INPATIENTS SATISFACTION


INPATIENTS SATISFACTION WITH NURSING SERVICES AT KING KHALID UNIVERSITY HOSPITAL, RIYADH, SAUDI ARABIA

Abdulla H. Al-Doghaither, PhD, Department  of  Community  Health, College of  Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia

مقدمة : أوجب تغير وتطور الخدمات الصحية بالمملكة العربية السعودية حديثا البحث عن أدوات شاملة وثابتة لقياس الجودة. ويعتبر رضى المرضى وعلى وجه الخصوص الرضى عن الرعاية التمريضية من الأدوات المهمة والحساسة لقياس جودة الخدمات الصحية المقدمة عن طريق المستشفيات.

الأهداف :تهدف هذه الدراسة إلى تقييم مستوى رضى المرضى المنومين عن الرعاية التمريضية في مختلف أقسام تنويم المرضى بمستشفى الملك خالد الجامعي وكذلك تقييم المحددات الاجتماعية والديمغرافية الى جانب تحديد أثر مدة المكوث بالمستشفى على مستوى رضى المرضى.

طريقة الدراسة : تم اختيار450 مريضاْ منوماْ بشكل عشوائى بحيث كان الاحتمال متناسباْ مع حجم المرضى المنومين بالمستشفى. وجمعت المعلومات عن طريق المقابلة الشخصية بواسطة استبانة تتكون من 21 سؤالاْ تشمل الجوانب المختلقة للرعاية التمريضية.

نتيجة الدراسة : أوضحت النتائج أن الأداة المستعملة لجمع البيانات صادقة وثابتة. وكان المتوسط الكلي 2,4  أي ما يعادل 77% وكان أعلى متوسط رضى للمهارات الفنية التمريضية بينما كان أقل متوسط لمهارات الاتصال. وأثبت التحليل الانحداري المتعدد أن الجنس والعمر والزواج وفترة المكوث بالمستشفى من أهم المتغيرات التي تؤثر على رضى المرضى المنومين على خدمات الرعاية التمريضية.

الخلاصة :خلصت هذه الدراسة إلى وجود بعض أوجه القصور في الرعاية التمريضية لتعالج من قيل إدارة المستشفى   ويتمثل في نقص أعداد الممرضات إلى جانب مشاكل الاتصال بين المرضى والممرضات.

الكلمات المرجعية :  رضى المرضى المنومين, الرعاية التمريضية, مستشفى الملك خالد الجامعي, المملكة العربية السعودية

Abstract: Recent development and changes in health care services in Saudi Arabia have encouraged a search a search for comprehensive and established measurements of the quality of care. Patient satisfaction with nursing care in particular has ferquently been used as a sensitive and objective measure of quality of hosiptal services.

Objectives: The objectives of this study are: (1) to assess the level of inpatient satisfaction with nursing care (PSWC) in the various wards of the hospital; (2) to assess the socio-demographic determinants of PSWC in addition to the effects of duration of hospital stay and type of wards on the level of satisfaction.

Methods: The sample consisted of randomly selected 450 inpatients with probability proportion to the size of the wards. The data was collected by personal interviews

Correspondence to:

Dr. Abdulla H. Al-Doghaither, Director of Education and Training Department,    College of Applied Medical Sciences, King Khalid University Hospital, P.O. Box 10219, Riyadh 11433, Saudi Arabia

using a 21-item structured questionnaire pertaining to nursing services.

Results: The results revealed that the instrument of measurement was valid and reliable. The overall mean satisfaction score was 2.4 (77%) and the highest mean satisfaction was for items on skillfulness and the lowest score was for communication items. Multiple regression analysis indicated that sex, age, marital status and duration of stay are the most imortant predictors of PSWC; female, young, married and short duration of hospital stay have the highest satisfaction score.

Conclusion: In conclusion, this study has highlighted the aspects of nursing care at King Khalid University Hospital (KKUH) which need re-examination by the management. The most importance findings have been that there is: (1) a shortage of nurses at the hospital; (2) limited communication between nurses and patients: most probably due to cultural and language barriers; (3) no proper oversight of patients personal hygiene; (4) dissatisfaction of male patients with most of the nursing care rendered.  These results offer the hospial management the opportunity to work out stategies to connect the deficiencies highlighted.

Key Words: Inpatient satisfaction, nursing care, King Khalid University Hospital, Saudi Arabia


 

INTRODUCTION

As care delivery institutions hospitals are always faced with the challenge of providing the quality of care that meets the expectation of its clients. As a service industry, it is expected to provide its customers with quality of care they need. Patient satisfaction is an important component of the quality of care. Satisfaction is a function of the discrepency between what is expected and what is perceived to be actually occurring.1 Therefore, it is imperative for hospital managers and administrators to identify patients' perceptions and expectations of the quality of care, from time to time and to asess the extent to which these ideals are met by their institutions. Various studies have concluded that satisfied patients are more likely to continue using the medical care service, to maintain the relationship with a specified provider and to comply with medical regimen.2

Patients' expectations as a set of preconceived notions about type of care anticipated, tend to be formulated around a variety of dimensions among which are the hospital environment, admission and discharge procedures, nutrition and housekeeping services and physician and nursing care. Out of these, nursing care occupies a critical position in molding patients' perception of quality of care.3,4 Indeed, several research findings have pointed out that patients' perceptions of the quality of care tend to be related to their interpersonal interaction with the care givers.4-8

In the provision of health care, nurse-patients interactions predominate over those with either physicians or other hospital personnel. A study by Cleary et al4 found nursing care to be the most important factor for evaluation of patients' satisfaction with care. Cleary's finding was supported by results from a survey conducted by Koska7 where 97.3% of 663 chief executives interviewed ranked nursing care as the top factor in quality of patient care.

Because quality patient care is considered essential to instiutional survival, it is an attribute sought after by hospitals and emphasized by administrators.9-13 A study comparing patient perception of quality care and patient satisfaction with quality care found that failing to meet the expectations of quality was synonymous with poor quality and resulted in patient dissatisfaction.14 Patient satisfaction with nursing care was found to be an important predictor of overall satisfaction with hospital care.15

A recent study on quality improvement, compared nurses' and pateints' definitions of quality and the values each placed on different aspects of care.13 The values held by patients were found to be different from the values health professionals thought were held by pateints. Young and colleagues13 suggested that the organizational culture of the unit, driven by the values of the nurse manager and unit staff, may have reinforced differences between patient and caregiver values. As a result of this study, there was an effort to transform the unit culture to support aspects of care valued by the patients.

The present study was initiated at King Khalid University Hospital (KKUH) to assess: (1) the level of inpatient satisfaction with nursing care (PSWC) in the various wards of the hospitals; (2) the socio-demographic determinants of PSWC in addition to the effects of duration of hospital stay and the type of ward on the level of satisfaction. To he best knowledge of the author, this is the first study in Saudi Arabia, that has focused on nursing care in appraising patient satisfaction.

MATERIAL AND METHODS

The study was conducted at King Khalid University Hospital (KKUH), Riyadh, during the period from October 1995 to March 1996 on various aspects of services rendered to inpatients admitted in the hospital. The hospital, established in 1982 provides free medical services to eligible patients. The average daily census is 547, average occupancy rate is 81, average turnover interval is 2, bed productivity is 4, average of length of stay is 5 and beds available are 701. There are six wards in the hospital (Medical male, Medical female, Surgical male, Surgical female, Obstetrics and Gynecology and Pediatric). The study population consisted of all patients admitted as inpatients. The criteria for inclusion were that (1) the patient should have been in admission for at least 3 days, (2) consent to be interviewed should be given. Since the establishment of KKUH, there has been no evaluation of the quality of care delivered by nurses to patients admitted to variuos wards in the hospital. The questionnaire used to collect information from inpatients included 83 questions relating to various aspects in the hospital, out of which 21 pertained to nursing services. These questions were compiled from several researches on patients' perception of quality of care.7-12 For pediatric patients too young to be interviewed, the person attending to the patient, from his family, was interviewed. Informed consent was obtained from each respondent before the conduction of an interview, and assurance of the confidentiality of responses given. A simple random sample of 450 patients was selected from the different wards with probability proportional to size of a ward. The department of patient affairs collected the data.

The aim of the present study was to assess inpatients' satisfaction with nursing services at KKUH based on the respondents' replies to the 21 items pertaining to nursing care on a three-point scale of very satisfied, somewhat satisfied and dissatisfied.

Statistical Methods

The statistical methods used in the analysis of the data included the Chi-Square test to investigate the association between duration of stay in hospital and ward of admisison. Multiple regression analysis was undertaken, with the mean score of satisfaction being the dependent variable and sociodemograhic, wards and duration of stay as the dependent variables. Student's t-test and ANOVA were used for the comparisons of distributions of interval data for two or more than two independent groups, respectively. Data was analyzed using SPSS package.

RESULTS

Results relating to patients' satisfaction with various nursing services are shown in Table 1. The highest mean satisfaction score was obtained for patient prepared for medical investigation (2.72) and for patient being placed in bed (2.67). The lowest mean satisfaction score was obtained for nurses' attention to patients' cleanliness (1.73) and for listening to and talking to patients (1.81).

