SPONTANEOUS EXPULSION


SPONTANEOUS EXPULSION OF INTRABRONCHIAL METALLIC FOREIGN BODY: A CASE REPORT

Maha A. Hadi, FRCSI*, Laila M. Al-Telmesani FRCSEdn†

*Department of Surgery and †ENT, King Fahd Hospital of the University, College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia

استنشاق الأجسام المعدنية إلى القصبة الهوائية تعد من الحالات النادرة وغالباً ما تكون عند الأطفال ، ويتطلب استخراجها في معظم الأحيان التدخل الجراحي لتفادى المضاعفات . في هذه الحالة المقدمة تم لفظ الجسم المعدني بصورة تلقائية عند شخص بالغ بعد مرور ساعتين على استنشاقه .

________________________________________________________________

Inhalation of metallic foreign bodies is a rare event occurring mostly in children, and often requires early surgical intervention to avoid complications. We report a case of spontaneous expectoration of an intrabronchial metallic nail in an adult, 2 hours after inhalation.

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INTRODUCTION

Foreign body inhalation, is common in children and is usually hazardous and potentially lethal. The larynx performs a very efficient sphincteric function to protect the lower respiratory tract and, therefore, it is unusual for a foreign body to be inhaled rather than swallowed.1 In 1921, Jacksonsuggested that spontaneous expulsion of intrapulmonary foreign bodies occurs so rarely that removal should be performed early to avoid subsequent complications.2,3

We report a case of inhaled nail into the right lower lobe bronchus with spontaneous expulsion after 2 hours.

CASE REPORT

A 23-year-old male prisoner presented to our hospital with a history of having attempted to swallow a nail while under surveillance. A struggle had ensued, and the patient had had bouts of coughing followed by right-sided and retrosternal chest pain which was relieved almost instantly. There was no associated dyspnoea, hemoptysis or abdominal pain. He was fully conscious, alert and cooperative on arrival to the Emergency Room. Physical examination showed no abnormality. Chest roentegenogram demonstrated a curved nail lodged in the right lower lobe bronchus (Figure 1 & 2). This was  confirmed by CT scan. It was decided that bronchoscopic removal would be attempted; in case it fails failed surgical removal would be adopted. During the pre-operative preparation, the patient turned on his left side, started to cough and expectorated the foreign body spontaneously. It was about 2 cm long and weighed 2.6 gm (Figure 3).

There was no post expectoration dyspnoea, hemoptysis or chest pain. He was kept for 24 hours under observation. Repeated chest roentegnogram was normal and he was discharged.

DISCUSSION

Intrathoracic foreign bodies are classified into intrapulmonary and extrapulmonary .



____________________________________________________________________

Correspondence to:

Dr. Maha A. Hadi, P.O. Box 2208, Al-Khobar 31952, Saudi Arabia



Figure 1: Radiograph of the chest postanterior film demonstrating the foreign body

Figure 2:Radiograph of the chest lateral film demonstrating the foreign body

Figure 3: The expectorated foreign body

                                                                                                                                                                   

Extrapulmonary foreign bodies are usually due to penetrating injuries such as bullets or shrapnel. These are usually asymptomatic because they are encapsulated by fibrous tissue and, therefore, have minimal propensity to impinge upon surrounding structures.4 Bronchial erosion and migration by retained intrathoracic foreign bodies is an extremely rare event. To our knowledge there are only 5 reported cases in literature. On the other hand, intrapulmonary foreign bodies are usually aspirated most commonly by children with peak incidence between 1 and 2 years.5 From anatomic  consideration, inhaled foreign bodies are commonly located in right bronchial system as compared to the left (Table 1).5

Types of inhaled foreign bodies are usually food items such as peanuts, water melon seeds etc. Metallic foreign body aspiration is rare and often requires surgical removal.

Clinical manifestations depend on type, size and location of the foreign body. The diagnosis can be immediately established as in our patient, or, it can be delayed for the weeks or months especially if the history is not clear. Such cases may present with established complication such as emphysema, atelectasis, bronchectasis, pneumonia or lung abscess.

Roentegnograms  are mandatory  in establishing the diagnosis, locating the site of the foreign body and can also be helpful in demonstrating the presence of respiratory complications.

Removal of intrabronchial foreign bodies should be performed once the diagnosis is made. This can be achieved either by bronchoscopy or thoracotomy. Spontaneous expectoration of foreign bodies is rare. Since time is of essence, delay in intervention complicates the picture and makes subsequent removal even more difficult.

Table 1:Comparison of inhaled foreign bodies in the right and left bronchial systems

Site

%

Right main stem bronchus

42.0-70.0

Left main stem bronchus

18.7-32.6

Right segmental bronchi

22.0

Left segmental bronchi

3.0

Trachea

27.5

Larynx

1.0-7.5

  In conclusion, extrapulmonary foreign bodies, if asymptomatic, are best left alone. Intrapulmonary ones on the other hand, should be diagnosed promptly both clini­cally and radiologically and early intervention is advised to avoid complications.


REFERENCES

1. Kent SE, Watson MG. Laryngeal foreign  bodies. The Journal of Laryngology and Otology 1990;104:131-3.

2. Jackson C. Prognosis of foreign body in the lung. JAMA 1921;77:1178.


3  Marc SS, Alan JC, Munir A. Spontaneous endobronchial erosion and expectoration of a retained intra thoracic bullet: Case report. The Journal of Trauma 1992;33:6:909-11.

4. Van W CW III. Intrathoracic and intravascular migratory foreign bodies. Surg Clin North Am 1989; 69:125.

5. Liancai Mu, Ping He, Degiang Sun. Inhalation of foreign bodies in Chinese children: A review of 400 cases. Laryngoscope 1991;101.

6.  Ryndin VD, Octavio F. Two cases of spontaneous expulsion of aspirated needles from the lungs Grundn Khir 1986;6:90-1.

7. Cohen SR, Herbert WI, Lewis GB Jr. Foreign bodies in the airway. Five year retrospective study with special reference to management. Ann Otol Rinol Laryngol 1980;89:437-42.

8. Brooks JW. Foreign bodies in the air and food passages. Ann Surg 1972;175:720-31.

9. Banaszews Ki-B. Case of spontaneous expectoration of pin from the primary bronchus of the posterior segment of the lower lobe of the right lung. Pol Tyg Lek 1972;27:108-9.

10. Mital OP, Prasad R, Singhal SK, Malika A, Singh PN. Spontaneous expulsion of a long standing endobronchial metallic foreign body. Indian J Chest Dis Allied Sci 1979; 21:45-7.


-0001-11-30

INFANTILE HYDROCEPHALUS


INFANTILE HYDROCEPHALUS IN SOUTHERN SAUDI ARABIA

Mohamed E.  El Awad, FRCP, Ahmed A. Al-Barki, CABP

Department of Pediatrics, College of Medicine, King Saud University - Abha Branch, Abha, Saudi Arabia

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هدف البحث :دراسة معدل ومسببات القيلة الدماغية عند أطفال السنة الأولى من العمر .

طريقة البحث :أجريت هذه الدراسة في مستشفى عسير المركزي ( أبها ) الجزء الجنوبي من المملكة العربية السعودية في الفترة من يناير 1990 إلى ديسمبر 1995م . وتمت دراسة سجلات أطفال السنة الأولى المصابين بالقيلة الدماغية لمعرفة المرضى ومقارنة النتائج بالمعدلات المحلية والعالمية .

نتائج البحث :وجد أن معدل القيلة الدماغية فى السنة الأولى من العمر 71و0 /1000 . كان عدد الحالات 62 من مجموع 87127 حالة مواليد في فترة الدراسة . شوهدت الشفة المشقوقة المتكيسة في 18 حالة ( 29%) ، ضيق قناة سيلفيس في 15 حالة ( 2و24 % ) ، التهاب السحايا الصديدي في 9 حالات (5و14%) ، نزيف بالمخ في 6 حالات (7و9%) ، التشوهات الدماغية في 6 حالات (7و9%) ، و3 حالات (9و4%) غير معروفة السبب ، وحالتين (2و3%) متلازمة داندي ووكر ، وحالتين (2و3%) داء المصورات الذيفانية ، وحالة واحدة (6و1%) أكندروبلاسيا. شكلت أسباب ما قبل الولادة 46 حالة (2و74%) وحالات ما بعد الولادة 16 حالة ( 8و 25%) . ضمن المجموعة الأخيرة كانت هنالك 9 حالات (5و14%) التهاب سحايا و 6 حالات (6و9%) نزيف دموي دماغي . ضمت حالات ما بعد الولادة 8 أطفال خدج (بنسبة 7و4% من كل المجموعة و 3و53% من مجموعة ما بعد الولادة).

الاستنتاجات :لوحظ ثبات معدل القيلة الدماغية عند أطفال السنة الأولى وزادت نسبة الأطفال الخدج ضمن أسباب ما قبل الولادة . كما لوحظ ازدياد تشوهات الجهاز العصبي في نفس الفئة  ومازالت حالات ما قبل الولادة تشكل غالبية الحالات.

الكلمات المرجعية : القيلة الدماغية ،  السنة الأولى ، جنوب المملكة العربية السعودية .

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Objective: To study the prevalence and causes of infantile hydrocephalus.

Methodology: Retrospective study of cases of infantile hydrocephalus comparing results with regional and international trends.

Results: Infantile hydrocephalus (IH) affected 62  infants from among 87,127 registered total live births giving an overall incidence of 0.71/1000.  Eighteen cases (29%) with spinal dysraphism, 15 cases (24%) with acqueductal stenosis, 9 (14.5%) post meningitis, 6 (9.7%) post haemorrhagic, 6 (9.7%) with structural Central Nervous System (CNS) anomalies (holoprosencephaly 2, hemispheric cysts 2, brain dysgenesis 1, and vascular anomaly 1), 3 (4.9%) congenital idiopathic, 2 (3.2%) Dandy-Walker malformation, 2 (3.2%) toxoplasmosis and one case (1.6%) achondroplasia. Prenatal factors accounted for 46 cases (74.2%) of this series, while postnatal factors accounted for 16 cases (25,8%). Of the latter group, 9 (14.5%) were due to meningitis while 6 (9.7%) were post haemorrhagic.

Correspondence to:

Dr. M. E. ElAwad, Associate Professor, Department of Pediatrics, College of Medicine, King Saud University, Abha Branch, P.O. Box 641, Abha, Saudi Arabia

Of the postnatal group there were 8 preterm babies (4.7% of the total series and 53.3% of the postnatal group).

