The same thresholds and

goals are recommended for hypertensive adults with diabetes or no diabetic chronic kidney

disease (CKD) as for the general hypertensive population younger than 60 years (3). They are

many factors that cause uncontrolled hypertension. These factors include modified and non

modified factors. Non modified factors are age, gender, ethnicity and family history .modifiable

factors include compliance, access to health care, and life style.(1)

The World health organization (WHO) has estimated that about 62% of cerebro-vascular and

49% of ischemic heart disease burden, World Wide, are attributable to suboptimal blood pressure

levels. High blood pressure was estimated to cause 7.1million death annually, accounting for

13% of all deaths globally.(4)

The prevention and control of hypertension has not received due attention by many developing

Countries. However, awareness about treatment and control of hypertension was extremely

low among developing nations including Ethiopia .In these countries health care resources are

over whelmed by other priorities including HIV/AIDS, tuberculosis and malaria (5)

Statement of the problem

Hypertension was a serious public health problem worldwide. It is the leading cause of death in

the world and it’s the commonest cause for outpatient visits to physicians(6). Therefore,



hypertension was an important public health problem accounting for about 6% of deaths world

wide .As much as 1 billion people have hypertension world wide and 7.1 million deaths a year

may be attributable to hypertension (7)

In Africa, 15% of the population has hypertension. Although there was shortage of extensive

data, 6% of the Ethiopian population has been estimated to have HTN. Approximately 30% of

adults in Addis Ababa have hypertension above 140/90mmHg or reported use of anti-

hypertensive medication. This indicates an urgent need for strategies and programmers to

prevent and control high blood pressure, and promote healthy lifestyle behaviors primarily

among the urban populations of Ethiopia(8).

Hypertension was a risk factor for all clinical manifestations of atherosclerosis since it was a risk

factor for atherosclerosis itself. It was an independent predisposing factor for heart

failure, coronary artery disease stroke, renal disease, and peripheral arterial disease. It was the

most important risk factor for cardiovascular morbidity and mortality.

With regard to the two main cardiovascular consequences of hypertension – coronary heart

disease and stroke the British Heart Foundation Health Promotion Research Group has calculated

the economic burden for the UK at 1999 prices. The total costs (direct healthcare, informal care

and lost productivity) are equivalent to about £7.06 billion for coronary heart disease and £5.77

billion for stroke. Taking into account the WHO estimates of the contribution raised blood

pressure (115/75mmHg or above) makes to coronary heart disease (49%) and stroke (62%), the

total cost burden of raised blood pressure for these two diseases alone amounts to over £7 billion

at 1999 prices, to say nothing of the additional costs incurred by other health consequences such

as heart failure and renal disease.

http://en.wikipedia.org/wiki/Atherosclerosis

http://en.wikipedia.org/wiki/Heart_failure



http://en.wikipedia.org/wiki/Stroke

http://en.wikipedia.org/wiki/Renal_disease

http://en.wikipedia.org/wiki/Peripheral_arterial_disease

http://en.wikipedia.org/wiki/Risk_factor

http://en.wikipedia.org/wiki/Cardiovascular

http://en.wikipedia.org/wiki/Morbidity

http://en.wikipedia.org/wiki/Mortality_rate



CONCEPTUAL FRAMEWORK

Significance of study

Significance of the study

Currently like developed nations, here in Ethiopia the prevalence of hypertension is raising. The

rationale of conducting this study is to determine the factor that affect the BP control. On the

other hand this study has great role in increasing awareness of hypertensive patients towards

blood pressure control and factors that affect the control of blood pressure. It can also be used as

a reference for further research.

BP control

Co-morbidity

DM

CVD

CKD

Sociodemographic factors

Age

Sex

residence

Number of medications

Less than three

Greater than or equal to

three

External factors

BMI

Life style

Financial problems



Objectives

General objective

To assess extent of blood pressure control and factors affecting it in Adama General

Hospital.