Table 2 summarizes the mean level of satisfaction for socio-demographic variables. Females tended to be more satisfied (2.47) than males (2.16). Saudi and non-Saudi exhibited the same level of satisfaction. Education, marital status and age were significantly related to satisfaction with nursing services. Those with university degree reported higher levels of satisfaction (2.41), while patients with lower education level showed lwer level of satisfaction (2.21). Elderly patients showed lower level of satisfaction (2.14) than younger groups. The marrieed were more satisfied (2.41) than single individuals (2.25). Regarding duration of stay, patients who stayed for 


 

Table 1: Patient satisfaction with nursing care at King Khalid University Hospital

Nursing services items

Mean

SD

General Impression

1.  There were no enough nurses at the hospital

1.93

0.81

2.  Nursing staff were skilful at their work

2.56

0.65

Receptions

3.  Nurses listen to patients and converse with them

1.80

0.92

4.  Nurses approach patients with gentility

2.13

0.91

5.  Patients requests are promptly attended to

2.01

0.95

6.  Nurses promptly respond to pateints call

2.54

0.71

7.  Nurses promptly takes action during emergency

2.60

0.54

Environmental upkeep

8.  Nurse in-charge controls sources of noise in the unit

2.56

0.72

9.  Nurses dispose soiled linen promptly

2.48

0.74

Patient upkeep

10. Nurses attend to cleanliness of patients

1.73

0.89

11. Nurses attend to patients unable to care for self

2.32

0.76

12. Nurses conveniently place patients in bed

2.67

0.62

13. Nurses safely lift and move patients

2.49

0.78

14. Nurses prepare patients for medical investigations

2.71

0.56

15. Nurses follow through patients diet

1.87

0.90

Communication

16. Nurses inform patients about physician's order

2.37

0.81

17. Nurses give adequate explanation about their activities

1.88

0.80

18. Nurses immediately report to physician patient's current state

2.62

0.61

19. Nurses confirm patients' appointment to other department

2.48

0.67

20. Nurses accurately report patients' complaints to physician

2.35

0.78

21. Nurses document patient complaints and take prompt action

2.49

0.72


 

more than two weeks showed less satisfaction (2.19) compared to patients who stayed for less than 1 week (2.46). With regards to wards, the highest mean satisfaction score was obtained for Obstetrics (2.64) and the lowest was for Male Surgical Ward (2.10).

Table 2: Analysis of variance to identify the effects of different variables on patient satisfaction with nursing care

Variables

Mean

SD

Sex

Male

2.16

0.03

Female

2.47

0.03

Marital Status

Single

2.46

0.03

Married

2.41

0.03

Education

Illitrate

2.21

0.04

Primary

2.35

0.02

Seconday

2.32

0.03

University

2.41

0.05

Nationality

Saudi

2.34

0.02

Non-Saudi

2.31

0.04

Age

<25

2.44

0.03

25-35

2.44

0.04

36-45

2.21

0.05

46-55

2.17

0.07

56

2.13

0.04

Wards

Male surgical

2.09

0.03

Female surgical

2.41

0.05

Male medical

2.12

0.05

Female medical

2.25

0.04

Obstetrics

2.64

0.03

Paediatrics

2.46

0.04

Duration of hospital stay

<7 days

2.46

0.03

7-14 days

2.24

0.04

14 days

1.89

0.04

                The influence of sociodemographic factors on patients' satisfaction with the nursing services was also investigated further by regression analysis and the results are shown in Table 3. The strongest predictor variable that influenced mean satisfaction was sex. Females had a mean satisfaction score of 0.187 more than males. The second variable was marital status. Married patients reported higher satisfaction score than patients who were single (0.186). The third variable to influence mean satisfaction was age, with older patients rating their satisfaction lower than the younger. The fourth variable was duration of stay. The fifth variable was the type of ward. None of the other independent variables were significantly associated with nursing services. The set of independent varaiables included in this equation accounted for 53% of the variation in mean satisfaction in the led services.

Table 3: Multiple regression analysis to identify the effects of different variables on patient satisfaction with nursing care

Variables

Standardized coefficients (Beta)

Significance

Duration of hospital stay

-0.146

0.001

Sex

0.187

0.000

Nationality

-0.004

0.933

Age

-0.159

0.001

Marital status

0.186

0.000

Education

0.049

0.344

DISCUSSION

Recently, patient satisfaction with nursing care has become a subject of interest to many researchers and administrators. Moreover, it is an indicator of the hospital's accountability to the society and a marker of the quality of health services offered. Nurses have longer contact with inpatients compared to any oher health professionals. Therefore, patient desires and expectations for nursing care warrant scrutiny because of their potential influence on hospital care utilization, patient satisfaction and patient's perception of quality of care. This has urged researchers to develop reliable and valid scales for appraising patient satisfaction with nursing care (PSWC). Mc Donald and Nash reviewed 21 current PSNC instruments in a compendium, which provides information on the developer, the date of publication or first use, types of items and sub-scales, mode of administration, reliability, validity, formulas and availability.16 The most common used scales are the Newcastle Satisfaction Nursing Scale (NSNS)17 and La-Obert patient satisfaction scale.18 The selection of a scale for measuring PSNC depends on several factors among which are the underlying theoretical models and theories of patient satisfaction, local circumstances and cultural aspects, in addition to patient perception of, and quality of nursing care. Therefore, the self-administered questionnaire used in this study is a modified version of several validated scales of measuring PSNC. Oviously, the first logical step was to measure the quality of the scale in terms of reliability and validity. The content validity of the scale was reviewed by fiver experts in the field from the Department of Nursing, and the College of Applied Medical Sciences at King Saud University. It was found that the scale covered all the essential components of hospital nursing care in a Saudi context. Additionally, the reliability of the scale was measured. The internal consistency of the major sub-dimensions and the overall scale was high with Cronbach's alpha ranging from 0.81 to 0.91.

                The overall mean PSNC was found to be 2.3 amounting to 77%. This figure is comparable to few studies and lower than other studies particularly in similar Arab cultures.19 This difference could be genuine and might be explained by the fact that the majority of nurses are fom non-Arabic speaking countries, which hinders fluent communication with patients. However, Sargeant20 stated that it was difficult to interpret this wide divergence in range without adequate iformation about such aspects as the methodology used, study population, the characteristics of the heal th systems and socio-cultural values and attitudes. Other authors argue that patient satisfaction with nursing care is determined by many other factors including job satisfaction of nurses, nursing care delivery models, organizational structures, supportive environment, patients' perception of nurses, nurse-patient ratio and inability to discriminate nursing care from the rest of their overall patient experience. Based on this information, the authors question the accuracy of the measurement of patient satisfaction and raise issues that need to be considered, in order to further clarify the measurement of this concept.21-23

                With all diverse theories, models of training and methods of nursing, two aspects of nursing remain constant: the need to care and the need to communicate. Both are essential to the process of nursing.24 The conduct of interpersonal communication must meet individual and social expectations whether these aid or hamper technical performance.25 In the present study, the perception of skill "skillfulness" with respect to nursing care was conceptualized in gentleness. The preparation of a patient for medical investigations and the placing of a patient in bed obtained the highest satisfaction score. This might be explained by the fact these skills rely heavily on manual and manipulation skills with minimal requirement of communcation skills.

                On the other hand, the lowest satisfaction was with nurses' attention to patients' cleanliness and for listening to and conversing with patients. It is clear that longer interaction with patients in a two-way communication is required for these skills to be manifest. This is difficult for nurses in KKUH for whom language is a barrier. The vehicle for the implementation and success of technical care is nurse-patient communication. Findings from international studies have revealed that the highest satisfaction scores for nursing care were obtained for nurses' interpersonal skills such as sense of humor and teaching behavior.26-28 This suggests that patients perceive these skills as an important indicator of the quality of nursing care. Therefore, the recruitment of nurses from Arab-speaking countries and the training of indigenous nurses in the long-term are strongly recommended. In the interim, foreign nurses must be given an intensive Arabic course and communication training. Additionally, the existing curricula must concentrate on communication and inter-personal skills training.

                Views of inpatients were uncertain about the adequacy of the number of nurses allocated to the various wards. Some (29%) felt there were not enough nurses at the hospital but the remaining 36.4% believed there were enough. Only those in the pediatric and obstetrics and gynecology wards were satisfied with number of nurses attending to them. The almost equal split of opinions among inpatients interviewed about the adequacy of the number of nursing staff assigned to the various wards may be a clue to the management, for a need to review the number of nurses available and institute better allocation between the wards. However, if the number for some wards is found to be inadequate a nursing recruitment drive could be undertaken to allevaiate the shortage.

                Results in Table 2 have highlighted that patients in male wards have the least mean satisfaction score while obstetrics and gynecology and pediatric patients tended to have the highest mean satisfaction score with nursing services rendered to them. A number of factors might be responsible for the above phenomenon. First of all, Saudi culture restricts communication between males and females except for spouses, and close relatives. Secondly, since the majority of nurses at KKUH are females, and can be assigned to either female or male wards, it is likely that male patient would be able to communicate freely with or relate to female nurses, ad this could be interpreted as dissatisfaction. Furthermore, the inability of many nurses to communicate effectively in Arabic might have further worsened the patient-nurse interaction.

                It is likely that the duration of stay in hospital influenced patients' attitudes about quality of nursing care. As revealed in Table 2, inpatients who stayed longer in hospital, were more dissatisfied. Patients admitted to the female surgical ward and the obstetrics and gynecology ward had the shortest stay of 3-7 days while those admitted to the pediatric, the male surgical and medical wards tended to stay longer than one week. The lack of satisfaction here could be attributed to the psychological impact of the disease itself, adoption of the "sick role", shortage of nursing staff in those wards or the reflected negative attitude of nurses towards longer stays, or chronic cases.29

                As shown in Table 2, the results of this study appear to reveal a consistent pattern of association between the overall satisfaction and the studied socio-demographic variables except for nationality. Females tended to be more satisfied with nursing care then males. A literature review revealed contradictory findings. One study states that males were more satisfied,24 while other studies as the present one revealed that females were more satisfied.30-32 Further studies found that there was no association between sex and satisfaction with nursing care.33 This finding could be explained by cultural reasons in the lack of interaction between male patients and female nurses as discussed earlier. Married women reported higher satisfaction score than single women. This finding is comparable to a previous study in Riyadh which measured overall patient satisfaction.34 Older subjects are generally more conservative and les demanding than younger people.35 In contrast, our study found that older patients were less satisfied with their nursing care. This might be explained by the fact that older patients were too conservative to interact with female nurses in the Saudi culture. Other studies found similar association.32,33 There was also an association betwee education and patient satisfaction. Those with university degrees reported higher levels of satisfaction compared to those with a lower level of education. This might be explained by the ability of educated patients to communicate with nurses in English. Findings from some studies revealed the reverse,36 while other studies did not find any association between education and satisfaction with nursing care.32,33 Multiple regression analysis suggests that a short hospital stay, being female, married and young were the strongest predictors of patient satisfaction with nursing care. In this study, these variables contributed to 53% of the total variation. Tucker reported only 5% of the variability.33

                In conclusion, this study has highlighted the aspects of nursing care at KKUH which need to re-examined by the management. The most important findings have been that: (1) there is a shortage of nurses at the hospital; (2) there is a limited communication between nurses and patients: most probably due to cultural and language barriers; (3) the personal hygiene of individual patients was not supervised; (4) male patients were dissatisfied with most of the nursing care rendered. Short hospital stay, being a female, married, young were the most predictors of patient satisfaction with nursing care. These results offer the hospital management the opportunity  to  work   out  strategies  for  improvement.