Conclusion: While the incidence of infantile hydrocephalus in this region remains statistically unchanged,  new characteristics have emerged. It is interesting to notice the increased number of premature babies in the postnatal group. More associated CNS malformations have been noticed in the prenatal group. Still prenatal causes form the bulk of all cases.

Key Words:Infantile hydrocephalus, Southern Saudi Arabia.

 

INTRODUCTION

This paper explains the scarcity of information on the prevalence and incidence of infantile hydrocephalus in this part of the world and compares the different emerging trends (e.g. prevalence, causes, associated defects, etc) to international trends.1

There has been a tremendous improvement in the social life, health care and other services in this region. This has resulted in improved maternal and childhood health but not without expected changing pattern of diseases. Hence the importance of studying the many factors that might significantly affect the well-being of children in this region. Infantile hydrocephalus (IH) remains an important problem as its causes both antenatal and postnatal are multi-factorial and always requires expensive management. The outcome is invariably unpredictable since a large proportion of the affected children end up with significant neurological and intellectual handicap.2,3 This places a heavy burden on the family and the community at large. In the west, the impact of many congenital  diseases has been significantly reduced with the improvement in socioeconomic conditions and antenatal screening.

MATERIAL AND METHODS

Asir Central Hospital (ACH) is the only unit in this region that deals with management of hydrocephalus. All cases of IH are referred to this hospital for the necessary management. The case notes of all infants admitted with IH during the period 1/1/1990to 31/12/1995were analyzed. Chi square test was used for statistical analysis.  IH is defined as significant ventricular dilatation with increased CSF pressure in the first year of life.

RESULTS

During the study period the total registered live birth in the region was 87,127.  Sixty-two cases of IH were seen making a total incidence of 0.71/1000 births. The overall female to male ratio was 0.8:1.

Prenatal causes (Table 1)

There were 46 cases (74.2%) in this group. Spinal dysraphism constituted 18 cases (29%) (14 cases of myelomeningocele and 4 cases of encephalocele). The female to male ratio was 1:0.6. The other associated malformation of this group were: dysmorphic facies in 3 cases of myelomeningocele and hydronephrosis in one case of encephalocele (Meckel-Gruber’s syndrome (Table 2).

Fifteen cases  (24.2%) had acqueductal stenosis. The female to male ratio was 1:2. One case of this group had pulmonary stenosis with atrial septal defect while another case had tracheoesophageal fistula.

Three cases (4.9%) were idiopathic.  Two cases (3.2%) were due to Dandy-Walker malformation while another 2 cases (3.2%) were due to congenital toxoplasmosis. Six other cases were associated with other CNS structural anomalies: 2 cases with holoprocencephaly, 2 cases with hemispheric cysts (one of them had agenesis of the corpus collosum), one case with brain dysgenesis and another with vascular anomalies

Postnatal factors

There were 16 cases in  this group representing 25.8% of the whole series. Nine cases (14.5%) were postmeningitic, 6 cases (9.7%) were posthaemorrhagic and one case (1.6%) was secondary to achondroplasia. Of all the postnatal factors there were 8 preterm babies (4.7% of the whole series and 53.3% of the postnatal group). Four of them were postmeningitic while the other four were posthaemorrhagic.

Associated malformations

The associated malformations detected by initial assessment were as follows: (1) dysmorphic facies - three  myelomeningocele cases were associated  with dysmorphic facies; (2) renal anomalies - one case of encephalocoele had hydronephrosis (Meckel-Grubers syndrome) and another case of encephalocoele had hypospadius;  (3) Cardio-respiratory defects - the combination of tracheo-esophageal fistula, pulmonary stenosis, and atrial septal defect was noted in one case of acqueductal stenosis. One case of Dandy-Walker malformations had  the combination of patent ductus arteriousus (PDA) and coarctation of the aorta; (4) eye defects - one case of Dandy-Walker malformation had bilateral anophthalmia, one case of the idiopathic group had micro-ophthalmia; (5) other associated brain anomalies - the cases here had hydrocephalus (with no obvious cause) beside other brain anomalies, two cases had associated holoprosencephaly, one case was associated with brain dysgenesis and one case had agenesis of the corpus collosum.

DISCUSSION

The drop in the overall incidence of IH from 0.81/10001 in an earlier study to 0.71/1000 in our present study is not significant (P0.5) meaning that it still remains an important medical problem. The predominance of prenatal factors over postnatal factors is still very noticeable. Nearly three quarters of all cases are due to prenatal factors. In this group, the contribution by spinal dysraphism has fallen from 39.3% to 29.0%. However, it is still the most prevalent cause of prenatal (congenital) hydrocephalus. This study indicated that the contribution of acqueductal stenosis had increased from 16.4 to 24.2% and that primary CNS structural anomalies had increased. These have been associated with defects in other systems as well. It is hoped the incidence of neural tube abnormalities in this region will follow the international trend and decrease further.4 Negoro, et al in 19945 found the incidence of IH in Japanto be 0.58/1000 in live births with significant contribution by spinal dysraphism. It is interesting to notice the drop in incidence of IH (which implies a significant drop in the incidence of spinal dysraphism). In the West, antenatal screening coupled with selective termination have much reduced antenatal hydrocephalus. With the  great improvement of socioeconomic conditions and the care of expectant mothers, it is expected that there would be a further reduction in the incidence of this problem.6 The administration of Periconceptional folic acid should reduce this incidence still further.

               We have observed that the high rate of consanguinity in this region accounts for the overall high rate of congenital malformation .6 Consequently, the high incidence of these primary CNS structural anomalies among the prenatal factors. It is impossible for all these defects to amplify the complexity  of this disabling condition. The lack

 

Table 1:Infantile hydrocephalus: break down of cases

Number

%

Females

Males

Female: Male ratio

Prenatal

46

74.2

21

25

-

Spinal dysraphism

18

29.0

11

7

1.6:1

Acqueductal stenosis

15

24.2

5

10

0.5:1

Congenital idiopathic

3

4.9

1

2

0.5:1

Dandy-Walker malformation

2

3.2

1

1

1:1

Toxoplasmosis

2

3.2

1

1

1:1

Associated with other structural CNS anomalies*

6

9.7

2

4

0.5:1

Postnatal

16

25.8

7

9

-

Post meningitis

9

14.5

5

4

1.3:1

Post haemorrhagic

6

9.7

2

4

0.5:1

Achondroplasia

1

1.6

0

1

-

Total

62

100

28

34

0.8:1

*Holoprosencephaly 2, hemispheric cyst 2 (one with agenesis of copus collosum), brain dysgenesis 1, and vascular anomaly 1)

Table 2:Associated non CNS malformations

Malformation

No. of cases

Associated type of hydrocephalus

Dysmorphic facies

3

Myelomeningocoele

Hydronephrosis

1

Encephalocoele

Hypospadius

1

Idiopathic

Coarctation of aorta/patent ductus

    arteriosus

1

Dandy-Walker malformation

Pulmonary stenosis/atrial septal defect

1

Acqueductal stenosis

Tracheoesophageal fistula

1

Acqueductal stenosis

Cleft lip and palate

1

Toxoplasmosis

Anophthalmia

1

Dandy-Walker malformation

Microphthalmia

1

Idiopathic

Coloboma of eyes with hyperteleorism

1

Toxoplasmosis

Micrognathia

1

Idiopathic

of a proper registration system make it difficult to ascertain the family history of these defects.

                In the postnatal group, we encountered more premature babies, (as neonatal units in the region are handling more premature babies with improving survival rates). However, the proportion of this group of infants does not reach that encountered in the West.7-10 In  our study, intracranial hemorrhage affected 50% of preterm babies with IH. In  Japan, 30% of the  hydrocephalus  in

preterm babies was due to  intracranial hemorrhage. This is expected to increase further with the improvement in the care of the preterm in this region.5 The most recent Swedish  studies showed even higher contribution of intracranial hemorrhage in the preterm hydrocephalic population (89% of very preterm suffered confirmed intraventricular hemorrhage).11 Septic meningitis remains the most important causative factor in the postnatal group. Early detection with prompt medical treatment should greatly reduce its impact both in the neonatal period

and thereafter. The administration of Hib vaccine should significantly reduce the incidence of meningitis in infancy.12

More males were affected in this series (female to male ratio 0.8:1). This is due to predominance of males in the acqueductal stenosis (which could be sex linked in some cases), posthaemorrhagic, and the structural CNS anomalies groups.

Among childhood neurodevelopmental disorders IH causes significant disability and needs continuous and expensive medical care2,3,9 (shunting procedures, etc). Therefore, we  should continue to observe its prevalence, causative factors and associated defects in order to implement effective preventive measures. Also a proper nationwide register for all congenital malformations should be instituted.

REFERENCES

1.El Awad ME. Infantile hydrocephalus in south-western region of Saudi Arabia. Ann Trop Paed 1992;12:335-8.

2.O’Brien MS, Harris ME. Long term results in the treatment of hydrocephalus. Neurosurg Clin N Am 1993;4:625-32.

3.Mutoh K, Mikawa H, Okuno T. Pathophysiology of  infantile  hydrocephalus:   studies  with   multivariate analysis. No To Hattatsu  1994; 3: 227-31.

4.Lorber J, Ward AM. Spina bifida - a vanishing nightmare? Arch Dis Child 1985;60(11):1086-91.

5.Negoro T, Watanabe K, Nakashima S, Kikuchi H, Tamokoshi A. Clinico-epidemiological study of infantile hydrocephalus in Japan. No To Hattatsu 1994;26(3):211-15.

6.El Awad ME, Sivasankaran S. Neural tube defects in southwestern region of Saudi Arabia. Ann Saud Med 1991;12(5):449-52.

7.Fernell E, Hagberg G, Hagberg B. Infantile hydrocephalus on the impact of enhanced preterm survival. Acta Paed Scand 1990;79:1080-6.

8.Fernell E, Hagberg G, Hagberg B. Infantile hydrocephalus in preterm, low-birth-weight infants - A nationwide Swedish cohort study 1979-1988. Acta Paed Scand 1993;82(1):45-8.

9.Fernell E, Hagberg B, Hagberg G, Von Wendt H. Epidemiology of infantile hydrocephalus in  Sweden. 1-birth prevalence and general data. Acta Paediatrica Scand 1986;75:975-81.

10.Hagberg B, Hagberg G. The changing panorama of infantile hydrocephalus and cerebral palsy over forty years - a Swedish survey. Brain Dev 1989;11(6):368-73.

11.Fernell E, Hagberg G, Hagberg B. Infantile hydrocephalus epidemiology: an indicator of enhanced survival. Arch Dis Child 1994;70(2):123-31

12.Santosham M. Prevention of haemophilus influenzae type B disease. Vaccine Ii (suppl 1) 1993;S52-7.