Specific objectives

To evaluate the extent of blood pressure control in 12 months

To assess factors that affect BP control

Methods

The Study Area and Period

The study was conducted in Adama Hospital Medical College. The hospital is located in Central

Ethiopia, Oromia regional state, in Adama town 99 km from Addis Ababa on Ethio-Djibuti main

road. It was established in 1942 by Italian Missionaries. The hospital was named as

Hailemariam Mammo memorial hospital little bit after establishment but its name was changed

to Adama Referral Hospital in mean time and now it renamed as Adama Hospital Medical

College by Oromia regional state health bureau after it enrolled students in different programs

like accelerated medicine, emergency surgery and some specialties in 2012. Currently the college

hospital has catchment population of about 5 million serving as referral hospital for all nearby

hospitals and the adjacent regions. It has capacity of 200 beds for inpatient with five disciplines

(Surgery, Internal medicine, pediatrics, Gynecology/Obstetrics and ophthalmology) with four

pharmacies (OPD, ward, emergency and ART pharmacy) and serves about 850 patients per day

at OPD during working hours and on average 52 patients per day after working time in private

wing clinic. The hospital has about 465 workers of which 257 were health professionals and the

remaining are administrative workers and teachers. The hospital is now working in collaboration

with Adama General Hospital and Medical College (AGHMC). The study was undertaken from

01 March – 01 June, 2014.

Study design

- A retrospective cross sectional study was conducted.

Population

Source of population

All ambulatory hypertension patients in Adama medical college hospital.



Study population

The study populations were patients with hypertension, who were using antihypertensive

treatment and attending at Adama medical college hospital for the last one year.

The inclusion criteria

Patients who were on one follow up for the last one year.

Exclusion criteria

1) Patients who have no complete information

2) Patients less than 17 years of age.

Sample size and sampling techniques

Sample size was calculated from the source population using sample size determination formula

and a convenience sample was drawn from patient who fulfill the criteria

n= Z2 P (1-P)

D2

Where:

n- Sample size

Z- Confidence level = 95% (1.96)

P- Anticipated proportion = 50% (0.5) to allow maximum sample size

D- Margin of errors = 5% (0.05)

There was no study done on factors affecting blood pressure control in Adama Hospital Medical

College in the past. We use proportional (p) 50%, So the sample size will be:

n = (1.96)2 (0.5) (1-0.5)

(0.05)2

n= 384

There were 251 patients who fulfill inclusion criteria.

N =215

Therefore the corrected sample size was calculated as:

Nf= n/ (1+n/N)

Nf= 384/ (1+384/251) = 152 cards

Allowance of 5% =0.05x152 = 8

Therefore total sample size = 160 patients



From patients record card who are attending at hypertension clinics in Adama referral medical

collage who met the inclusion criteria, were eligible for inclusion in the sampling list for the

study. Simple random sampling procedure was employed to select the study participants.

Study variables

Dependent variable

Blood pressure control

Independent variables

Age

Sex

Resident area

Assessment

Number of drug

Presence of co morbidity

Data collection tools and techniques

Data were collected from the patient record card on check list.

Data quality management

A pretest was done by the student on 5 patient cards 2 week prior to actual data collection. The

collected was cheeked daily for consistency and accuracy.

Data analysis

The data were cleaned, edited, and entered into a computer to be analyzed using SPSS version

20.0. Logistic regression was used to analyze the associations between different variables, and

other descriptive statistics were used where necessary. Repeated measure ANOVAs and post hoc

analysis were performed to analyze the BP difference among 12 months.

Ethical consideration

Prior to data collection, official letter was obtained from department of pharmacy in order to get

permission from the medical director and research office. The name of the patient was not

mentioned and the entire secret was kept for patient confidentiality.

Result

Socio –demographic characteristics

A total of 160 patients were involved. The mean age was 52.4 + 11.4 years, with a range from 30

to 77 Years. 64 (40%) of them were men while 146 (91.3%) of them were from urban. Greater



than half of the patients (84, 52.5%) had hypertension with diabetes, on the other hand 9(5.6%)

had hypertension with cardiovascular. All in all 66.9 % of the participants had co morbidity.

79.1% of them took less than 3 drugs.

Table 1 Socio-demographic characteristics of the study participants from ambulatory unit in

Adama hospital medical college from May 2013 up to April 2014(n= 160)

No Variables Frequency

(%)

P value AOR CI (95%)

Lower Upper

1 Age

<17

17-59

>59

0

111(69.4)

49(30.6)

0.982

01.0101

0.425

2.403

2 Sex

Male

Female

64(40)

96(60)

0.366

1.485

1

0.630

3.504

3 Area

Urban

Rural

146(91.3)

14(8.8)

0.400

1.824

1

0.451

7.380

4 Assessment

HPN+DM

HPN+CVD

HPN

HPN+ Other

HPN+ DM +other

84(52.5)

9(5.6)

53(33.1)

12(7.5)

2(1.3)

0.952

1462779290

2545339692

1973590809

1.208E+18

1

0.000

0.000

0.000

0.000

-

-

-

-

5 Presence of co morbidity

No

Yes

53(33.1)

107(66.9)

0.999

1973589705

1

0

-

6 Number of drug in April

0-3

>3

87(79.1)

23(20.9)

0.164

0.468

1

0.160

1.362

Key: Cardiovascular disease: coronary heart disease, dyslipidemias.