REFERENCES

1.     Adulaziz B, Abdel-Fatah M. Amer NNK. Consumer satisfaction: the core of quality. A comparative study at three organizational settings. Bulletin of the High Istitute of Public Health 1997; 27(1):171-7.

2.     Abramowitz I, Cote A, Berru S. Analyzing patient satisfaction: A multi-analytic approach. Quality Review Bulletin 1987; 13: 122-30.

3.     Davis-Martin S. Outcome and accountability: Getting into the customer dimension. Nursing Management 1986; 17(10):25-8.

4.     Kleary PD, Keroy L, Karaponos G, McMullen W. Patient assessment of hospital care. Quality Review Bulletin 1989; 15(6):1782-9.

5.     Peterson MB. Using patient satisfaction data: An outgoing dialogue to solicit feedback. Quality Review Bulletin 1989; 15(6):168-71.

6.     Cleverly WO. Improving financial performance: A study of 50 hospitals. Hospital and Health Services Administration 1990; 35(2):173-87.

7.     Koska MT. Quality review their name is nursing care, CEOs say. Hospitals 1989; 63(3):32.

8.     Fosbinder D. Patients perceptions of nursing care: An emerging theory of interpersonal competence. Journal of Advanced Nursing 1994;20:1085-93.

9.     Curren CR, Miller N. The impact of corporate culture on nurse retention. Nursing Clinics of North America1990; 25(3):537-49.

10.   Kerfoot KM. Achieving excellence: The nurse manager's challenge. Nursing Economics 1992; 10(2):140-3.

11.   Scarding SA. SERVQUAL: A tool for evaluating patient satisfaction with nursing care. Journal of Nursing Care Quality 1994; 8:38-46.

12.   Goodridge D, Hack B. Assessing the congruence of nursing models with organizational culture: A quality improvement perspective. Journal of Nursing Care Quality 1996; 10(2):41-8.

13.   Young WB, Minnick AF, Marcantonio R. How wide is the gap in defining quality care? Comparison of  patient and nurse perceptions of important aspects of patient care. J Nurs Adm 1996; 26(5):15-20.

14.   Ludwig-Beymer P, Ryan CJ, Johnson NJ, et al. Using patient perceptions to improve care. Journal of Nursing Care Quality 1993; 7(2):42-51.

15.   Greeneich D. The link between new and return business and quality of care: Patient satisfaction. Advanced Nursing Studies 1993; 16:62-72.

16.   McDaniel C, Nash JG. Compendium of instruments measuring patient satisfaction with nursing care. Quality Review Bulletin 1990; 16(5):182-8.

17.   McColl E, Thomas L, Bond S. A study to determine patient satisfaction with nursing care. Nursing Standards 1996; 10(52):34-8.

18.   La Monica EL, Oberst T, Madea A, Wolf R. Development of a patient satisfaction scale. Research in Nursing and Health 1986; 9:43-50.

19.   Zahr LK, William SG, El-Haddad A. Patient satisfaction with nursing care in Alexandria, Egypt. International Journal of Nursing Standard 1991;28(4):337-42.

20.   Sargeant A, Kaehler J. Factors of patient satisfaction with care in programs for low income individuals. Journal of Community Health 1999; 24:381.

21.   Williams SA. The relationship of patients' perceptions of holistic nurses caring to satisfaction with nursing care. Journal of Nursing Care and Quality 1997; 11(5):15-29.

22.   Kagas S, Kee CC, McKee-Waddle R. Organizational factors, nurses' job satisfaction, and patient satisfaction with nursing care. Journal of Nursing Administration 1999; 29(1):32-42.

23.   O'Connel B, Young J, Twigg D. Patient satisfaction with nursing care: a measurement conundrum. International Journal of Nursing Practice 1999; 5(2):72-7.

24.   Morrison P, Burnard P. Caring and communicating. The interpersonal relationship. London: Mcmillan Press LTD;1991.

25.   Donabedian A. The quality of care. How it can be assessed? JAMA 1988; 260(12):1734-8.

26.   Leino-Kilpi H, Vuorenheimo J. Patient satisfaction as an indicator of the quality of nursing care. Vard Nord Utveckl Forsk 1992; 5:22-8.

27.   Hall MC, Elliot KM, Stiles GW. Hospital patient satisfaction: correlates, dimensionality, and determinants. Journal of Hospital Market 1993;7(2):77-90.

28.   Warner RS. Nurses' empathy and patients' satisfaction with nursing care. J N Y State Nurses Association 1992;4:8-11.

29.   Staniszewska S, Ahmed L. Patient expectations and satisfaction with health care. Nursing Standard 1998; 18:34-8.

30.   Labarere J, Francois P. Evaluation of patient satisfaction in health facilities. Review of the literature. Rev Epidemiol Sante Publique 1999;47:175.

31.   Roth T, Schoolcraft M. Patient satisfaction. The survey says. Nursing Care Management 1998; 3:184.

32.   Tucker JL. The influence of patient sociodemographic characteristics on patient satisfaction. Military Medicine 2000;165(1):72-6.

33.   Clark CA, Pokorny ME, Brown ST. Consumer satisfaction with nursing care in a rural community hospital emergency department. Journal of Nursing Care and Quality 1996;10(2): 49-57.

34.   Alfaris E, Khoja T, Falouda M, Saeed A. Patients's satisfaction with acessibility and services offered in Riyadhhealth centers. Saudi Medical Journal 1996;17(11): 11-17.

35.   Aldoghaither A, Saeed AA. Satisfaction and correlates of patients' satisfaction with primary health care centers services in Riyadhcity. Saudi Medical Journal. In press 2000.

36.   Scandina S. A tool for evaluating patient satisfaction with nursing care. Journal of Nursing Care Quality 1994; 8(9):38-46.


-0001-11-30

HYDATIDIFORM MOLE


HYDATIDIFORM MOLE: A STUDY OF 90 CASES

Abdulaziz A. Al-Mulhim, JBO&G, Department of Obstetrics and Gynaecology, King Fahd Hospital of the University, Al-Khobar, Saudi Arabia

هدف الدراسة :الهدف من الدراسة هو تحديد نسبة حدوث الحمل العنقودي وتحديد العوامل الرئيسية المؤدية إلى حدوثه وطرق التشخيص والمشاكل المصاحبة وطرق العلاج في مستشفى الملك فهد الجامعي بالخبر .

طريقة الدراسة :دراسة استبيانية أجريت خلال فترة خمس عشرة سنة من شهر مايو ( أيار) 1983م وحتى شهر مايو (أيار) 1998م كل الحالات ومجموعها تسعون حالة تمت دراستها وتحليلها من حيث العمر وعدد مرات الحمل والأعراض والمضاعفات وطرق العلاج والمتابعة .

نتائج الدراسة :أظهرت الدراسة أن معدل الحمل العنقودي كان ( 2, 2 في الألف ) وتزداد نسبة حدوثه مع تقدم السن وتعدد الحمل . 

إن من أهم أعراض الحمل العنقودي هو النزيف المهبلي وحدث في 18 حالة ( 90% ) فقر الدم في 46 حالة ( 51% ) والغثيان في 26 حالة ( 29% ) ، وحجم الرحم أكبر من عدد أسابيع الحمل في 56 حالة ( 62% ) وتضخم المبايض في 24 حالة ( 27% ) .

إن من المضاعفات المصاحبة للحمل العنقودي هي النزيف الرحمي في 19 حالة ( 27%) ، الانتان في 19 حالة وانتشار المرض داخل جدار الرحم والجسم في 9 حالات ( 10% ) .

كانت المضاعفات أكثر شيوعاً في الحالات التي راجعت المستشفى كانت هناك 6 حالات (7, 6% ) لحمل عنقودي غاز وثلاث حالات ( 3,3 % ) تحولت لسرطان خلال هذه الدراسة .

الخلاصة:بناء على هذه الدراسة يمكن القول إن نسبة حصول الحمل العنقودي مشابهة لمثيلاتها في دول الشرق ، ويمكن أن يؤدي التشخيص المبكر والمعالجة المبكرة إلى إنقاص نسبة المضاعفات التي لوحظت في هذه الدراسة ، ولذا نوصي النساء الحوامل بضرورة مراجعة الطبيب عند حدوث نزيف أو غثيان أثناء الحمل .

الكلمات المرجعية :الحمل العنقودي ، المضاعفات .

Objectives: To determine the incidence, epidemiology, complications and management of Hydatidiform mole (HM) at the King Fahd Hospital of the University (KFHU), Al-Khobar, Saudi Arabia.

Methods: A retrospective study was conducted covering a period of 15 years from May 1983 to May 1998. There were 90 cases of hydatidiform mole. The details of maternal characteristics, clinical presentation, tumor behavior, management and complication were studied.