-0001-11-30

DRUG-SUSCEPTIBILITY PATTERN


DRUG CONTROL OF HYPERTENSION IN PRIMARY HEALTH CARE CENTERS-REGISTERED PATIENTS, AL-KHOBAR, SAUDI ARABIA

Ahmed G. Elzubier,MRCP*, Mohammed A. Al-Shahri, FFCM(KFU)†

*Department of Family and Community Medicine, College of Medicine & Medical Sciences, King Faisal University, Dammam and †Ministry of Defense & Aviation, Al-Hada Military Hospital, Taif, Saudi Arabia

هدف البحث :تقييم نوعية السيطرة الدوائية على ارتفاع ضغط الدم .

طريقة البحث :تم من خلال دراسة مقطعية دراسة المرضى المصابين بارتفاع ضغط الدم والمسجلين بمراكز الرعاية الصحية الأولية بمدينة الخبر بالمملكة العربية السعودية . حيث تم تسجيل البيانات باستخدام استبيان وذلك عن طريق مقابلات مباشرة مع المرضى ، ومن ملفاتهم الطبية . وشملت البيانات معلومات ديموغرافية ،  معلومات ذات علاقة بالأطباء ، ومعلومات تتعلق باستخدام المرضى لمؤسسات صحية أخرى ، وما إذا كانوا يعانون من أمراض مزمنة أخرى.

نتائج البحث :أظهرت الدراسة أن نسبة السيطرة الدوائية على ارتفاع ضغط الدم لدى المرضى كانت 37% . وكانت هذه النسبة أعلى – بدلالة إحصائية – بين المرضى الذين تقل أعمارهم عن 55 عاماً ، وبين السعوديين ، والمرضى الذين تلقوا العلاج لمدة أقل من 5 سنوات ، وأولئك الذين يعالجون بدواء واحد . ولم يكن الفرق ، في هذه النسبة ، نتيجة للمتغيرات المتعلقة بالأطباء ذات دلالة إحصائية ؛ مما يعطى انطباعاً بأن مستوى متابعة المرضى قد يكون متدنياً .

الاستنتاجات :أظهرت الدراسة أن نسبة السيطرة الدوائية على ارتفاع ضغط الدم غير عالية ، ومتعلقة بالعمر ، واستعمال دواء واحد ، وأن مستوى متابعة المرضى بواسطة الأطباء قد لا يكون جيداً .

الكلمات المرجعية :السيطرة على ارتفاع ضغط الدم ، مراكز الرعاية الصحية الأولية ، المملكة العربية السعودية .

________________________________________________________

Objective: To assess the quality of the pharmacological control of hypertension.

Design:A cross-sectional study.

Subjects:Primary health care centers-registered hypertensive patients.

Setting:Primary health care centers in Al-Khobar, Saudi Arabia.

Methods:Data was recorded, using a structured questionnaire, through direct interviewing of patients, and from their medical records. It included demographic characteristics, hypertension related, and doctors’-related variables; and patients’ utilization of other health facilities and whether they had other chronic diseases.

Results:The proportion of patients with controlled hypertension was 37%. It was significantly increased with age below 55 years, with non-Saudis, duration  of  treatment  shorter  than  5 years;  and  with the  use  of  monotherapy.

________________________________________________________________________

Correspondence to:

Dr. Mohammed A. Al-Shahri, P.O. Box 40173, Al-Khobar 31952, Saudi Arabia

Doctors’ care-related variables did not show significant variation with the number of controlled patients which may imply that the quality of follow-up might not be adequate.

Conclusions:The proportion of controlled patients cared for in the PHC centers is low. The factors associated with control were age, and the use of a single antihypertensive drug. The study questions the quality of follow-up of patients by the PHC physicians.

Key Words: Hypertension control, Primary health care, Saudi Arabia

________________________________________________________________________


INTRODUCTION

In accordance with the studies carried out in Saudi Arabia,1-3 hypertension seems to affect about one-tenth of the Saudi population. The high prevalence of hypertension in Saudi Arabianecessitates that this disorder be best managed in the primary health care (PHC) centers. The arguments for this concept are: firstly, the follow-up procedure for hypertensive patients does not require sophisticated techniques. Secondly, there is a potential of continuity of care in the PHC centers that could not be afforded for patients in the busy secondary and tertiary care system; and in this regards it has been shown that uncontrolled hypertension may be associated with the patients’ lack of a PHC care physician.4 Thirdly, the way for the management of hypertension in PHC centers, has already been paved by the expansion in the number of well-equipped and staffed PHC care centers in the Kingdom;5 and in most of those centers there are lists of hypertensive patients who are registered for long-term care. The aim of this study was to assess the quality of pharmacological control of hypertension among PHC centers care-registered hypertensive patients and the variables associated with it.

MATERIAL AND METHODS

This is a cross-sectional study which was carried out on hypertensive patients registered at the PHC centers, in Al-Khobar city, during 1996. The total population of Al-Khobar is approximately 341,024 according to the last national census.6 Health services in Al-Khobar are offered by nine PHC centers and three government hospitals. In addition, there are a few private hospitals, dispensaries and clinics. The study population was the PHC center-registered hypertensive patients. A two-stage random sampling technique was used. In the first stage, a systematic sampling procedure was used to select five PHC centers out of the nine centers. At the second stage, a systematic sampling was used to select hypertensive patients by means of their records, within each selected PHC center. The total number of PHC centers-registered hypertensive patients in Al-Khobar in 1996 was 1246, 25% of whom was to be the sample. This was achieved by using a one-in-three systematic sampling technique, in the chosen PHC centers (including 919 registered patients), thus obtaining a sample size of 311 patients. This sample was proportionally allocated from the five selected PHC centers. A reserve sample of 5% was also selected in an attempt to overcome possible non-responsiveness.

Data collection took place in the period between August 2 and October 30, 1996. An interviewer-administered questionnaire containing open and close-ended questions was used. Interview arrangements were made through telephone calls. The interviews of hypertensive patients were conducted by interviewers in PHC centers using Arabic and other languages when.

necessary. Each patient was interviewed in a quiet room after the aim of the study had been explained to him/her. Patients who refused to be interviewed were replaced by the next ones on the list. The medical records of selected patients were also reviewed to record more data as shown below. The questionnaire form was composed of two parts: (i) The first part was about patients demographic data (age, gender, educational level, and nationality). It also included questions related to hypertension and its pharmacological treatment such as duration of hypertension, duration of drug treatment for hypertension, number of antihypertensive drugs used; and the names of those drugs, and presence of hypertensive complications (which were checked from medical records). Drugs’ names were also checked from the records and the response was recorded as correct, or incorrect. The questionnaire also included questions related to doctors’ care such as whether patients were always seen by the same, or different PHC physician at each follow-up visit; and whether health education had been given by their PHC physicians about the name(s) of drug(s) prescribed for hypertension, drugs’ side effects, and about compliance with drugs. Inquiry was also made about whether a patient was utilizing other health care facilities for follow-up of hypertension (such as other health centers, or governmental or private hospital outpatient clinics). Patients were also asked if they were being treated for other chronic diseases, and whether they were receiving drugs for them. (ii) The second part of the questionnaire was recorded from the patients medical records, which included presence and type of hypertensive complications, frequency of follow-up (whether monthly, quarterly, biannually or annually) during the previous year (1995); and the names of the antihypertensive drugs received. A systolic blood pressure (SBP) of 140 mm Hg, or less, a diastolic blood pressure (DBP) of 90 mm Hg or less were considered as representing controlled SBP and DBP, respectively. On the other hand, a patient with both controlled SBP and DBP was considered as having controlled hypertension.7-9

Data was analyzed using an IBM-compatible personal computer. The statistical package for the Social Sciences ( SPSS/PC+) version 610 was used for data entry and analysis. Means were calculated and expressed as mean + 1 standard deviation (M + 1 SD). Differences between two means and differences between two categories were tested using the students’ t-test for unequal samples; and Chi-squared tests; respectively. A p-value of 0.05 or less (one or two sided as appropriate) was considered to represent statistical significance.

RESULTS

All hypertensive patients in the selected sample (n=311) were interviewed. Twenty percent of the sample were then re-interviewed to check the reliability of the questionnaire. The percentage of agreement between the investigator and the interviewers ranged from 85-100% with an average of 93.5%.

The mean age of sampled cases was 53.2 + 0.65 years, two-thirds of whom were females. The majority of the sample (81.4%) were of Saudi nationality; and about two-thirds of the sample were illiterate.

The majority of patients (80.4%) were being treated with a single antihypertensive drug. On the other hand, about half of the patients (53.7%) knew the name(s) of antihypertensive drug(s) they were using. Hypertensive complications were present in 16.4% of the patients. About a quarter of patients (27.0%) were always being seen for follow-up by the same PHC center physician. As regards health education received, the proportions of patients who received health education about drugs’ names, drugs’ side effects, and advice on compliance; were 19.6%, 31.5%, and 46.9% respectively. Forty-three patients (13.8%) had been followed up with a frequency of three months or less, while the rest were followed up every six months or longer than that.

Other chronic diseases (which were diabetes mellitus, coronary heart disease, and renal diseases) were present in about half of the sample,  while a similar proportion used drugs for treatment of those diseases. On the other hand, two-fifths of the patients (41.2%) attended other medical facilities, governmental or private, for follow-up of hypertension.

The mean systolic and diastolic blood pressure of the sample was 140.03 +1.83, and 84.05 + 1.05 respectively. The mean duration of hypertension among the sample was 8.5 + 5.7 years, while the mean duration of treatment was 7.0 + 5.1 years. Three quarters (75.2%) and about a half (42.4%) of the patients had controlled levels of diastolic or  systolic blood pressures, respectively. About one-third of the patients (37.2%) had controlled both systolic and diastolic blood pressure; i.e., DBP < 90 mmHg and SBP < 140 mmHg, and were considered as having controlled hypertension (Table 1).

There was a   significantly higher proportion of patient aged 54 years or less who had controlled hypertension than older ones (P < 001). Also there was a significantly higher proportion of patients with controlled hypertension among non-Saudi than Saudi patients (P < 0.01) (Table 2).

On the other hand, there was a significantly higher proportion of patients who had been on treatment for a duration of less than 5 years, who had controlled hypertension, than those who had been hypertensive for a longer duration  (P < 0.01). Also, significantly more patients who used one antihypertensive drug had controlled hypertension, than those who were on two, or more drugs (P < 0.04). Table 3).

As regards doctors’-related variables there was no significant variation of numbers of patients with controlled hypertension as regards whether they are seen by one or more doctors, offered health education about drug names, drug side effects, and on compliance; nor  whether they were followed up every three months or less or longer than three months (Table 4).