Mean blood pressure in each month

The average mean of BP in 12 months was 140.58/80.92mmHg. Majority of the participants in

this study had also mean systolic blood pressure above 130mmHg, while only four of the mean

diastolic BP where below 80mmHg. The highest mean systolic blood pressure (200mmHg) was

obtained at the sixth month and the lowest mean systolic blood (102mmHg) pressure. On the

other hand the highest (120 mm Hg) and lowest mean diastolic blood pressure (51mmHg) were

obtained on the seventh and eighth month respectively (fig 1)

Figure 1: The mean blood pressure of the participants in each month of the year for study

participants in Adama hospital medical collage from may 2013 up to April 2014 (n=160).

Key

Series 1: systolic BP

Series 2: diastolic BP

BP measurements of April month

The mean systolic and diastolic blood pressure measurement of April was 136.4 ±18.2 and

85.5±15.8 mmHg respectively. About 19(17.3%) of them had approximately 130/80 mm Hg.

56.4% of hypertensive patients had greater than 130mmHg systolic BP while 26.3% had less

140 140

160

124130

200

102

140 141 140 140130

8090 90

67

80 80

120

51

90

73 7080

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10 11 12

Series1

Series2

Series3

Months of the year

Mean BP

in mm Hg



than 130mmHg. The highest and lowest systolic blood pressure was 200 and 90 mm Hg

respectively.

When we consider diastolic BP of April month, 22.7% of patients had greater than 80mmHg

while 23.6% had less than it.

Figure 2: Blood pressure measurement of April for study participants in Adama hospital medical

collage 2014(n=160)

Key

Series 1: systolic BP

Series 2: diastolic BP

Repeated measure ANOVAs result

There were mean BP difference among eight months except June, July and August. The highest

mean systolic blood pressure and mean diastolic blood pressure was obtained at March with

mean 155mmHg (SD=35.3) and 90.9mmHg (SD=23.4) respectively. Whereas the lowest mean

systolic blood pressure was obtained at April with mean of 126.2mmHg (SD=19.2) and lowest

mean diastolic blood pressure was at April with mean of 74.4mmHg (SD=10.1).

Table 2: Repeated measure ANOVAs for diastolic and systolic blood pressure for study

participants of Adama hospital medical collage from September up to April month 2014 (n=160)

0

50

100

150

200

250

1 6

11

16

21

26

31

36

41

46

51

56

61

66

71

76

81

86

91

96

10

1

10

6

BP

of

apri

l in

mm

Hg

Series1

Series2

No of patient



Diastolic blood

pressure

Month Mean Std.

Deviation

N

BP of the patient September 79.090909 8.3120941 11

BP of the patient October 83.636364 5.0452498 11

BP of the patient November 86.363636 5.0452498 11

BP of the patient December 74.363636 10.1318579 11

BP of the patient January 82.727273 4.6709937 11

BP of the patient February 76.363636 5.0452498 11

BP of the patient March 90.909091 23.4326889 11

BP of the patient April 77.636364 24.5000928 11

Systolic blood

pressure

BP of the patient September 140.000000 0E-7 11

BP of the patient October 128.181818 12.5045446 11

BP of the patient November 143.636364 13.6181697 11

BP of the patient December 134.181818 8.0723997 11

BP of the patient January 147.272727 4.6709937 11

BP of the patient February 130.000000 0E-7 11

BP of the patient March 155.454545 35.3167485 11

BP of the patient April 126.181818 19.1719492 11

Systolic blood pressure Diastolic blood pressure

Wilks lambda=0.001 Wilks lambda =0.011

Partial eta squared =0.776 partial eta squared =0.636

Pair wise comparison of Systolic and diastolic blood pressure in specific months

The mean difference between September and January was -7.3(P=0.012, CI=-13.209_-1.337)

whereas January and February had mean difference 17.3 (P=0.000, CI= 11.337_23.209). The

mean difference between December and January was -8.4 (P=0.015, CI= -15.400_-1.327).