Results: There were 40,700 deliveries during the study period giving an incidence of hydatidiform mole (HM) of 2.2/1000 deliveries. The most common clinical feature was vaginal bleeding which was noted in 81 (90%) cases. Fifty-six (62%) cases had uterus larger than dates, while in 12 (13%) cases, the uterine size was smaller than dates. Ovarian enlargement was noted in 24 (27%) cases. Complications in the form of hemorrhage occurred in 19 (21%) cases and 9 (10%)  cases were  complicated  by

Correspondence to:

Dr. Abdul Aziz Al-Mulhim, College of Medicine, King Faisal University, P.O. Box 40093, Al-Khobar 31952, Saudi Arabia

cated by sepsis. The complications were more common in patients presenting late to the hospital. There were 6 (6.7%) cases of invasive mole and 3 (3.3%) cases of choriocarcinoma during the follow-ups of the study group.

Conclusion: On the basis of this study, the incidence of hydatidiform mole is comparable to the incidence in some oriental countries. Earlier diagnosis and treatment of HM will probably result in the decrease of complications found in this study.

Key Words: Hydatidiform mole (HM) complication.


 

INTRODUCTION

For reasons not well understood, the incidence of hydatidiform mole (HM) varies greatly in different parts of the world. The highest rates are reported in the Far East where the decrease is 7 to 8 times more common than the west.1,2

                The purpose of this study was to explore the incidence and epidemiological correlates of HM, the clinical behavior, the complications and management of this disease in our hospital. The details of the records of 90 patients with HM seen and managed at the KFHU, Al-Khobar, Saudi Arabia from May 1983 to May 1998 were reviewed.

MATERIAL AND METHODS

During the study period, there were 90 cases of HM. Most of the patients admitted with HM were initially diagnosed as threatened abortion. The diagnosis of HM was based on a pelvic ultrasound scan, quantitative estimation of serum beta human chorionic gonadotrophin (BhCG) and histopathological examination of the specimen. During this period 40,700 patients delivered in our hospital.

                Ninety-six percent of the patients in the study groups were Saudis. The details of maternal characteristics, clinical presentation, management and complications of the condition were noted from the case records. The patients were followed up for period between 8 months to 2 years after treatment. A quantitative serum BhCG was carried out by the Amerlex-M radioimmunoassay kits.

RESULTS

There were 40,700 deliveries during the period giving an incidence of HM as one in 452 deliveries.

                Table 1 shows the age distribution of the patients. The patients' ages ranged from 16 to 45 years with a mean of 28.9 years. HM occurred more in the age group 21-35 years, was lowest in patients below 20 years and increased steadily thereafter.

Table 1: Age distribution of patients with hydatidiform mole

Age (years)

Hydatidiform mole (N=90)

No. (%)

     20

5 (5.6)

21 – 25

17 (18.9)

26 – 30

21 (23.3)

31 – 35

23 (25.6)

     35

24 (26.7)

Table 2 shows the parity distribution of the patients. The parity of the patients ranged from 0 to 9 with a mean of 3.1. HM was low in nulliparous as compared to the parous patients.

                Table 3 shows the prominent clinical features of HM. Vaginal bleeding occurred in 81 (90%) cases, disparity between uterine size and period of gestation in 56 (62%) cases, anemia in 46 (51%) cases, hyperemesis gravidarum in 26 (29%) cases and ovarian enlargement in 24 (27%) cases.

                Table 4 shows the complication of HM. Moderate to severe hemorrhage occurred in 10  (21%)  cases.  Twelve  (13.3%)  patients

Table 2: Parity distribution of patients with hydatidiform mole

Age (years)

Hydatidiform mole (N=90)

0

6 (6.7)

1

10 (11.1)

2

16 (17.8)

3

21 (23.3)

4

17 (18.9)

20 (22.2)

Total

90 (100)

aborted the mole spontaneously, followed by an evacuation of the uterus, while in 78 (87%) patients, the uterus was evacuated by suction curettage. Two patients aged 43 years, para 8 and aged 38 years, para 6, required hysterectomy as a life saving procedure on account of uncontrollable hemorrhage during evacuation, while a third patient underwent laparotomy as a result of perforation of the uterus to repair the tear. Sepsis complicated HM in 9 (10%) cases and all the patients were found to be incompletely evacuated.

                During the follow-up, invasive mole was diagnosed in 6 (6.7%) cases based on pelvic ultrasound and persistently high serum BhCG levels after evacuation of uterus. Three patients (3.3%) developed choriocarcinoma. All these patients had a history of intermittent vaginal bleeding and presented late to the hospital. The diagnosis was confirmed histologically by a biopsy of a metastatic vaginal nodule in one patient and endometrial curettings in two patients. Pulmonary metastasis was also present in two patients with choriocarcinoma. All these patients were treated with chemotherapy and are alive and well. There was no maternal death in this series.

                All the patients of HM were routinely followed by a quantitative estimation of serum BhCG and ultrasonic scanning. These patients were advised to avoid pregnancy until BcHG levels had become normal and remained normal for at least 6 months. Combined  oral contraceptive pills were prescribed to  them as a method of birth control.

Table 3: Clinical features of Hydatidiform Mole (N=90)

Presenting feature

No. of cases (%)

Bleeding per vaginum

81 (90)

Hyperemesis gravidarum

26 (28.9)

Anemia

46 (51.1)

Pregnancy associated hypertension

11 (12.2)

Thyrotoxicosis

3 (3.3)

Uterine size:

Larger than the dates

56 (62.2)

Smaller than the dates

12 (13.3)

Compatible with the dates

23 (25.6)

Ovarian enlargement

24 (26.7)

Table 4: Complications of Hydatidiform Mole (N=90)

Complications

No. of cases (%)

Hemorrhage

19 (21.1)

Sepsis

  9 (10.0)

Thyrotoxicosis

3 (3.3)

Invasive mole

  6 (6.71)

Choriocarcinoma

3 (3.3)

DISCUSSION

The incidence of hydatidiform mole (HM) in this series corroborates the reports from some oriental countries.3,4 The true incidence in the population may be even lower than this hospital-based study, since KFHU functions as both a general and a specialist hospital with a bias in favor of the admission of complicated and abnormal cases. The incidence of invasive mole after hydatidiform mole has been reported as fluctuating between 5.8% and 3.1%.3 Choriocarcinoma could develop after antecedent normal pregnancy, abortion and hydatidiform mole. However, 25% of the cases of choriocarcinoma follow the hydatidiform mole, and with adequate follow-up of molar pregnancy, there is a decrease in the incidence of choriocarcinoma after hydatidiform mole.3

                Hydatidiform mole (HM) varies greatly in incidence around the world and this is due to the fact that many reports lack a clear, and precise definition of the disease, over-reporting of pregnancies with gestational trophoblastic disease and different denominators used in different published series.

                Sixty-eight percent of the patients in the study were in their second and third decades of life, the period of maximum fertility. As the data on maternal age and parity for all the mothers delivered during the same period of time was not available, it was not possible to calculate the incidence of hydatidiform mole the different age and parity groups. However, some studies indicate an increase in the incidence of HM with decreasing maternal age below 20 years,5-8 while others report an increased risk in patients over 35 years.9-11 Early marriage and teenage pregnancy are the norm in Saudi women and child bearing often continues into the later years of reproductive life. It is relevant to note that the number of HM analyzed in this report was rather small and this may have affected the results.

                Vaginal bleeding occurred in 90% of our patients, anemia occurred in 51%, hyperemesis gravidarum occurred in 29%, uterine enlargement beyond that expected for the gestational age was seen in 62% of cases, uterine size was small for dates in 12% of cases, ovarian enlargement occurred in 27% of cases, bilateral in 72% and unilateral in 28% of cases. Our   findings   are   similar  to   corresponding  figures  reported  in  other  series.13-16

                Pregnancy induced hypertension occurred in 12% of cases which is less than the figure reported in other series.13-16 The possible explanation for the differing incidence of pre-eclampsia in different studies could be related to the timing of the diagnosis of molar pregnancy. Molar pregnancy is diagnosed and managed earlier now because of the routine use of ultrasonic scanning in all pregnant patients.

                Clinical hyperthyroidism was noted in 3% of the cases and these patients received beta-adrenergic blocker prior to the molar evacuation. Nisulaard Talidourous (1980) suggested that human chorionic gonadotrophin is the thyroid stimulator in patients with hydatidiform mole.17 Soto-Wright et al (1995) postulated that the clinical presentation of complete hydatidiform mole has changed in recent years and fewer current patients in their study as compared to historic control presented with traditional symptoms of molar pregnancy (large uterine size, hyperemesis gravidarum, anemia, pre-eclampsia, and hyperthyroidism).18 However, vaginal bleeding remained the most common symptom with no significant change in the incidence of persistent trophoblastic tumour. The incidence of invasive mole and choriocarcinoma in this study was 6.7% and 3.3%. Chemotherapy is now the established method of treatment of choriocarcinoma and hysterectomy and surgical resection of the tumor is rarely required in cases resistant to chemotherapy.19,20 It is often difficult clinically to distinguish between an invasive mole and choriocarcinoma without histological examination of the tissue. The interval between evacuation of the mole and detection of post-molar gestational trophoblastic disease in these patients ranged from 2 to 12 months (mean 6 months). All patients with evidence of persistent trophoblastic activity in the absence of a new pregnancy should receive chemotherapy.

                The combined oral contraceptive pill was the commonly prescribed method of contraception  for at least one year.

                The availability of ultrasound scans and estimation of serum BhCG contributed to the early diagnosis and follow-up of these patients.

CONCLUSION

The incidence of hydatidiform mole in this study is comparable to the incidence in some far eastern countries. The common clinical features of hydatidiform noted were vaginal bleeding in early pregnancy, uterine size being larger than the dates and the presence of ovarian thecalutein cysts. When a patient presents with symptoms of pregnancy in an exaggerated form specially hyperemesis gravidarum the clinician should be alerted to the presence of gestational trophoblastic disease. However, due to the frequent use of ultrasonic scan, the diagnosis of hydatidiform mole is now made early in pregnancy. If hydatidiform mole is suspected on clinical grounds, ultrasonic scanning and quantitative estimation of serum BhCG should be carried out to confirm the diagnosis.