Similarly, there  was no significant variation of number of patients with controlled hypertension regarding the presence of other chronic diseases, having other drugs (for treatment of other unrelated diseases), nor whether they were utilizing other health facilities, such as hospitals or private clinics (Table 5).

DISCUSSION

The sample of patients involved in this study is composed of middle-aged, and predominantly female patients with low or no level of education, and with a relatively long duration of hypertension. This finding supports that shown by a previous study in the same area.11 Thus, hypertensive patients in our sample are not expected to know much about their disease and aspects of its control. Moreover, they might have had some misconceptions arising from the native cultural beliefs.11 This emphasizes the importance of efficient doctor/patient communication by the PHC physician12 in a background of the continuity of  care provided by the PHC system. But unfortunately, in this regards, our findings showed  that  a  minority  of  the sample has enjoyed.


continuity of care in their follow-up; a matter that needs much consideration and correction.



Table 1:Blood pressure status of hypertensive cases in PHC centers, Al-Khobar 1996

Characteristic

Mean + 1 SE

Patients (n = 311)

No.

%

SBP

140.03 + 1.83 mmHg

DBP

84.05 + 1.05 mmHg

Duration of hypertension

8.5 + 5.7 years

Duration of treatment

7.0 + 5.1 years

DBP < 90 mmHg

controlled

234

75.2

uncontrolled

77

24.8

SBP < 140 mmHg

controlled

132

42.4

uncontrolled

179

57.6

SBP < mmHg and DBP < 90 mmHg

controlled

117

37.6

uncontrolled

194

62.4

Table 2:Effects of demographic variables on blood pressure control among PHC centers-registered hypertensive patients

Variable

Total

Controlled (%)

p-value

Age in years

< 55

160

76 (47.5)

< 0.001

55

151

41 (27.2)

Gender

Males

111

40 (36.0)

NS

Females

200

77 (38.5)

Nationality

Saudis

253

87 (34.4)

< 0.01

non-Saudis

58

30 (51.7)

Education

Any education

31

16 (51.6)

NS

Drug name not known

280

101 (36.1)

NS = Not significant

Table 3:Effects of disease-related variables on blood pressure control among PHC centers-registered hypertensive patients

Variable

Total

Controlled (%)

p-value

Duration of hypertension

< 5 years

80

37 (46.3)

NS

5 years

231

80 (34.6)

Duration of treatment

< 5 years

130

60 (46.2)

< 0.01

5 years

181

57 (31.5)

Number of drugs

One

250

101 (40.4)

< 0.04

Two or more

61

16 (26.2)

Knowledge of drugs’ name

Drug name known

167

61 (36.5)

NS

Drug name not known

144

56 (38.9)

Complications

Present

51

14 (27.5)

NS

Not present

260

103 (39.6)

NS = not significant


Table 4:Effects of doctors’-related variables on blood pressure control among PHC centers-registered hypertensive patents

Variable

Total

Controlled (%)

p-value

Continuity of care

Available

84

30 (35.7)

NS

Not available

227

87 (38.3)

Drug names

Told to patient

61

22 (36.1)

NS

Not told

250

95 (38.0)

Drugs’ side effects

Explained to patient

98

38 (38.8)

NS

Not explained

213

79 (37.1)

Advice on compliance

Offered

146

58 (39.7)

NS

Not offered

156

59 (35.8)

Follow-up

1-3 monthly

43

16 (37.2)

NS

More than 3-monthly

268

101 (37.7)

NS = not significant

Table 5:Effects of demographic variables on blood pressure control among PHC centers-registered hypertensive patients

Variable

Total

Controlled (%)

p-value

Other chronic diseases

Present

164

56 (34.1)

NS

Not present

146

61 (41.5)

Use of other drugs

Yes

143

45 (31.5)

NS

No

168

72 (42.9)

Other health facilities

Utilized

128

51 (39.8)

NS

Not utilized

183

66 (36.1)

NS = not significant


Our results showed that 37% of the sample had controlled hypertension. This figure is better than that found previously by Dharrab,11 but still seems to be low by international standards.13 The study revealed that there were significantly more patients with controlled hypertension among those younger than 55 years of age. It has been shown by other studies that patients older than 60 years had poor compliance with therapy for hypertension.14 This finding calls for more attention to older patients especially since, from an epidemiological point of view, the prevalence of hypertension tends to increase with age;15 and thus the numbers of such patients would be large in the community.

Our findings also revealed that there were significantly more patients with controlled hypertension among non-Saudis. This could not be solely explained by racial differences, as non-Saudis who represent an.


expatriate work-force tend to be younger than the proportion of Saudi patients in the sample. A similar age-related explanation could be put forward for our finding that there were significantly more patients with controlled hypertension among those who had treatment for a shorter duration.

On the other hand, the study has clearly shown that there were significantly more patients with controlled hypertension among those who were being treated with a single antihypertensive drug. This is an expected finding since monotherapy is usually associated with better compliance with drugs, and hence better control.16-18

Our study has revealed that all doctor care-related variables did not show any significant variation with numbers of patients with controlled hypertension. This is an important finding as it may imply that the quality of follow-up of patients, including aspects of doctors’/patient communication, such as health education, may need reconsideration. This finding has already been documented by Al-Dharrab.19 Poor doctors’/patient communication has been cited as one of the barriers to effective therapeutic adherence;20 and it was specially so in case of elderly hypertensive patients.21


CONCLUSION

The study has revealed that the proportion of controlled patients cared for in the PHC centers is low. The factors associated with control were age, and the use of a single antihypertensive drug. The study also questions the quality of follow-up of patients by the PHC physicians.

REFERENCES

1.Ahmed AF, Mahmoud ME. The prevalence of hypertension in  Saudi Arabia. Saudi Medical Journal 1992;6:548-51.

2.Al-Nozha M, Al-Shabrawy MA, Karar A. Arterial hypertension in Saudi Arabia. Proceedings of the 5th Scientific Session; 1994 Jan 25-27; Al-Khobar, Saudi Arabia: Saudi Heart Association. 1994:19.

3.Abolfatouh MA, Abu-Zeif HAH, Abdelaziz M, Alakija W, Mahfouz AA, Bassuni WA. Prevalence of hypertension in south-western Saudi Arabia. East MediterraneanHealth Journal 19967;2:211-18.

4.Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Predisposing factors for severe uncontrolled hypertension in an inner-city minority population. N Engl J Med 1992;327:776-81.

5.Ministry of Health Annual Report 1415/1416, Saudi Arabia, Riyadh1995.

6.Ministry of Finance and National Economy. Preliminary report of the national census. Saudi Arabia; 1992 (Arabic).

7.Waggoner DM. Application of continuous quality improvement techniques to the treatment of patients with hypertension. Health Care Manage Rev 1992; 17:33-42.

8.Green MS, Peled I. Prevalence and control of hypertension in a large cohort of occupationally-active Israelis examined during 1985-1987: The Cordis study. Int J Epidemiol 1992;21:676-82.

9.World Health Organization. Hypertension Control. WHO Technical Report Series (862). Geneva, WHO, 1996:7.

10.Statistical Package for Social Sciences ( SPSS/PC+) for Windows Release 6.0 (1993) [Computer Program]. SPSS Inc 1989-93.

11.Al-Dharrab SA. Evaluation of hypertensive patients’ care in Dammam primary health care centers. (Dissertation), Dammam, King Faisal University, 1995:62.

12.Grueninger UJ, Goldstein MG, Diffy FD. A conceptual framework for interactive patient education in practice and clinic settings. J Hum Hypertens 1990;4(suppl.1):21-31.

13.Marques-Vidal P, Tuomilehto J. Hypertension awareness, treatment and control in the community: is the ‘rule of halves’ still valid?  hum Hypertens 1997;11:213-20.

14.Balazovjech I, Hnilica P-Jr. Compliance with anti-hypertensive treatment in consultation rooms for hypertensive patients. J Hum Hypertens 1993;7:581-3.

15.Whelton PK. Epidemiology of hypertension. Lancet 1994;344:101-6.

16.Detry JM, Block P, De-Backer G, Degaute JP. Patient compliance and therapeutic coverage: comparison of amlodipine and slow release nifedipine in the treatment of hypertension. The Belgian Collaborative Study Group. Eur J Clin Pharmacol 1995;46:477-81.

17.Elliot WJ. Compliance strategies. Curr Opin Nephrol Hypertens 1994;3:271-278.

18.Waber B, Eme P, Saxenhofer H, heynen G. use of drugs with more than twenty-four hour duration of action. J hypertens Suppl 1994;12:S67-71..

19.Al-Dharrab SA. Evaluation of hypertensive patients’ care in Dammam primary health care centers. (Dissertation), Dammam, King Faisal University, 1995:114.

20.Clark LT. Improving compliance and increasing control of hypertension: needs of special hypertensive population. Am Heart J 1991;121:664-9.

21.           Taylor JL. Overcoming barriers to blood pressure control in the elderly. Geriatrics 1990;45:35-8.


-0001-11-30

CARDIOVASCULAR RISK FACTORS


THE P REVALENCE OF CARDIOVASCULAR RISK FACTORS AMONG STUDENTS IN JEDDAH, SAUDI ARABIA

Tawfik M. Ghabrah,PhD, Ahmed A. Bahnassy, PhD, Bahaa A. Abalkhail, DrPH, Hussein M. Al-Bar, DrPH, Waleed A. Milaat, PhD

Community Medicine & Primary Health Care Department, King Abdulaziz University, Jeddah, Saudi Arabia

هدف البحث:وصف معدلات الانتشار لعوامل الخطورة المسببة لأمراض القلب والأوعية الدموية بين طلاب وطالبات المدارس بمدينة جدة .

طريقة البحث :دراسة مقطعية خلال عام 1994م على عينة من الطلاب والطالبات في (49) مدرسة حكومية ، تم اختيارها باستخدام الطريقة العشوائية الطبقية المتعددة الخطوات . تم تعبئة استبانات وعمل قياسات الطول والوزن وسمك الجلد وضغط الدم لهم ، كما تم قياس مستوى السكر والكوليسترول الكلي في الدم لعينة جزئية منهم .