Table 3: pair comparison of systolic and diastolic blood pressure in specific month of the study

participants in Adama hospital medical collage from June up to April 2014(n=160)



Blood pressure Month Mean difference P 95%CI for mean

difference

Lower

bound

Upper

bound

Systolic 1&5 -7.273 0.012 -13.209 -1.337

2&5 -19.091 0.001 -29.655 -8.527

5&6 17.273 0.000 11.337 23.209

Diastolic 1&3 -7.273 0.012 -13.209 -1.337

2&6 7.273 0.012 1.337 13.209

4&5 -8.364 0.015 -15.400 -1.327

Key: 1.sept 2.oct 3.nov 4. Dec 5. Jan 6.feb

Factors affecting blood pressure control

There was no significant association between age (p=0.982, CI=0.425_2.403), sex (P=0.366,

CI=0.630_3.504), residence (P=0.400, CI=0.451_7.380), presence co morbidity (P=0.999,

CI=0), assessment (P=0.952, CI=0.000), and number of drug (p=0.164, CI=0.160_1.362) with

blood pressure control. (Table1).

Discussion

The study confirmed that blood pressure was poorly controlled in both middle aged and elderly

patients. In Jordanian renal transplant recipient and PREseAP study showed, BP controll was

poor in elderly greater than 65 years (9-10). A possible explanation for poor BP control in this

population was due to elders are highly risky to communicable and non-communicable diseases

(6, 9, 11).

Depending on the area of participants’ resident, urban participants had uncontrolled BP than

rural. This finding is in line with study conducted in Accra(12). The reason for uncontrolled BP

may be environmental, cultural, traditional and socioeconomic factors as well as the life style or

way of living of resident.

In this study BP was more controlled in patients with hypertension and diabetes but, other studies

show that BP was poorly controlled in these patients (11). This might be due to; patients with

this co morbidity are likely adherent to the prescribed medication and regularly follow their

status than others.



The study also found that participants who had taken greater than 3 drugs (73.9%) had poor BP

control than who took less than 3 (51.7%) drugs. This may be due to non adherence to the drug

and financial problems.

From the result of pair wise comparison it is conclude that the systolic BP of January was greater

than February and diastolic BP of December is less than January by 17.3mmHg and 8.34mmHg

respectively. The reason for this difference was that the non adherence of participants to refill,

BP measurement, and different type and dose of medication in each month, life style difference,

and environmental difference.

It was found that SBP is controlled better than DBP. This might be due to higher prevalence of

isolated systolic hypertension and other reasons.

Finally, the BP of three months (June, July and august) were elevated. This is because of the

temperature during this month were cold (summer) so, this climate change can constrict blood

vessels.

The study in Bedele and Jordanian renal transplant Blood pressure found, BP was more

controlled by females than males unlike this study (6, 9, 11).

The effect of age, sex, diagnosis, number of co morbidity and drugs not shows significant

association with blood pressure control.

Conclusion

The average mean SBP and DBP obtained in 12 month were above the goal of BP needed.

Greater than half of the participants had uncontrolled BP in data collection time (April 2014).The

highest mean systolic and diastolic blood pressure were obtained at March. Whereas from pair

wise comparison the highest mean difference of systolic and diastolic was obtained between

January and February, and October and February respectively, as well as the lowest was obtained

between October and January and December and January respectively. Age, sex, area, diagnosis,

presence of co morbidity and number of drug were not associated with BP control.

Recommendation

Policy makers: to make this chronic illness as part of the public health agenda

Ministry of health: to give health education and other measures by providing an emphasis on

the prevention, early detection, and treatment of hypertension. Funding agency or the

government should had to provide their aid for the hospital to have hypertension clinic

separately to avoid crowding and the health care providers should had to provide their great



efforts to help the patients as well as to increase the intensity of already started treatment and to

pay special attention to patients diagnosed with co morbidity. Furthermore, researchers and

health care providers should work to uncover the burden of hypertension overall.

Acknowledgement

We are very grateful to our college staff members for unreserved guidance and constructive

suggestions and comments from the stage of proposal development to this end. We would like to

thank Ambo University for supporting the budget which required for this research. Finally our

deepest gratitude goes to Adama Hospital Medical College staff workers who help and allow us

in conducting this research.

Abbreviation and acronyms

AA=Addis Ababa

BMI=Body mass index

P=Blood pressure

CKD=Chronic kidney disease

DBP=Diastolic blood pressure

HIV/AIDS=Human immune virus/acquired immune deficiency syndrome

HTN=Hypertension

SBP=systolic blood pressure

UK=United Kingdom

WHO=World health organization.

1-22 | P a g e International Standard Serial Number (ISSN): 2347-4785


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BLOOD PRESSURE CONTROL AND ITS CONTRIBUTING FACTOR AMONG AMBULATORY HYPERTENSIVE PATIENTS IN ADAMA HOSPITAL MEDICAL COLLEGE, EAST SHOA, ADAMA, ETHIOPIA

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