REFERENCES

1.     Kim SJ. Epidemiology of gestational trophoblastic disease. In: Hancock BW, New-Land ES, Berkowitz RD.Eds. Gestational Trophablastic Disease. Chapman & Hall Medical: London: 1997, 27-42.

2.     Hando T, Ohno M, Kurose T. Recent aspects of gestational trophoblastic disease in Japan. Int J Gyne Obs 1998;60(1): S71-S6.

3.     Kim SJ, Bae SN, Kim JH, Han KT, Chung JK, Lee JM. Epidemiology and time trends of gestational trophoblastic disease in Korea. Int J Gyne Obst 1998; 60(1):S33-S8.

4.     Mazzanti P, Lavecchia CL, Prazzani F, Bolic G. Frequency of hydatidiform mole in Lombardy. Northern Italy. Gynecol Oncol 1986;24:377.

5.     Fukunga M, Mshigome S, Endo Y. Incidence of hydatidiform moles in Tokyo Hospital: a 5-year study (1989-1993) prospective, morphological and flow cytometric study. Hum Pathol 1995; 26:758-64.

6.     Baghsawe KD, Dent J, Webb J. Hydatidiform mole in Englandand Wales1973-1983. Lancet 1987;2:673.

7.     Hayashi K, Borken MB, Freeman DJ Jr., Hellanbrand K. Hydatidiform mole in the United States (1970-1977). A statistical and theoretical analysis. A M of Epidimiol 1982; 115:67.

8.     Jacobs PH, Hunt PA, Matsurura JS, Wilson CC, Szulman EA. Complete and partial hydatidiform mole in Hawaii: Cytogenetics, Morphology and Epidemiology. Br J Obstet Gynecol 1982; 89:258.

9.     La Vacchia CL, Parazzani F, Deanli A, et al. Age of parents of gestational trophoblastic disease. J Nat'l Cancer Instit 1984;73:639.

10.   Nakano R, Sasaki K, Yamato M, Hata H. Trophoblastic disease analysis of 342 patients. Gynecol Obste Invest 1980;11:237.

11.   Matsuura J, Chiu D, Jacobs PA, Szulman AE. Complete hydatidiform mole in Hawaii. An epidemiological study. Genet Epidemiol 1984;1:171.

12.   Matalon M, Madan B. Epidemiologic aspects of hydatidiform mole in Israel. Am J Obstet Gynecol 1972; 112:107.

13.   Grimes DA. Epidemiology of gestational trophoblastic disease. Am J Obstet Gynecol 1984; 150:309.

14.   Atrash HK, Hague CJR, Grims DA. Epidemiology of hydatidiform mole during early gestation. Am J Obstet Gynecol 1986;154:906.

15.   Beischer NA, Bettinger HF, Fortune OW, Pepperell R. Hydatidiform mole and its complication in the State of Victoria. J Obstet Gynecol Br Common 1970;77:263.

16.   Akinkugbe A. Incidence and malignancy rate in hydatidiform molar pregnancy in Ile-lfe. Nig Med J 1976;6(3):310.

17.   Nisula BC, Talidouros GS. Thyroid function in gestational trophoblastic neoplasia: Evidence that the thyrotrophic activity of chorionic gonodotrophin mediate the thyrotoxicosis of choriocarcinoma. Am J Obst Gynecol 1980;138:77-85.

18.   Soto-Wright V, Bernstein M, Goldstein DP, et al. The changing clinical presentation of complete molar pregnancy. Obstet Gynecol 1995;86:775-9.

19.   Berkowits RS, Goldstein DP. The management of molar pregnancy and gestational trophoblastic tumors. In: Knapp RC, Berkowitz RS, eds. Gynecologic Oncology 2nd ed. New York: McGraw-Hill. 1993:328-38.

20.   Goldstein DP, Berkowitz RS. Current management of complete and partial molar pregnancy. J Reprod Med 1994;39:139-46.


-0001-11-30

ADOLESCENTS AND CANCER


ADOLESCENTS AND CANCER: A SURVEY OF KNOWLEDGE AND ATTITUDES A BOUTCANCER IN EASTERN PROVINCEOF SAUDI ARABIA

Talal J. Hashim, PhD, Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia

هدف الدراسة :دراسة معرفة ومواقف المراهقين والمراهقات عن مرض السرطان بالمنطقة الشرقية .

طريقة الدراسة :تم تصميم استبيان وتوزيعه على شريحة عشوائية تتكون من أربع مدارس لطلاب وطالبات الثانوية العامة ( اثنان للبنين واثنان للبنات ) بمدينة الظهران في المملكة العربية السعودية.

نتائج الدراسة :اشتملت العينة على 572 مراهق ومراهقة . أوضحت الدراسة أن نسبة إلمام الطلاب والطالبات بمرض السرطان تختلف حسب معرفتهم بأسباب حدوثه وكيفية الوقاية منه.

تبين الدراسة أن هناك بعض المعرفة بين الطلاب والطالبات ، ولكن مستوى المعرفة متساو ، كما تبين أن هناك مغالطات في بعض المفاهيم عن مرض السرطان وكيفية الوقاية منه . تتضح من البيانات الحاجة لتصميم وتطوير برامج صحية تثقيفية عن هذا المرض موجهة لطلاب وطالبات مدارس الثانوية العامة بالمملكة العربية السعودية .

الكلمات المرجعية :مرض السرطان،  المعرفة ، المواقف ، المملكة العربية السعودية .

Objective: To determine the knowledge and attitudes of adolescents in the Eastern Province of Saudi Arabia towards cancer.

Methodology: A pre-structured tested and revised questionnaire was administered to a randomly selected sample from four high schools (two males and two females) in Dhahran, Saudi Arabia.

Results: Data were obtained from 572 adolescents. There was a marked variability in knowledge across informational items, particularly about the possible causes and how to avoid developing cancer.

Conclusion: Students possess some knowledge of cancer, although this knowledge was not uniform. There were misconceptions about cancer and its pervention. The researcher concludes that the development and implementation of school health education programs on cancer are needed in this population.

Key Words: Cancer, Knowledge, Attitude, Saudi Arabia

INTRODUCTION

Cancer is a global disease. It is estimated that it affects at least nine million people every year and around five million patients die of it.1

Recent studies revealed that cancer has become an ever-increasing problem in Saudi Arabia due to the affluent lifestyle and the increase in life expectancy.2-6 In Saudi Arabia, the incidence of cancer has been

Correspondence to:

Dr. Talal J. Hashim, P.O. Box 92628, Riyadh 11663, Saudi Arabia

estimated as around 800 new cases per million population per year,1 70% of whom are in an advanced stage. According to the National Cancer Registry of the Ministry of Health, the total number of cases in the year 1994 was 7,028 cases. Males accounted for 3,954 of the cases and the rest were females. The number of Saudis diagnosed with cancer represents almost 72% of the total number of cases reported during that period.7

                Prevention of cancer is possible and for many types of cancers cure is feasible when detected early. The incidence in the country could be reduced with behavior, changes as knowledge improves. Several studies have suggested a severe lack of knowledge among the public about the disease.8-12 Unfortunately, very limited work has been done in Saudi Arabia with public knowledge and attitude towards cancer. A study by Ibrahim et al13 suggested that general knowledge except about breast cancer is lacking. He reported that education was the most significant factor that influenced individual's misconceptions on cancer in Saudi Arabia. The aim of this study was to assess the level of knowledge and attitudes of secondary school boys and girls in Dhahran, Saudi Arabia.

SUBJECTS AND METHODS

The survey was administered to 12th grade students at the beginning of the academic year 1998-1999, to a randomly selected sample of 572 students from four high schools in Dhahran, Saudi Arabia, two males and two females.

                A three part prestructured, tested and revised questionnaire consisting of 22 questions was developed. Part one included 15 true/false items to evaluate students' knowledge of cancer. Part two included five questions, eliciting information on students' attitudes and the need for instruction on cancer to be included in the school curricula. Part three of the questionnaire consisted of two open-ended questions namely: (1) "What would you like to know about cancer," and (2) "What are the eating habits that reduce the risk of developing cancer?"

                The survey which was administered by the teachers to all 12th grade students who were present took approximately 20 minutes to complete. Students were told that the questionnaire was designed to find out how much they knew about cancer and that their answers would be used to develop cancer education materials for high school students in Saudi Arabia. Internal reliability of the questionnaire was calculated using Cronbach's alpha.

                A copy form was developed to reflect the range of responses to each question. Each response mentioned was recorded. Students could and often did mention more than one response for a particular question. Questions left unanswered were considered missing. Actual comments and the coded data were analyzed using SPSS (Statistical Package for Social Sciences). Statistical analysis included frequency distribution for each variable. The total score of knowledge was computed. Students' t-test was computed to identify the effect of gender and different attitudinal variables on knowledge.

RESULTS

The alpha coefficient was found to be 0.84. Table 1 shows that students possess some knowledge of cancer, although this knowledge was not consistent. The majority of responses (83%) stated that cancer was a life threatening disease, and 55% indicated cancer as uncontrolled growth of cells. Other responses indicated that everyone was susceptible to cancer (62%). On the causes of cancer, 93% of the students correctly indicated that smoking was one of the causes. Continuous    exposure    to   environmental

Table 1:  Subject's correct responses for each knowledge statement by sex

STATEMENT

TOTAL

MALE

FEMALE

N

%

N

%

N

%

Cancer is uncontrolled growth of cells of the body

331

54.7

165

57.5

148

51.9

Cancer is caused by virus

263

46.0

111

38.7

152

53.3*

The cause of cancer is unknown

189

33.0

83

28.9

106

37.2†

Anybody is susceptible to cancer

353

61.7

192

66.9

161

56.7‡

Cancer is not a life threatening disease

476

83.2

244

85.0

232

81.1

Early detection of cancer is difficult because there are no specific symptoms.