النتائج :بلغ عدد أفراد العينة المختارة ( 4042) طالباً وطالبة ، مثل الذكور منهم 71% وكان متوسط أعمارهم 3ر15 ±7ر2 سنة . وجد أن 23% منهم يعانون من السمنة ، كما أن 4ر6% و 9% منهم يعانون من ارتفاع ضغط الدم الانقباضي والإنبساطي على التوالي دون أن يكون هناك فرق ذو دلالة إحصائية بين الطلاب والطالبات . ومن بين (1432) طالباً وطالبة وجد أن 4% من الطلاب و2% من الطالبات لديهم ارتفاع في مستوى الكوليسترول بالدم ، كما أن 4ر0 %  من الطلاب و6ر0 % من الطالبات لديهم ارتفاع في مستوى السكر في الدم . وبالنسبة للتدخين فقد وجد أن 9ر6 % من الطلاب 5ر0 % من الطالبات من مجموع طلبة الثانوية والثالثة متوسط       ( 1843 ) يدخنون حالياً .

الاستنتاجات والتوصيات :بناءً على نتائج الدراسة وحيث أن التوجهات والسلوكيات التي تؤثر على صحة الفرد في حياته المستقبلية من الممكن أن تبدأ في سن الطفولة والمراهقة فإن الجهود الوقائية لمنع حدوث أمراض القلب والأوعية الدموية عند البالغين لابد أن تبدأ منذ الطفولة وعند الشباب وتعتبر المدارس مجالاً خصباً للرقى بالصحة والوقاية من المرض .

الكلمات المرجعية :عوامل الخطورة لأمراض القلب والأوعية الدموية ، طلاب وطالبات المدارس ، المملكة العربيةالسعودية .

Objectives:To determine the prevalence of cardiovascular risk factors among students in Jeddah, Saudi Arabia.

Methods:A cross-sectional study was conducted during 1994 on a sample of students selected from 49 public schools using a multistage stratified random sampling technique. For all students, an interview was conducted and anthropometric and blood pressure measurements were obtained. Fasting glucose and total cholesterol levels on a capillary blood sample were measured using Accutrend for a subsample of students.

Results: Of the 4042 students selected, 71% were males and the overall mean age was 15.3 ± 2.7 years. After age adjustment, about 23% of the students were found overweight. In addition, 6.4% and 9% of the students were found to have

____________________________________________________________

Correspondence to:

Dr. Tawfik M. Ghabrah, P.O. Box 448, Jeddah 21411, Saudi Arabia

systolic and diastolic hypertension, respectively, with no statistically significant difference between males and females. Among 1432 students, 4% of males and 2% of females had hypercholesterolemia (p=0.06). Hyperglycemia was found in 0.4% of males and 0.6% of females. Among 1834 students in the 9th to 12th grades, 6.9% of males and 0.5% of females were current cigarette smokers.

Conclusions:Since attitudes and behaviors that influence future health are established during childhood and adolescence, intervention to prevent cardiovascular diseases (in adult life) should take place in childhood and youth to reduce the risk factors and schools have a great role to play in the promotion of good health.

Key Words:Cardiovascular risk factors, school students, Saudi Arabia.

__________________________________________________________________


 

INTRODUCTION

Cardiovascular diseases ( CVD) account for a major proportion of all deaths during adulthood  in both developed and developing countries.1 The major risk factors in adulthood appear to be determined by patterns  of behavior established in childhood and adolescence. Preventing the development of such behavior in childhood is easier than the attempt to reverse the situation and reduce the resulting risk of atherosclerosis in adulthood.2 Therefore, schools have a great  role to play in promoting good health. Data on the prevalence of CVDrisk factors among children and adolescents in Saudi Arabiais scarce. To our knowledge, only one report3 from Saudi Arabiadealt with the prevalence of these risk factors in children. The sample in that study was confined to only one primary school where neither girls nor adolescents were considered. It is the aim of this study to describe the prevalence of CVDrisk factors among male and female school children of various ages and at different educational levels and to discuss the potential for future intervention.


 


 

MATERIAL AND METHODS

Setting and population

Jeddah with a population of 2.1 million is one of the largest cities in the Kingdom. It has a total of 620 public schools (335 male schools and 285 female schools) with a total number of 200,000 pupils.

Study design

To achieve the objectives of this study a cross-sectional or prevalence study design was followed.

Sample selection and study subjects

A multi-stage stratified random sampling technique with proportional allocation (involving three major stages) was used to choose the required number of schools all over Jeddah at each educational level and the required number of students from the selected schools according to their study grade. The sample size was determined by means of one of the conventional equations with a 90% power, a= 0.05  and  an estimated prevalence

for any CVDrisk factor of at least 5%. In order to handle any missing data, as large a sample size as possible was aimed for. Therefore, a total number of 4042 students were selected from 49 public schools (25 male schools and 24 female schools) at the three educational levels (primary, intermediate and secondary) during 1994.

Methods of data and specimen

collection

Medical students trained on interviewing skills, anthropometric measurements, blood pressure measurement, and blood testing using the Accutrend® GC meter were recruited and divided into task groups to conduct the study under the direct supervision of the authors.

All students were interviewed using a structured questionnaire which included information on sociodemograhic factors, physical activity and family history. For students in the third grade intermediate and first, second and third grades secondary, additional information on smoking habits were also obtained using a separate self-administered questionnaire. The following measurements were also taken on all students: weight using Seca® (model 777) personal scale to the nearest 0.1 kg and height using a standard measuring tape to the nearest 0.1 cm, both without shoes and lightly clothed from which body mass index ( BMI) (weight in kg/height2 in meters) was calculated; triceps, skinfold thickness using Slim Guide® skinfold caliper; and blood pressure using Baumanometer® desk model. In addition, fasting glucose and total cholesterol levels on a capillary blood sample were measured for a random subsample of the students using Accutrend® GC, Boehringer Mannheim.

Throughout the study, scales were calibrated at the beginning of each session and each time they were moved. Similarly, different meters were constantly checked for accuracy  of reading according to the manufacturer’s protocol.

                                                                                                                                                                                    After adjusting for age, cut-off points for BMIand skinfold thickness to determine obese and overweight students, respectively, were based on a published reference data for obesity.4 Similarly, cut-off points to determine those with systolic or diastolic hypertension were based on the criteria for arterial hypertension outlined by the WHO5 and the third JNCclassification of blood pressure,6 after adjusting for age. For the age groups 6 - <10, 10 - <14, and 14-18 years, systolic/diastolic hypertension was defined as blood pressure readings of =120/80, =125/85, and =135/90 mmHg respectively. Physical activity was assessed through only the performance of regular physical exercise based on the total number of hours per week and then categorized accordingly. Hyperglycemia was defined as a fasting glucose level of 120 mg/dl and hypercholesterolemia was defined as a fasting total cholesterol level of =200 mg/dl. The criteria used follow known scientifically acceptable cut-off points for children of the same age range as the study population.7

Data management and statistical analysis

Data were entered in a database file and scrutinized for outliers and influential points.


 

The statistical analysis was done using SPSSstatistical package. Descriptive statistics, chi-square test and t-test were used as appropriate. The analyses of BMI, skinfold thickness and blood pressure were adjusted for age. Level of significance was set to be <0.05 throughout the analysis.

RESULTS

A total of 4042 students were studied, 2870 (71.0%) males and 1172 (29.0%) females, with a mean age of 15.3 ± 2.7 years and a range of 9 years to 20 years. The mean age for males was 15.2 ± 2.7 years while for females it was 15.6 ± 2.5 years. The majority of the students were in age groups 13-15 years and 16-18 years (34.3% and 40.0% respectively) (Table 1). About 67% of the students were Saudis and 33.2% were non-Saudis.

Mean values and standard deviations of weight, height, BMIand triceps skinfold  thickness, of male and female students are shown in tables 2 and 3. On the average, females between the age of 10 and 14 years had a higher weight than males. But at 15 years of age, the  picture was reversed with males weighing more than females. Females were also taller than males between the age of 10 and 13 years but this was reversed at 14 years in favor of the males. With minor exceptions, mean values of both BMIand skinfold thickness for female students were higher than those for males of all ages. Overall mean BMIadjusted for age was 21.0 ± 5.7. Mean BMI  for males was significantly lower than females (20.6 ± 5.6 vs 21.9 ± 5.8, p < 0.001). Overall, 23.5% of the students were obese (23.3% males and 26.4% females were obese, p<0.005). This was confirmed by results of skinfold thickness adjusted for age where 22.7% of the students were found to be overweight.

Table 1: Age distribution of school students by sex

Age Group

Sex

(Years)

Male

Female

No (%)

No (%)

9-12

  508  (17.7)

129 (11.0)

13-15

  963  (33.6)

424 (36.2)

16-18

1114 (38.8)

501 (42.7)

19+

285 (9.9)

118 (10.1)

Total

2870

1172

X3 = 28.56, p<0.001

   

Overall mean systolic blood pressure was 114.8 ± 12.7 mmHg and mean diastolic blood pressure was 74.4 ± 10.0 mmHg and there were consistent increments with age for both. After adjusting for age, females were of higher mean systolic blood pressure than males (p<0.001). As for mean diastolic blood pressure, no significant difference was noted between males and females after adjusting for age. Analysis among various age groups showed that in the first two groups, females had significantly higher systolic and diastolic blood pressure than males while in the third age group the converse was true (figures 1 and 2).


 


 

Figure 1: Mean systolic blood pressure and standard error for school students by age


 

Figure 2:Mean diastolic blood pressure and standard error for school students by age


 

Table 2:Mean values and standard deviations of selected anthropometric measurements of male students

Age (years)

No.

Weight (kg)

Height (cm)

BMI*(kg/m2)

SKF† (mm)

9

22

27.8 (7.5)

131.9 (6.6)

15.6 (3.2)

9.1 (2.7)

10

144

30.5 (8.8)

134.7 (8.5)

16.2 (4.2)

10.2 (5.0)

11

147

34.3 (9.5)

139.3 (7.3)

17.0 (3.9)

11.4 (6.6)

12

195

  38.1 (11.2)

  144.1 (10.2)

17.7 (4.2)

11.7 (5.5)

13

290

41.9 (13.7)

  147.8 (10.3)

18.4 (5.0)

11.6 (6.2)

14

360

49.8 (15.1)

156.2 (9.7)

19.8 (5.2)

11.9 (6.0)

15

313

54.2 (15.1)

162.7 (9.2)

19.8 (4.9)

11.5 (6.1)

16

357

58.0 (14.8)

165.5 (9.4)

20.8 (5.5)

11.3 (6.2)

17

407

63.9 (16.6)

  168.7 (10.1)

22.2 (6.7)

12.2 (7.0)

18

350

64.9 (15.7)

169.8 (9.0)

22.1 (5.6)

12.2 (7.0)

19

160

64.9 (15.2)

172.2 (6.7)

21.2 (4.6)

11.3 (5.9)

20

83

66.7 (16.2)

171.6 (6.2)

22.1 (5.2)

12.2 (7.0)

* BMI= Body Mass Index    †SKF = Triceps skinfold thickness

Table 3:Mean values and standard deviations of selected anthropometric measurements of female students

Age (years)

No.