362

63.3

183

63.4

179

63.0

Cancer is an infectious disease

426

74.5

208

72.5

218

76.6

Smoking can cause cancer

534

93.4

274

95.5

260

91.2†

Any sun-exposure or ultra violet rays can cause cancer

161

28.1

85

29.7

76

26.7

Continuous exposure to environmental hazards can cause cancer

311

54.4

173

60.3

138

48.4‡

Alcohol addiction can cause cancer

368

64.3

159

55.4

209

73.3*

A balanced diet reduces the possibility of getting cancer

331

57.9

168

58.5

163

57.2

Regular health check-up helps detect cancer early

481

84.1

241

84.0

240

84.2

Self breast examination is the best way to detect cancer early

418

73.1

186

64.8

232

81.4*

Regular exercise reduces the chances of getting cancer

347

60.7

201

70.0

146

51.2*

Total Mean Score

570

9.3

286

9.3

284

9.3

*p < 0.001; †p < 0.05; ‡p < 0.01

Table 2:  Subject's attitudes towards cancer by sex.

STATEMENT

SEX

YES

NO

p-VALUE

N

%

N

%

I am afraid of developing cancer

M

F

231

256

84.0

94.5

44

15

16.0

5.5

0.00

I would rather get any other diseases than cancer

M

F

95

155

46.1

71.1

111

63

53.9

28.9

0.00

I have heard enough about cancer and I don't want to hear anymore about it

M

F

62

83

28.4

29.3

218

200

77.6

70.7

0.03

It is important that students learnt about cancer in the school

M

F

261

259

93.2

92.5

19

21

6.8

7.5

NS

The media is the best source for cancer information

M

F

240

253

87.3

90.0

35

28

12.7

10.0

NS

NS = Not significant

hazards was indicated by 54%, alcohol addiction by 64% and an unbalanced diet by 38% of the surveyed population. The adolescents were well informed on cancer detection. About 84% indicated that regular health-checks help in the early detection of cancer. Table 1 shows that there were significant differences among the males and females in relation to the eight statements particularly on the statements that cancer was caused by virus, everyone was susceptible to cancer and that smoking could cause cancer. This table also shows that there was no significant difference in total score of knowledge with respect to sex.

                It is evident from Table 2, that adolescents' attitude about cancer showed fear, 89.2 percent of the respondents reported "being afraid of developing cancer" and 74.2 percent reported that they "have not heard enough about it". A majority of the adolescents (58.2%) surveyed indicated that they would rather contract any disease other than cancer. Most of those surveyed, 95.9% indicated it was important for students to have some education on cancer at school. Also, it was found there was a significant difference between male and female adolescents on the three statements: "I am afraid of developing cancer", "I'd rather get any disease other than cancer," and "I have heard enough about cancer and I don't want to hear anymore about it".

Figure 1 shows responses to what you would like to know about cancer. The majority of the students (66%) wanted to have more information about cancer. Most of the students wanted general information (e.g. types of cancer, whether prevention was possible for all types of cancer and how), information about symptoms (how to find out if one has it whether it was painful, what the specific symptoms were). Girls were more concerned than boys to talk about cancer symptoms. Types of treatments were mentioned almost equally by both sexes (28%). Some of the students (12%) were interested to know the effects of cancer (what it does to the body, whether it leaves scars in your body, whether it deforms)

Figure 2 indicates responses to the eating habits. What eating habits to follow to reduce the risk of developing cancer? The general responses mentioned by 27% of students were eating the basic four groups, quality food, and balanced meal. Lots of vegetables and low fat were mentioned by 20% and 14% respectively. Specific recommendations about cholesterol were mentioned by 5% of the students. One third (35%) stated "don’t know" or left the question unanswered.

Other eating practices, including a wide variety of responses, were mentioned by 25% of students. Other examples include, “eating protein rich food, wash hands before eating, cook all meat,” and avoiding certain food (e.g. fast food, all restaurant food, high carbohydrates and all red meats).

DISCUSSION

The focus of this study is on knowledge and attitudes towards cancer among Saudi high school students. The rationale behind the survey was that the lack of public knowledge about cancer, particularly about the importance of early detection was a potential barrier that prevent people from participating in cancer control activities.14 However, other studies have pointed out that other factors such as easy access to screening programs and other social and psychological factors are important in changing behaviour.10 The total mean knowledge score was 9.3 (60%) which indicates a reasonable general knowledge in comparison to another study conducted elsewhere in Saudi Arabia.13 However, students' knowledge on certain questions on cancer such as the causes and prevention of cancer was poor.

                Students in the present study sample consider cancer as a life threatening disease, but knew little about causes and prevention of the disease. Since the awareness of the seriousness of a disease can influence patterns of behaviour, this can be used in health education programs as a means of guiding choices and effecting change in behaviour.15 Fifty four percent indicated environmental hazards, 64% alcohol addiction as causes but 39% of the students were unable to understand that everyone was susceptible to cancer. The health belief model proposed that perceived susceptibility is an essential predictor of likelihood for adopting healthy behaviour.16

                It was evident that students' knowledge of cancer was generally low since an average of 60% of the students gave correct responses to the general questions on cancer. They did not know what the risk factors were and had little knowledge on its prevention. Besides, 66% of the students indicated a need for more information about the disease. Gender was not a factor in total score on the knowledge on cancer though there were significant differences in the answers to certain items on the questionnaire. For instance, more girls knew about breast cancer detection, and alcohol as a risk factor while more boys stated that smoking was a risk factor and exercise was a preventive factor. This could be explained by the educational drive on breast cancer prevention currently being conducted among women. On the other hand, the boys had more knowledge about smoking, regular exercise and its relation to cancer prevention. This difference in knowledge between the sexes could obviously be explained by the differences in public health education programs. It is also indicative of the lack of appropriately structured information/education for students. It is important for this section of the society to be given proper information about cancer and its prevention.

                The findings indicate the need for a teaching module to be included in the school curricula to deal with misconceptions about cancer and cancer prevention. Schools are a valuable asset in health education17 and cancer education is no exception. Accurate knowledge and information could encourage young people to adopt behaviour patterns that would reduce the risk of cancer.18 Various studies have suggested that educating young people on cancer can affect their attitude to the diseases.19 Gribb20 and Resnicow et al21 pointed out that curricula that foster a positive attitude towards cancer prevention include information and skill - building on how to make informed decisions about health. Increasing people's knowledge about cancer is an important strategy in influencing their decisions about whether or not they participate in cancer preventive practices. It must be recognized, however, that the school represents only part of the students' educational experience. Parental involvement has an important role to play particularly in the area of diet.22 Similar to data reported for other western students, relatively few students were aware of the association between diet and cancer and the specific dietary recommendations that to reduce the risk of cancer.23,24 There is a need for a joint effort between the agents that influence students' social behaviour to foster the making of healthy choices in such complex social behaviour as smoking and eating habits.25,26 Much of the behaviour recommended to reduce the risk of cancer require the making of lifelong healthy decisions early.27 The role of the mass media in raising public awareness about cancer cannot be overemphasized. Special cancer education programs should be directed to adolescents and the youth.

                As the incidence of cancer in Saudi Arabia continues to escalate,2-6 more attention must be directed at adolescent population, if the burden of chronic illness (cancer) among Saudis is to be lightened.

REFERENCES

1.     World Health Organization: Cancer control in the Eastern Mediterranean Region. AlexandriaWHO, 1995; 30–42.

2.        Akhtar SS, Reyes LM. Cancer is in Al-Qassim Saudi Arabia: a retrospective study (1987–1995). Ann Saudi Med 1997; 19(6):595–600.

3.     Al-Saigh AH, Allam MM, Khan KA, Al-Kawsawi AM. Pattern of cancer in Medina Al-Munawora Region. Ann Saudi Med 1995; 15(4):350-3.

4.     Ezzat A, Raja M, Teofelia, Michels D, Bazarbashi S. Frequency and distribution of 22,836 adult cancer cases referred to King Faisal Specialist Hospitaland Research Center. Ann Saudi Med 1996; 16(2):152-8.

5.     Sebai ZA. Cancer in Saudi Arabia. Ann Saudi Med 1989; 9(1):55-63.

6.     Tandon P, Pathak V, Akthar Z, Chatterjee A, Walfor N. Cancer in Gizan Province of Saudi Arabia. Ann Saudi Med 1995; 15(1):14-20.

7.     Ministry of Health: National Cancer Registry 1994 report; Cancer incidence in Saudi Arabia1994. Riyadh; MOH 1996; 1-43.

8.     Breslow R, Sorkin J, Frey C, Kessler L. American knowledge of cancer risk and survival. Preventive Medicine 1997; 26:170-7.

9.     Jadalla A and Sharaya H. A Jordanian view about cancer knowledge and attitudes. Cancer Nursing 1998; 21(4):269-273.

10.   Luther S, Price J, Goomastic M. Measuring common public misperceptions about cancer. J Cancer Education 1987; 2(3):177-187.

11.   Ali N, Ibrahim A, Shafik N. An investigation into knowledge and attitude toward cancer among Egyptian lay public and cancer patients. J EgyptNat Cancer Ins 1986; 2:585-95.

12.   Sariego J, Sariego L, Matsumoto T, Vosburgh M, Kerstenin M. Cancer knowledge and misconceptions among college undergraduates: A pilot study. J Cancer Education 1992; 7(1):73-8.

13.   Ibrahim EM, Al-Muhanna FA, Said I, et al. Public knowledge, misperceptions, and attitudes about cancer in Saudi Arabia. Ann Saudi Med 1991; 11(1):518-523.

14.   Mettlin D, Cummings KM. Communication and behaviour change for cancer control, Issues in Cancer Screening and Communications. Edited by Mettlin and Murphy, Alan R. Liss, Inc., New York, 1982.

15.   Janz NK, Beker MH. The health belief model: A decade later. Health Edu Quart 1984; 11:1-47.

16.   Baric L. Health promotion and health education module 1: The problem and solution. England: Brans Publication. 1994; 46.

17.   Jones K, Tilford S, Robinson Y. Health education: effectiveness and efficiency. London, England: Chapman and Hall, 1990.

18.   Carey P, Sloper P, Charlton A, While D. Cancer education and the primary school teacher in England and Wales. J Cancer Education 1995; 10(1):48-52.

19.   Charlton A. Assegai: teaching about cancer in the general studies. Int. Health Education 1983; 34: 67-73.

20.   Cribb A. School teacher’s perceptions of relative importance of cancer education in the United Kingdom. J Cancer Education 1990; 5:225-9.

21.   Resnicow KA, Orlandi MA, Wynder EL. Towards an effective school health education policy. A call for legislative and educational reform. Prev Med 1989; 18:147-55.

22.   Walter HJ and Wynder EL. The development, implementation, evaluation, and future decisions of a chronic disease prevention program of children: The “know your Body” studies. Prev Med 1989; 18: 59-71.

23.   McCrregor SL, Murphy E, Reeve J. Attitudes about cancer and knowledge of cancer prevention among Junior High Students in Calgray, Alberta. Can J PH 1992;83(4):256-9.

24.   Pattnoy B, Christenson GM. Cancer knowledge and related practices: results from the related practices: results of the National Adolescent Student Health Survey. J Sah Health 1989; 59:218-24.

25.   Cameron H, Mutter G, Hamilton N. Comprehensive school health; back to the basics in the 90s. Health Promotion 1991; 10:2-5.

26.   D'Onofrio CN. Making the care for cancer prevention in the schools. J Sch Health 1989; 59:225-31.

27.  Troabi MR, Seffrin JR. Evaluation of the effects of cancer education on knowledge, attitude and behavior of University undergraduate students.  J Cancer Education 1989; 4:39-47


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HYPERTENSION IN DIABETICS


HYPERTENSION IN DIABETICS REGISTERED IN PRIMARY HE ALTHCARE CENTERS IN MAKKAH DISTRICT, SAUDI ARABIA

Ahmed G. Elzubier, FRCPI, Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia

مقدمة:يعتبر فرض التوتر الشرياني للداء السكري من الأمراض الشائعة والمسببة في حدوث المضاعفات الخاصة بالأوعية الدموية. نظراً لشيوع الداء السكري وفرط التوتر الشرياني فأن متابعتهما في مراكز الرعاية الصحية الأولية تتطلب الحرص على الاكتشاف المبكر لفرط التوتر الشرياني. و تهدف هذه الدراسة إلى تقدير حجم هذا المرض المصاحب للداء السكري بين مرضى الداء السكري المسجلين بمراكز الرعاية الصحية الأولية.

منهج الدراسة:تمت مقابلة 1039 من مرضى السكري في المركز الصحية الحضرية والريفية بمنطقة مكة المكرمة. و قد تم جمع المعلومات الديموغرافية و ذات الصلة بمرض السكري, كما تم قياس الوزن و ضغط الدم لكل أفراد العينة.

نتائج الدراسة :بلغت نسبة مرضى السكري المصابين بفرط التوتر الشرياني 54.9% من العينة كما بلغت نسب درجات ضغط الدم المرتفع في مراحله الأولى والثانية والثالثة 5 و25% ، 00و7 % ، 5 و2% , على التوالي. وبلغت نسبة المرضى غير المعروفين بإصابتهم بضغط الـدم المرتفع 22.1%. و أظهرت الدراسة علاقة ذات أهمية إحصائية بين ضغط الدم المرتفع و العمر , وفي الذكور و البدانة وانخفاض مستوى التعليم .

الخلاصة:أظهرت الدراسة نسبة عالية من فرط التوتر الشرياني بين مرضى السكري , وأن نسبة منهم غير معروفة. وهنالك حاجة ماسة لتقصى و اكتشاف مثل هذه الحالات.

الكلمات المرجعية :مرض السكري ضغط الدم المرتفع مراكز الرعاية الصحية الأولية.

Background:Hypertension in diabetes is a common and important problem, which

aggravates diabetic macro- and microvascular complications. Since both diabetes and hypertension are common diseases, their follow up in primary health care centers should emphasize the early detection of hypertension in diabetes. This study aims at studying the magnitude of hypertension in diabetic subjects registered in primary health care centers.

Methods: A sample of 1039 diabetic subjects registered at the primary health care in urban and rural Makkah region were interviewed. Information gathered included demographic and diabetes-related variables. Blood pressure and body mass index were determined for 1020 subjects.

Results: Diabetic subjects who had high blood pressure readings amounted to 560 (54.9%), of whom with stage 1, 2, and 3 hypertension formed 25.5%, 7.0% and 2.5%, respectively. Subjects with undetected high blood pressure amounted to 225 (22.1%). There was significant association of high blood pressure with age, male gender, body mass index and low education.

                                                                 

Correspondence to:

Dr. Ahmed G. Elzubier, P.O. Box 40187, Al-Khobar 31952, Saudi Arabia

Conclusion: The problem of hypertension in diabetes could be sizeable. Many patients may remain undetected. A diligent search for diabetic subjects with elevated blood pressure should be made through an efficient system of follow up in the PHCC centers.

 

Keywords: Diabetes mellitus   Hypertension  Primary Health Care Centers

INTRODUCTION

Hypertension in diabetes is a common problem.1 In insulin dependent diabetes mellitus (IDDM) the condition is common in subjects with diabetic nephropathy.2 However, in non-insulin dependent diabetes (NIDDM) it is even more common, and is invariably associated with obesity.3 As in the case of essential hypertension, hypertension complicating diabetes mellitus represents a strong risk factor for cardiovascular complications, and aggravates the micro- and macrovascular complications of diabetes mellitus.4,5 Hypertension is also twice as common in diabetic than in non-diabetic subjects. Unlike the case of IDDM, hypertension associated with NIDDM may be present at the time of diagnosis of diabetes. This is because, in a considerable number of individuals, the two diseases may have common underlying mechanisms.6 Hypertension in diabetes is also associated with  all the behavioral problems encountered with essential hypertension, such as unawareness, and non-compliance with drugs and non-drug management. Since both diabetes and hypertension are common problems in Saudi Arabia, it is important to shed some light on the problem of hypertension in diabetes. Both conditions are being mostly managed in the primary health care ( PHCC) centers. This study aims to study the magnitude of the problem of hypertension in diabetes among diabetic  subjects  cared  for in  PHCCcenters. 

MATERIAL AND METHODS

The study population were adult diabetic subjects at the age of 15 years or more, who had had a confirmed diagnosis of diabetes mellitus for the last one year, and who were registered in the diabetic registries of the PHCC centers, in Makkah City, and in rural Makkah district during the year 1420H. (1999G.). There was a total of 11,614 diabetic subjects, 8,110 (70%), and 3504 (30%) of whom were registered in the urban and rural PHCC centers, respectively.

A two-stage stratified random sampling technique, with proportional allocation to choose about (10%) of diabetic subjects, from 9 urban and 12 rural PHCC, was adopted. In the first stage, simple random sampling technique was used to choose 9 urban and 12 rural PHCC. In the second stage, the sample of diabetic subjects from each chosen PHCC was also chosen, using simple random sampling.

Data were collected by pre-trained PHCCcenter physicians, using a structured questionnaire form. The questionnaire included socio-demographic data, such as age, sex, nationality, and educational level. Education level was categorized as low (primary and intermediate schooling), average (secondary schooling), and high (university and postgraduate). The questionnaire also included information regarding duration of diabetes mellitus, and the presence of hypertension. Diabetes mellitus was classified into type 1 and 2 according to whether the patient was being treated with insulin or oral hypoglycemic drugs, respectively. Measurement of weight in kilograms, and height in meters was done and body mass index ( BMI) was calculated as weight in kilograms divided by the square of the height in meters. A BMI of more than 25 kilograms/ square meter was considered as high. Blood pressure measurement was done using a mercury sphygmomanometer with a suitable cuff size while the patient was seated and systolic (SBP), and diastolic blood pressure (DBP) were recorded at the onset and disappearance of Kortokoff's sounds, respectively. Blood pressure was classified as normal (SBP < 130,  DBP < 85 mmHg), high normal (SBP = 130-139, DBP = 85-89 mmHg), stage 1 (SBP = 140-159, DBP = 90-99 mmHg), stage 2 (SBP = 160-179, DBP = 100-109 mmHG) and  stage 3 hypertension (SBP 180, DBP 110 mmHg); in accordance with criteria adopted by the Joint National Committee on Detection, evaluation and Treatment of High Blood Pressure.7

Data was analyzed using the Statistical Package for Social Science ( SPSS PC) version 7.0. Chi-squared test was used to assess the significance of differences between categories. A p-value of 0.05 or less was considered statistically significant.

RESULTS

The study sample consisted of  1039 diabetic subjects. Males and females constituted 66.7% and 33.3% of the sample, respectively. The overall mean age was 54.6±12.6 years (55.6±12.9 and 52±11.8 years for males and females, respectively). The majority of subjects (93.7%) were of Saudi nationality.

Subjects with type 2 diabetes mellitus constituted (95.1%), and almost two-thirds of these had had diabetes mellitus for less than 10 years. An abnormally high BMI was manifested by 72.4% of the sample (Table 1).