Weight (kg)

Height (cm)

BMI*(kg/m2)

SKF† (mm)

  9

    7

27.6 (3.8)

127.8 (6.0)

16.6 (2.6)

11.2 (3.9)

10

  30

  35.9 (14.0)

134.8 (7.8)

19.2 (7.7)

12.2 (4.6)

11

  31

35.2 (6.7)

140.2 (5.5)

17.3 (3.0)

12.1 (6.1)

12

  61

45.5 (13.2)

147.1 (9.3)

20.6 (6.2)

16.1 (7.4)

13

113

45.2 (11.6)

150.2 (7.0)

19.5 (4.5)

17.4 (6.3)

14

153

50.7 (13.0)

154.0 (7.7)

20.8 (5.2)

20.5 (7.8)

15

158

53.4 (15.6)

154.2 (9.3)

22.0 (6.9)

19.9 (8.3)

16

175

53.3 (13.1)

155.0 (7.6)

21.7 (5.7)

20.7 (8.3)

17

171

54.7 (14.0)

155.5 (6.6)

22.1 (5.3)

20.1 (7.0)

18

155

53.4 (12.1)

154.3 (6.0)

21.9 (5.0)

21.3 (8.2)

19

67

54.3 (13.9)

154.8 (5.9)

22.1 (5.5)

21.1 (9.1)

20

30

57.4 (16.9)

153.7 (7.1)

23.7 (6.5)

21.7 (10.9)

* BMI= Body Mass Index    †SKF = Triceps skinfold thickness


 

After adjusting for age, 6.4% of the students were found to have systolic hypertension while 9.0% of them were found to have diastolic hypertension. More males significantly had systolic hypertension than females (p<0.0001). However, no statistically  significant  difference  was found between males and females in diastolic hypertension.

                    Overall, 64.8% of the students reported that they perform physical exercise for at least half an hour per week on a regular basis. However, this was more evident among male students than females (78.8% vs 30.5%, p<0.001).

                    Blood testing for fasting total cholesterol and glucose levels was done on 1432 students. The overall mean total cholesterol was 154.8 ±13.0 mg/dl. Mean total cholesterol for male students was significantly lower than for females (153.6 ±11.7 vs 159.8 ±16.7, p<0.001). In addition, 2.3% of the students were found hypercholesterolemic and the proportion of female students with hypercholesterolemia was double that for males (4.0% vs 2.0%, p=0.06). Only 0.5% of the students were found to be hyperglycemic with no significant differences between males and females (0.4% vs 0.6%, respectively).

                    As for smoking, of the students who answered this question, i.e. the 3rd grade of intermediate schools and the three grades of secondary schools (n=1834), the proportion of current cigarette smokers and ex-smokers were 4.8% and 5.9%, respectively. The proportion of both current smokers and ex-smokers was significantly greater among males than those among females (6.9% and 8.5% vs 0.5% and 0.5%, respectively, p<0.0001). Mean duration of cigarette smoking among current smokers was 3.1 ±2.1 years and the mean number of cigarettes per day was 11.3 ±8.8.

                    With respect to shisha smoking, 1.6% of the students in the above mentioned grades were current smokers and 2.2% were ex-smokers. The proportion of male students in both categories were significantly higher than female students (2.3% and 3.3% vs 0.3% and 0.2%, respectively).

DISCUSSION

Compelling evidence exists that the atherosclerotic process begins in childhood and progresses slowly into adulthood, when it frequently leads to coronary heart disease (CHD).8 In addition, cardiovascular risk factors found in children are potentially predictive of adult CHD9. Therefore, identification and modification of CVD risk factors in children together with early development and maintenance of healthy lifestyles are advocated as important precursors to the reduction of adult onset of cardiovascular disease.10

                    Obesity is a well-known predisposing factor for CVDespecially through its role in the development of other risk factors like diabetes mellitus, hypertension and high blood cholesterol level.  BMI, as measure of obesity, increased in our sample with age in both sexes and was found to be higher for females than males, which is consistent with results from previous studies done in Saudi Arabia3,11,12 and elsewhere.1

                    The proportion of obese students (23.5%) in our sample, although considerably high, is not different from what has been reported previously.3,13  However, a greater proportion of females (26.4%) than males (23.3%) were found obese, which is, again, consistent with the finding of Al-Sekait et al13 (31.8% of females vs 27.1% of males). This has been further confirmed in our study by the measurement of triceps skinfold thickness indicating a greater fat deposition among females. In fact, these sex-related differences could be explained by lack of physical activity among females in our Saudi society as compared to male students, a situation which was confirmed in this study. This, in turn, calls for the urgent inclusion of physical activity programs in the curriculum of female schools in an appropriate way that does not conflict with the Saudi culture, in addition to dietary intervention for all students.

                    Recent studies14-17 have shown that levels of blood pressure and serum cholesterol in childhood are predictive of levels during adulthood. Apart from diastolic blood pressure (DBP) for females in the age group 10 to <14 years, both male and female students exhibited consistent increase in systolic blood pressure (SBP) and DBP with age which conforms to a previous report.3


 

Moreover, for students <14 year-old, females had both higher mean SBP and DBP than males which is the opposite of what held for students of 14 years and above. This could be partly explained by the fact that blood pressure level is influenced by various factors including physiological and emotional state of the child, which could vary between males and females.

                    The proportion of hypertensive students in the present study was higher than that reported from a similar study in Japan (1%)18 or that found in another study done in Saudi Arabia (0-4%),3 but similar to some other studies 19-21 done elsewhere. Many factors could explain these variations including genetic, environmental, dietary pattern, technical and methodological issues.

                    The mean values of total cholesterol reported in this study are generally lower than those levels reported previously from Saudi Arabia3 and several other studies on European and American children,10,20,22,24 but similar to some other studies done elsewhere.25,26 Although national dietary pattern might partly explain these differences, the comparison of these values between different studies could be affected by various technical and methodological considerations.27

                    The finding in our study that female students have higher total cholesterol levels as compared to males confirms to a similar study from USA.10 This might indirectly confirm the general trend in our study that females have higher BMI and skinfold thickness than males.

                    Measuring blood cholesterol levels in children and adolescents is important. This is supported by  numerous indications including the aggregation in children (as in adults) of elevated cholesterol levels with other CVDrisk factors, tracking of high cholesterol levels (and of other risk factors) from childhood to adolescence and early adulthood, and the association of risk factors in children with a parental history of cardiovascular disease.28 However, advocating screening programs in children and adolescents is a controversial issue that should be determined on the basis of its cost effectiveness and other technical criteria as well as the availability

of effective preventive measures. Interestingly, the 2.3% of school students with hypercholesterolemia reported in our study was much lower than that reported by Al-Hazzaa (22.9%)3 in his study from Riyadh or that reported by Wynder et al29 in the study from 15 countries, but similar to others.18,29

                    The adverse effects of tobacco smoking are now well known. Prevalence  rates  vary considerably among children and young people by age, sex and country. The percentages of current smokers among either male (6.9%) or female (0.5%) secondary school students in this study were less than that reported by a study30 from the Riyadh region conducted among secondary health institutes (17.5% for males and 8% for females), and much less for male secondary school students compared to that (24.8%) reported from Cairo, Egypt.31 However, much higher percentages were reported from developed countries like England32 where 33.3% and 29.9% of male and female secondary school students, respectively, were current smokers. Inspite of these low percentages in our sample, effective measures to prevent smoking among school students should be implemented and schools should have a greater role in health education.

                    Studies among children have shown that children’s smoking rates and nutrition habits can be influenced and their serum cholesterol levels can be modified.33,34 In fact, the promotion of lifestyles that are likely to result in optimum levels of CVDrisk factors in youth is the basis for early prevention of CVDand promotion of health.33 Thus, the inclusion of cardiovascular health education in general educational studies of children should be a major objective of the future.35 However, it should be clear that  an integrated school policy which calls for the promotion in schools of healthy heart implies not only health education lessons in the classroom but also a healthy workplace for teachers and a healthy   school   environment  complemented

with parents’ involvement since most of the curricula used in successful interventions were aimed at parents as well as children.1,36

ACKNOWLEDGEMENT

    The authors would like to thank the staff and the medical students who participated actively in the conduct of this study. Many thanks to the school authorities for their kind cooperation. Our thanks also to Mr. M. Abdulmajeed for the secretarial work.

REFERENCES

1.Report of WHO Expert Committee on: Prevention in childhood and youth of adult cardiovascular disease: time for action. WHO Technical Report Series No. 792, 1990.

2.Report of a WHO Expert Committee on: Prevention of coronary heart disease.  WHO Technical Report Series No. 678, 1982.

3.Al-Hazzaa HM, Sulaiman MA, Al-Mobaireek KF, Al-Attas OS. Prevalence of coronary artery disease risk factors in Saudi children. Journal of  the Saudi Heart Association 1993;5(3):126-133.

4.Must A, Dallal GE, Dietz EH. Reference data for obesity: 85th and 95th percentiles of body mass index and triceps skinfold thickness. Am J Clin Nutr 1991;53:839-844.

5.Report of a WHO study Group on: Blood pressure studies in children. WHO Technical Report Series No. 715, 1985.

6.The 1984 report of the Third Joint National Committee on the Detection, Evaluation and Treatment of Hypertension ( JNCIII). Arch Int Med 1984; 144:1045-57.

7.National Cholesterol Education Program. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. NIH publication No. 91-2732. Washington, DC:US Department of Health and Human Services, 1991.

8.National Cholesterol Education Program. Highlights of the Reports of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. NIH publication No. 91-2731 Washington, DC:US. Department of Health and Human Services, 1991.

9.Berenson GS, Srinivasan SR, Freedman DS, Radhakrishnamurthy B. Atherosclerosis and its evolution in childhood. Am J Med Sci 1987; 294(6):429-40.

10.Webber LS, Osganian V, Leupker RV, Feldman HA, Stone EJ, Elder JP, et al.  For the CATCH Study Group. Cardiovascular Risk Factors among Third Grade Children in Four Regions of the United States. Am J Epidemiol 1995; 141:428-39.

11.Magbool GM. Body mass index of Saudi children ages six to 16 years from the Eastern Province. Ann Saudi Med 1994; 14(6):495-8.

12.Al-Hazzaa HM. Anthropometric measurements of Saudi boys aged 6-14 years. Ann Hum Biol 1990; 17:33-40.

13.Al-Sekait MA, Al-Nasser AN, Bamgboye EA. The growth pattern of school children in Saudi Arabia. Saudi Med J 1992;13(2):141:6.