Table 1: Demographic variables and disease pattern of diabetic subjects (N=984)*

Variable

No. (%)

Age:

15-34

48 (4.9)

35-54

423 (43.0)

55+

513 (52.1)

Gender:

Males

658 (66.9)

Females

326 (33.1)

Education Level:

Low

716 (74.3)

Average

191 (19.8)

High

57 (5.9)

Type of diabetes:

Type I

48 (4.9)

Type 2

936 (95.1)

Duration of diabetes:

Less than 10 years

598 (61.5)

10 years and more

375 (38.5)

Body mass index:

Normal

257 (27.5)

High

677 (72.5)

*Missing numbers out of a total of 1039

Blood pressure readings were obtained from 1020 subjects constituting 98.2% of the sample. A total of 560 (54.9%) subjects had high blood pressure readings, which were classified as high normal (19.9%), stage 1 hypertension (25.5%), stage 2 hypertension (7.0%), and stage 3 hypertension (2.5%). The number of subjects with unrecognized high blood pressure was 225 (22.1%) (Table 2)

                There were significant increases in the proportions of patients at all stages of high blood pressure, with increasing age (P < 0.0001), male gender (P < 0.0001), and with low educational level (P < 0.0001) (Table 3).

                However, there was significantly higher incidence of all stages of high blood pressure (P < 0.0001, and P < 0.0001, respectively) in subjects with type 2 diabetes mellitus, and those with a high BMI. As regards the duration of diabetes, significantly more subjects who had had high blood pressure for less than 10 years at all stages of hypertension were observed (Table 4).

Table 2: Blood pressure level distribution among 1020 diabetic subjects

Blood pressure level

Number (%)

Normal (SBP<130, DBP <85)

460 (45.1)

High normal (SBP=130-139, DBP=85-89)

203 (19.9)

Stage I hypertension (SBP=140-159, DBP=90-99)

260 (25.5)

Stage 2 hypertension (SBP=160-179, DBP=100-109)

71 (7.0)

Stage 3 hypertension (SBP180, DBP110)

26 (2.5)

Total with high blood pressure detected

560 (54.9)

Grand total

1020 (100)

Subjects with known hypertension

226 (21.9)

Number with possible unrecognized hypertension

225 (22.1)

Table 3: Blood pressure level distribution according to age, gender and education level

Variable

Blood Pressure Stage

p-value

Normal

High normal

Stage I

Stage 2

Stage 3

Age (years):

15-34

36 (8.1)

5 (2.6)

7 (2.8)

35-54

236 (53.2)

68 (35.1)

90 (36.0)

21 (29.6)

8 (32.0)

55+

172 (38.7)

121 (62.4)

153 (61.2)

50 (70.4)

17 (68.0)

< 0.000

Total

444

194

250

71

25

Gender:

Males

302 (68.0)

153 (78.9)

161 (64.4)

29 (40.8)

13 (52.0)

Females

142 (32.0)

41 (21.1)

89 (35.6)

42 (59.2)

12 (48.0)

<0.000

Total

444

194

250

71

25

Education:

Low

308 (70.3)

142 (75.1)

184 (75.7)

64 (91.4)

18 (75.0)

Average

103 (23.5)

32 (16.9)

47 (19.3)

5 (7.1)

4 (16.7)

High

27 (6.2)

15 (7.9)

12 (4.9)

1 (1.4)

2 (8.3)

<0.009

Total

438

189

243

70

24

Table 4: Blood pressure level distribution according to type, duration of diabetics and body mass index

Variable

Blood Pressure Stage

p-value

Normal

High normal

Stage I

Stage 2

Stage 3

Type:

Type 1

36 (75.0)

5 (10.4)

7 (14.6)

Type 2

408 (43.6)

189 (20.2)

243 (26.0)

71 (7.6)

25 (2.7)

<0.000

Duration:

<10 years

286 (47.8)

101 (16.9)

152 (25.4)

41 (6.9)

18 (3.0)

10 years

152 (40.5)

92 (24.5)

96 (25.6)

28 (7.5)

7 (1.9)

<0.03

Body Mass Index

Normal

137 (53.3)

58 (22.6)

48 (18.7)

10 (3.9)

4 (1.6)

High

280 (41.4)

128 (18.9)

190 (28.1)

60 (8.9)

19 (2.8)

<0.000


 

DISCUSSION

Hypertension in diabetes implies a state of high risk of cardiovascular mortality;8 hence its detection, evaluation and effective management cannot be overemphasized. The prevalence of diabetes-related hypertension detected by this study amounts to 55% of the sample, with moderate to severe forms reaching 10%. This figure is high and is in agreement with similar figures cited in the literature.9,10 Moreover, the finding is significant in that  both diabetes mellitus and hypertension are risk factors for cardiovascular diseases, and  strong predisposing factors for  renal disease. Consequently, no effort should be spared in the detection and management of hypertension associated with diabetes.11 It may be necessary to adopt the guidelines given by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure which advocates that the management of patients with diabetes and hypertension should be carried out as if they were suffering from end-organ damage.12 The distribution of high blood pressure described by this study reveals that the majority of subjects have mild blood pressure elevation, together with high body mass index. This finding is significant since subjects with this degree of blood pressure  remain asymptomatic. It is important, therefore, that effective methods be employed for their  detection and evaluation, so that the modification of lifestyle could commence early.13

                The figures shown in this study were based on casual blood pressure measurement, so it is expected that a proportion of the subjects affected might have White Coat Hypertension.14 A meticulous follow up is necessary, so that proper evaluation and further intervention could be undertaken.

                Almost 50% of subjects with high blood pressure in this study were not aware of this. This figure is higher than that cited by other researchers,15 and reflects the quality of care that those subjects receive. Moreover, it again stresses the need for the employment of effective methods of early detection of high blood pressure. This could be achieved by training PHCC centers physicians on blood pressure audit.

                The study also reveals an expected positive association of high blood pressure with age, gender and BMI, a finding that agrees with the results of other studies.16,17 The study which supports similar findings in the Arabian Gulf Region reveals an inverse relationship of high blood pressure with educational level18 This can be accounted for as a marker of early-life socioeconomic deprivation induced by environmental factors as has been suggested.18 It may also reflect the inadequate functional health literacy,19 on the one hand, and the lack of health education needed for control of diabetes and hypertension20 on the other hand. 

                In conclusion, this study reveals that the problem of hypertension in diabetes may be sizable, and that many patients may remain undetected. The findings call for a diligent search for diabetic subjects with elevated blood pressure, through an efficient system of follow up in the PHCC centers.  

REFERENCES

1.        Hypertension in Diabetes Study Group. Hypertension in diabetes study (HDS): 1. prevalence of hypertension in newly presenting type 2 diabetic patients and the association with risk factors for cardiovascular and diabetic complications. J Hypertension 1993;11:309-17.

2.        Reavan  GM, Lithell  H, Landsberg  L.  Hypertension and associated metabolic abnormalities - the role of insulin resistance and the sympathoadrenal system. N Engl J Med 1996;334:374-81.

3.        Norgaard  K, Rasmussen  E, Jenssen  T, Feldt-Rasmussen  B.  Nature of elevated blood pressure in normoalbuminuric type 1 diabetic patients. Essential hypertension? Am J Hypertens 1993;6:830-6.

4.        Sowers  JR, Epstein  M.  Diabetes mellitus and associated hypertension, vascular disease, and nephropathy. Hypertension 1995;26:869-79.

5.        Cignarelli  M, De Cicco  ML, Damato  A, et al.  High systolic blood pressure increases prevalence and severity of retinopathy in NIDDM patients. Diabetes Care 1992;15:1002-8.

6.        Zimmet  P, Boyko  EJ, Collier  GR, de Courten  M.  Etiology of the metabolic syndrome: potential role of insulin resistance, leptin resistance, and other players. Ann N Y Acad Sci 1999;892:25-44.

7.        Joint National Committee. The sixth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure ( JNCVI). Arch Intern Med 1997;157(21):2413-24.

8.        Jamerson KA.  Treating high-risk hypertensive patients. Am J Hypertens 2000;13:68S-73S.

9.        Sugarman JR.  Prevalence of diagnosed hypertension among diabetic Navajo Indians. Arch Intern Med 1990;150(2):359-62.

10.     Le Floch  JP, Thervet  F, Desriac  I, Boyer  JF, Simon  D.  Management of diabetic patients by general practitioners in France1997: an epidemiological study. Diabetes Metabol 2000;26(1):43-9.

11.     Bakris  G, Sowers  J, Epstein  M, Williams  M.  Hypertension in patients with diabetes. Why is aggressive treatment essential? Postgrad Med 2000;107(2):53-6.

12.     Elliot  WJ, Weir  DR, Black  HR.  Cost-effectiveness of the lower treatment goal  (of JNC VI) for diabetic hypertensive patients. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 2000;160(9):1277-83.

13.     Julius  S, Jamerson  K, Mejia  A, et al.  The association of borderline hypertension with target organ changes and higher coronary risk. Tecumseh Blood Pressure study. JAMA 1990;264:354-8.

14.     Flores  L, Recasens  M, Gomis  R, Esmatjes  E.  White coat hypertension in Type 1 diabetic patients without nephropathy. Am J hypertens 2000; 13:560-3.

15.     Harris  MI.  Health care and health care status and outcomes for patients with type 2 diabetes. Diabetes Care 2000;23(6):754-8.

16.     Mason  EE, Renquist  K, Jiang  D.  Predictors of Two Obesity Complications: diabetes and hypertension. Obes Surg 1992;2(3):231-7.

17.     Bone  LR, Hill  MN, Stallings  R, Gelber  AC, Barker  A, Baylor  I, et al.  Community health survey in an urban African-American neighborhood: distribution and correlates of elevated blood pressure. Ethn Dis 2000;10(1):87-95.

18.     Al-Mahrous  F, Al-Roomi  K, McKeigue  PM.  Relation of high blood pressure to glucose intolerance, plasma lipids and educational status in an Arabian Gulfpopulation. Int J Epidemiol 2000;29(1):71-6.

19.     Williams  MV, Baker  DW, Parker  RM, Nurss  JR.  Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998;158(2):166-72.

20.     Bone  LR, Renquist  K, Jiang  D.  Predictors of Two Obesity Complications: diabetes and hypertension. Obes Surg 1992;2(3):231 -7.


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