14.Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: The Muscatine Study. Pediatrics 1989; 84:633-41.

15.Webber LS, Cresanta JL, Croft JB, Srinivasan SR, Berenson GS. Transitions of cardiovascular risk from adolescence to young adulthood: The Bogalusa Heart Study. II. Alterations in anthropometic, blood pressure and serum lipoprotein variables. J Chronic Dis 1986;39:91-103.

16.Lauer RM, Lee J, Clarke WR. Factors affecting the relationship between childhood and adult cholesterol levels: The Muscatine Study. Pediatrics 1988;82:309-18.

17.Webber LS, Srinivasan SR, Wattigney WA, Berenson GS. Tracking of serum lipids and lipoproteins from childhood to adulthood: The Bogalusa Heart Study. Am J Epidemiol 1991; 133:884-99.

18.Yanagi H, Hamaguchi H, Shimakura Y, Hirano C, Takita H, Tsuchiya S, et al. Cardiovascular risk factors among Japanese school age children: a screening system for children with high risk for atherosclerosis in Ibaraki, Japan. Nipon-Kosho-Eisei-Zasshi 1993; 40(2):1120-8.

19.Tell G, Veller O. Physical fitness, physical activity, and cardiovascular disease risk factors in adolescents: The Oslo Youth Study. Prev Med 1988;17:12-24.

20.Armstrong N, Williams J, Balding P, Gentle P. Cardiopulmonary fitness, physical activity patterns, and selected coronary risk factor variables in 11 to 16 years olds. Pediatr Exerc Sci 1991;3:219-28.

21.Hofman A, Walter HJ, Connelly PA, Vaughan RD. Blood pressure and physical fitness in children. Hypertension 1987; 9(2):188-91.

22.Tell G, Tuomilehto J, Epstein F, Strasser T. Studies of atherosclerosis determinants and precursors during childhood and adolescence. Bull WHO 1996;64(4): 595-605.

23.Williams DP, Going SB, Lohman TG, Harsha DW, Srinivasan SR, Webber LS, et al. Body fatness and risk for elevated blood pressure, total cholesterol, and serum lipoprotein ratios in children and adolescents.Am J Public Health 1992;82(3):358-63.

24.Armstrong N, Balding J, Gentle P, Kirby B. Estimation of coronary risk factors in British school children: a preliminary report. Br J Sports Med 1990;24(1):61-6.

25.Lipid Research Clinics Population Studies Data Book. National Instituteof Health: Government Printing Office, Publication No. 80-1527, Washington DC;1980.

26.Kafatos A, Panagiotakopoulos G, Bastakis N, Trakas D, Stoikidou M, Pantelakis S. Cardiovascular risk factor status of Greek adolescents in Athens. Prev Med 1981;10:173-86.

27.Blank DW, Hoeg JM, Kroll MH, Rudoel ME. The method of determination must be considered in interpreting blood cholesterol levels. JAMA 1986;25:2867-70.

28.Plaza PI. Report on cholesterol levels of Spanish children and adolescents. Group of Experts of Spanish Societies of  Arteriosclerosis, Cardiology, Pediatrics, Nutrition and Preventive Medicine. Rev Esp Cardiol 1992;44(9):567-85.

29.Wynder EL, Williams CL, Laakso K, Levenstein M. Screening for risk factors for chronic disease in children from fifteen countries. Prev Med 1981;10:121-32.

30.Saeed AA, Al-Johali EA, Al-Shahry AH. Smoking habits of students in secondary health institutes in Riyadhcity, Saudi Arabia. J Roy Soc Health 1993;113(3):132-5.

31.Gabal MS, Fahim HI, Kotb MM, Aisha AF. Smoking habit among secondary school students in the eastern region of Cairo: prevalence and social aspects. Scientific Medical Journal of CairoMedical Syndicate 1993;5(4):289-97.

32.Swan AV, Creeser R, Murray M. When and why children first start to smoke. Inter J Epidemiol 1990;19(2):323-30.

33.Puska P. Possibilities of a prevalence approach to coronary heart disease starting in childhood. Acta Paediatr Scand Suppl 1985;318:229-33.

34.Bush PJ, Zuckerman AE, Theisis PK, Taggart VS, Horowitz C, Sheridan MJ, et al. Cardiovascular risk factor prevention in black school children. Am J Epidemiol 1989;129(3):466-82.

35.Berenson GS, Srinivasan SR, Nicklat TA, Webber LS. Cardiovascular risk factors in children and early prevention of heart disease. Clin Chem 1988;34(88):B115-22.

36.Martine PAB. Promotion of heart health in schools. World Health Forum, 1992;13:257-60.

 


-0001-11-30

DRUG CONTROL


DRUG CONTROL OF HYPERTENSION IN PRIMARY HEALTH CARE CENTERS-REGISTERED PATIENTS, AL-KHOBAR, SAUDI ARABIA

Ahmed G. Elzubier,MRCP*, Mohammed A. Al-Shahri, FFCM(KFU)†

*Department of Family and Community Medicine, College of Medicine & Medical Sciences, King Faisal University, Dammam and †Ministry of Defense & Aviation, Al-Hada Military Hospital, Taif, Saudi Arabia

هدف البحث :تقييم نوعية السيطرة الدوائية على ارتفاع ضغط الدم .

طريقة البحث :تم من خلال دراسة مقطعية دراسة المرضى المصابين بارتفاع ضغط الدم والمسجلين بمراكز الرعاية الصحية الأولية بمدينة الخبر بالمملكة العربية السعودية . حيث تم تسجيل البيانات باستخدام استبيان وذلك عن طريق مقابلات مباشرة مع المرضى ، ومن ملفاتهم الطبية . وشملت البيانات معلومات ديموغرافية ،  معلومات ذات علاقة بالأطباء ، ومعلومات تتعلق باستخدام المرضى لمؤسسات صحية أخرى ، وما إذا كانوا يعانون من أمراض مزمنة أخرى.

نتائج البحث :أظهرت الدراسة أن نسبة السيطرة الدوائية على ارتفاع ضغط الدم لدى المرضى كانت 37% . وكانت هذه النسبة أعلى – بدلالة إحصائية – بين المرضى الذين تقل أعمارهم عن 55 عاماً ، وبين السعوديين ، والمرضى الذين تلقوا العلاج لمدة أقل من 5 سنوات ، وأولئك الذين يعالجون بدواء واحد . ولم يكن الفرق ، في هذه النسبة ، نتيجة للمتغيرات المتعلقة بالأطباء ذات دلالة إحصائية ؛ مما يعطى انطباعاً بأن مستوى متابعة المرضى قد يكون متدنياً .

الاستنتاجات :أظهرت الدراسة أن نسبة السيطرة الدوائية على ارتفاع ضغط الدم غير عالية ، ومتعلقة بالعمر ، واستعمال دواء واحد ، وأن مستوى متابعة المرضى بواسطة الأطباء قد لا يكون جيداً .

الكلمات المرجعية :السيطرة على ارتفاع ضغط الدم ، مراكز الرعاية الصحية الأولية ، المملكة العربية السعودية .

________________________________________________________

Objective: To assess the quality of the pharmacological control of hypertension.

Design:A cross-sectional study.

Subjects:Primary health care centers-registered hypertensive patients.

Setting:Primary health care centers in Al-Khobar, Saudi Arabia.

Methods:Data was recorded, using a structured questionnaire, through direct interviewing of patients, and from their medical records. It included demographic characteristics, hypertension related, and doctors’-related variables; and patients’ utilization of other health facilities and whether they had other chronic diseases.

Results:The proportion of patients with controlled hypertension was 37%. It was significantly increased with age below 55 years, with non-Saudis, duration  of  treatment  shorter  than  5 years;  and  with the  use  of  monotherapy.

________________________________________________________________________

Correspondence to:

Dr. Mohammed A. Al-Shahri, P.O. Box 40173, Al-Khobar 31952, Saudi Arabia

Doctors’ care-related variables did not show significant variation with the number of controlled patients which may imply that the quality of follow-up might not be adequate.

Conclusions:The proportion of controlled patients cared for in the PHC centers is low. The factors associated with control were age, and the use of a single antihypertensive drug. The study questions the quality of follow-up of patients by the PHC physicians.

Key Words: Hypertension control, Primary health care, Saudi Arabia

________________________________________________________________________

INTRODUCTION

In accordance with the studies carried out in Saudi Arabia,1-3 hypertension seems to affect about one-tenth of the Saudi population. The high prevalence of hypertension in Saudi Arabianecessitates that this disorder be best managed in the primary health care (PHC) centers. The arguments for this concept are: firstly, the follow-up procedure for hypertensive patients does not require sophisticated techniques. Secondly, there is a potential of continuity of care in the PHC centers that could not be afforded for patients in the busy secondary and tertiary care system; and in this regards it has been shown that uncontrolled hypertension may be associated with the patients’ lack of a PHC care physician.4 Thirdly, the way for the management of hypertension in PHC centers, has already been paved by the expansion in the number of well-equipped and staffed PHC care centers in the Kingdom;5 and in most of those centers there are lists of hypertensive patients who are registered for long-term care. The aim of this study was to assess the quality of pharmacological control of hypertension among PHC centers care-registered hypertensive patients and the variables associated with it.

MATERIAL AND METHODS

This is a cross-sectional study which was carried out on hypertensive patients registered at the PHC centers, in Al-Khobar city, during 1996. The total population of Al-Khobar is approximately 341,024 according to the last national census.6 Health services in Al-Khobar are offered by nine PHC centers and three government hospitals. In addition, there are a few private hospitals, dispensaries and clinics. The study population was the PHC center-registered hypertensive patients. A two-stage random sampling technique was used. In the first stage, a systematic sampling procedure was used to select five PHC centers out of the nine centers. At the second stage, a systematic sampling was used to select hypertensive patients by means of their records, within each selected PHC center. The total number of PHC centers-registered hypertensive patients in Al-Khobar in 1996 was 1246, 25% of whom was to be the sample. This was achieved by using a one-in-three systematic sampling technique, in the chosen PHC centers (including 919 registered patients), thus obtaining a sample size of 311 patients. This sample was proportionally allocated from the five selected PHC centers. A reserve sample of 5% was also selected in an attempt to overcome possible non-responsiveness.

Data collection took place in the period between August 2 and October 30, 1996. An interviewer-administered questionnaire containing open and close-ended questions was used. Interview arrangements were made through telephone calls. The interviews of hypertensive patients were conducted by interviewers in PHC centers using Arabic and other languages when.

necessary. Each patient was interviewed in a quiet room after the aim of the study had been explained to him/her. Patients who refused to be interviewed were replaced by the next ones on the list. The medical records of selected patients were also reviewed to record more data as shown below. The questionnaire form was composed of two parts: (i) The first part was about patients demographic data (age, gender, educational level, and nationality). It also included questions related to hypertension and its pharmacological treatment such as duration of hypertension, duration of drug treatment for hypertension, number of antihypertensive drugs used; and the names of those drugs, and presence of hypertensive complications (which were checked from medical records). Drugs’ names were also checked from the records and the response was recorded as correct, or incorrect. The questionnaire also included questions related to doctors’ care such as whether patients were always seen by the same, or different PHC physician at each follow-up visit; and whether health education had been given by their PHC physicians about the name(s) of drug(s) prescribed for hypertension, drugs’ side effects, and about compliance with drugs. Inquiry was also made about whether a patient was utilizing other health care facilities for follow-up of hypertension (such as other health centers, or governmental or private hospital outpatient clinics). Patients were also asked if they were being treated for other chronic diseases, and whether they were receiving drugs for them. (ii) The second part of the questionnaire was recorded from the patients medical records, which included presence and type of hypertensive complications, frequency of follow-up (whether monthly, quarterly, biannually or annually) during the previous year (1995); and the names of the antihypertensive drugs received. A systolic blood pressure (SBP) of 140 mm Hg, or less, a diastolic blood pressure (DBP) of 90 mm Hg or less were considered as representing controlled SBP and DBP, respectively. On the other hand, a patient with both controlled SBP and DBP was considered as having controlled hypertension.7-9

Data was analyzed using an IBM-compatible personal computer. The statistical package for the Social Sciences ( SPSS/PC+) version 610 was used for data entry and analysis. Means were calculated and expressed as mean + 1 standard deviation (M + 1 SD). Differences between two means and differences between two categories were tested using the students’ t-test for unequal samples; and Chi-squared tests; respectively. A p-value of 0.05 or less (one or two sided as appropriate) was considered to represent statistical significance.

RESULTS

All hypertensive patients in the selected sample (n=311) were interviewed. Twenty percent of the sample were then re-interviewed to check the reliability of the questionnaire. The percentage of agreement between the investigator and the interviewers ranged from 85-100% with an average of 93.5%.

The mean age of sampled cases was 53.2 + 0.65 years, two-thirds of whom were females. The majority of the sample (81.4%) were of Saudi nationality; and about two-thirds of the sample were illiterate.

The majority of patients (80.4%) were being treated with a single antihypertensive drug. On the other hand, about half of the patients (53.7%) knew the name(s) of antihypertensive drug(s) they were using. Hypertensive complications were present in 16.4% of the patients. About a quarter of patients (27.0%) were always being seen for follow-up by the same PHC center physician. As regards health education received, the proportions of patients who received health education about drugs’ names, drugs’ side effects, and advice on compliance; were 19.6%, 31.5%, and 46.9% respectively. Forty-three patients (13.8%) had been followed up with a frequency of three months or less, while the rest were followed up every six months or longer than that.

Other chronic diseases (which were diabetes mellitus, coronary heart disease, and renal diseases) were present in about half of the sample,  while a similar proportion used drugs for treatment of those diseases. On the other hand, two-fifths of the patients (41.2%) attended other medical facilities, governmental or private, for follow-up of hypertension.

The mean systolic and diastolic blood pressure of the sample was 140.03 +1.83, and 84.05 + 1.05 respectively. The mean duration of hypertension among the sample was 8.5 + 5.7 years, while the mean duration of treatment was 7.0 + 5.1 years. Three quarters (75.2%) and about a half (42.4%) of the patients had controlled levels of diastolic or  systolic blood pressures, respectively. About one-third of the patients (37.2%) had controlled both systolic and diastolic blood pressure; i.e., DBP < 90 mmHg and SBP < 140 mmHg, and were considered as having controlled hypertension (Table 1).

There was a   significantly higher proportion of patient aged 54 years or less who had controlled hypertension than older ones (P < 001). Also there was a significantly higher proportion of patients with controlled hypertension among non-Saudi than Saudi patients (P < 0.01) (Table 2).

On the other hand, there was a significantly higher proportion of patients who had been on treatment for a duration of less than 5 years, who had controlled hypertension, than those who had been hypertensive for a longer duration  (P < 0.01). Also, significantly more patients who used one antihypertensive drug had controlled hypertension, than those who were on two, or more drugs (P < 0.04). Table 3).

As regards doctors’-related variables there was no significant variation of numbers of patients with controlled hypertension as regards whether they are seen by one or more doctors, offered health education about drug names, drug side effects, and on compliance; nor  whether they were followed up every three months or less or longer than three months (Table 4).

Similarly, there  was no significant variation of number of patients with controlled hypertension regarding the presence of other chronic diseases, having other drugs (for treatment of other unrelated diseases), nor whether they were utilizing other health facilities, such as hospitals or private clinics (Table 5).

DISCUSSION

The sample of patients involved in this study is composed of middle-aged, and predominantly female patients with low or no level of education, and with a relatively long duration of hypertension. This finding supports that shown by a previous study in the same area.11 Thus, hypertensive patients in our sample are not expected to know much about their disease and aspects of its control. Moreover, they might have had some misconceptions arising from the native cultural beliefs.11 This emphasizes the importance of efficient doctor/patient communication by the PHC physician12 in a background of the continuity of  care provided by the PHC system. But unfortunately, in this regards, our findings showed  that  a  minority  of  the sample has enjoyed.

continuity of care in their follow-up; a matter that needs much consideration and correction.

Table 1:Blood pressure status of hypertensive cases in PHC centers, Al-Khobar 1996

Characteristic

Mean + 1 SE

Patients (n = 311)

No.

%

SBP

140.03 + 1.83 mmHg

DBP

84.05 + 1.05 mmHg

Duration of hypertension

8.5 + 5.7 years

Duration of treatment

7.0 + 5.1 years

DBP < 90 mmHg

controlled

234

75.2

uncontrolled

77

24.8

SBP < 140 mmHg

controlled

132

42.4

uncontrolled

179

57.6

SBP < mmHg and DBP < 90 mmHg

controlled

117

37.6

uncontrolled

194

62.4

Table 2:Effects of demographic variables on blood pressure control among PHC centers-registered hypertensive patients

Variable

Total

Controlled (%)

p-value

Age in years

< 55

160

76 (47.5)

< 0.001

55

151

41 (27.2)

Gender

Males

111

40 (36.0)

NS

Females

200

77 (38.5)

Nationality

Saudis

253

87 (34.4)

< 0.01

non-Saudis

58

30 (51.7)

Education

Any education

31

16 (51.6)

NS

Drug name not known

280

101 (36.1)

NS = Not significant

Table 3:Effects of disease-related variables on blood pressure control among PHC centers-registered hypertensive patients

Variable

Total

Controlled (%)

p-value

Duration of hypertension

< 5 years

80

37 (46.3)

NS

5 years

231

80 (34.6)

Duration of treatment

< 5 years

130

60 (46.2)

< 0.01

5 years

181

57 (31.5)

Number of drugs

One

250

101 (40.4)

< 0.04

Two or more

61

16 (26.2)

Knowledge of drugs’ name

Drug name known

167

61 (36.5)

NS

Drug name not known

144

56 (38.9)

Complications

Present

51

14 (27.5)

NS

Not present

260

103 (39.6)

NS = not significant

Table 4:Effects of doctors’-related variables on blood pressure control among PHC centers-registered hypertensive patents

Variable

Total

Controlled (%)

p-value

Continuity of care

Available

84

30 (35.7)

NS

Not available

227

87 (38.3)

Drug names

Told to patient

61

22 (36.1)

NS

Not told

250

95 (38.0)

Drugs’ side effects

Explained to patient

98

38 (38.8)

NS

Not explained

213

79 (37.1)

Advice on compliance

Offered

146

58 (39.7)

NS

Not offered

156

59 (35.8)

Follow-up

1-3 monthly

43

16 (37.2)

NS

More than 3-monthly

268

101 (37.7)

NS = not significant

Table 5:Effects of demographic variables on blood pressure control among PHC centers-registered hypertensive patients

Variable

Total

Controlled (%)

p-value

Other chronic diseases

Present

164

56 (34.1)

NS

Not present

146

61 (41.5)

Use of other drugs

Yes

143

45 (31.5)

NS

No

168

72 (42.9)

Other health facilities

Utilized

128

51 (39.8)

NS

Not utilized

183

66 (36.1)

NS = not significant

Our results showed that 37% of the sample had controlled hypertension. This figure is better than that found previously by Dharrab,11 but still seems to be low by international standards.13 The study revealed that there were significantly more patients with controlled hypertension among those younger than 55 years of age. It has been shown by other studies that patients older than 60 years had poor compliance with therapy for hypertension.14 This finding calls for more attention to older patients especially since, from an epidemiological point of view, the prevalence of hypertension tends to increase with age;15 and thus the numbers of such patients would be large in the community.

Our findings also revealed that there were significantly more patients with controlled hypertension among non-Saudis. This could not be solely explained by racial differences, as non-Saudis who represent an.

expatriate work-force tend to be younger than the proportion of Saudi patients in the sample. A similar age-related explanation could be put forward for our finding that there were significantly more patients with controlled hypertension among those who had treatment for a shorter duration.

On the other hand, the study has clearly shown that there were significantly more patients with controlled hypertension among those who were being treated with a single antihypertensive drug. This is an expected finding since monotherapy is usually associated with better compliance with drugs, and hence better control.16-18

Our study has revealed that all doctor care-related variables did not show any significant variation with numbers of patients with controlled hypertension. This is an important finding as it may imply that the quality of follow-up of patients, including aspects of doctors’/patient communication, such as health education, may need reconsideration. This finding has already been documented by Al-Dharrab.19 Poor doctors’/patient communication has been cited as one of the barriers to effective therapeutic adherence;20 and it was specially so in case of elderly hypertensive patients.21

CONCLUSION

The study has revealed that the proportion of controlled patients cared for in the PHC centers is low. The factors associated with control were age, and the use of a single antihypertensive drug. The study also questions the quality of follow-up of patients by the PHC physicians.

REFERENCES

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16.Detry JM, Block P, De-Backer G, Degaute JP. Patient compliance and therapeutic coverage: comparison of amlodipine and slow release nifedipine in the treatment of hypertension. The Belgian Collaborative Study Group. Eur J Clin Pharmacol 1995;46:477-81.

17.Elliot WJ. Compliance strategies. Curr Opin Nephrol Hypertens 1994;3:271-278.

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21.  Taylor JL. Overcoming barriers to blood pressure control in the elderly. Geriatrics 1990;45:35-8.

 


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