Patient related factors for optimal blood pressure control in patients with hypertension

Background : Patient related factors hindering optimal blood pressure (BP) control in patients with hypertension are unclear. Objectives: To investigate the barriers to optimal hypertension management. Methods: A survey on the awareness and management of hypertension was conducted in 556 patients (365 males, mean age 60.9 ± 10.1) from a rural community. Results: Of the 556 patients who had a clinical diagnosis of hypertension, 127 (22.8%) were unaware the existence of the condition and received no therapy. In the 429 patients who were aware the presence of hypertension, 206 (48.0%) did not receive any antihypertensive medication at the time of this study. Fifty-four (12.5%) had a BP of less than 140/90 mm Hg. Only 21 (4.9%) received formal counselling or education from health professionals and 74 (17.2%) were aware of the optimal level of BP. Difficulty in accessing a specialist doctor was reported by 126 (29.4%). In 279 (65.0%), missing regular antihypertensive medications was reported in the 4-week period prior to this study. Omitting prescribed antihypertensive drugs due to the costs was reported by 169 (39.4%). Conclusions: Inadequate counselling, lack of understanding on the disease, difficulties in accessing specialist care and poor medication adherence are the barriers to optimal BP control.


Introduction
Hypertension is one of the most important cardiovascular risk factors that are associated with significant complications such as coronary artery disease, stroke or renal failure. Although almost one in third of the adults may have hypertension, 1 the awareness of this condition by the patients is low, and the control of blood pressure is generally suboptimal in rural and urban communities. [2][3][4] Barriers to the blood pressure control appear to exist at patients, physicians and system levels. Poor knowledge of the disease and its management and poor adherence to antihypertensive drugs are wellknown patient factors for suboptimal blood pressure control 5 . Poor adherence to therapeutic guidelines and inadequate understanding of therapeutic goals are major physician-related barriers. 5,6 Furthermore, health care system and low socio-economic status may present a barrier to blood pressure control, as high costs of screening and treatment may hinder the optimal control of hypertension among the low socio-economic group. 7 Little is known about the barriers to the hypertension management in rural Chinese communities. The primary objective of this study was to determine the patient-related barriers to blood pressure control in a rural community in East China.

Patients
This study was approved by the Institutional Review Board of our hospital, and written consent form was obtained from all participants. Between January 2010 and May 2012, 556 hypertensive patients were interviewed for the management of hypertension. These patients were selected from those who attended the free health check clinics in our hospital after a radio and television advertisement. All patients had lived in Liaocheng City, a regional city in the south-west of Shandong Province of China, for more than five years. After obtaining medical history, a full physical examination including blood pressure measurements were conducted in all patients. An electrocardiogram and blood biochemistry tests were also performed. Information on patient's antihypertensive treatment, in particular the use of antihypertensive medications was collected.
Blood pressure was measured with the patient in a sitting position after 10 min of resting, using a mercury sphygmomanometer. Phase V Korotkoff sounds was used to determine the diastolic blood pressure. 2 Hypertension was defined as either systolic BP e" 140 mm Hg or diastolic BP e" 90 mm Hg. 8

Interview questionnaires
The questionnaires during the interview were comprised of four categories. The first was in relation to formal education on hypertension provided by health professionals, either doctors or nursing staff during visits to hospitals or clinics since the first diagnosis of the disease. Patients were also asked whether they had sought information from social media in particular the Internet about hypertension and related cardiovascular risk factors.
The second part of the questionnaire was about the patient's knowledge on hypertension, on the optimal level of blood pressure and on the consequences of uncontrolled hypertension. Patients were asked to name two or more of the hypertension-related complications, such as coronary heart disease, stroke, renal failure, or eye disease (retinopathy).
Access to health care was assessed by asking whether patients had difficulties in making regular appointments to visit a cardiologist due to the unavailability of the doctor. They were also asked if financial concerns were a factor in preventing them to see a specialist on a regular basis.
Two questions were asked to evaluate medication adherence or compliance. The first was whether patients had forgotten to take antihypertensive drugs at least on three occasions each week in the 4-week period prior to the interview. They were also asked if they had omitted antihypertensive drugs because of the costs of the medications.

Statistical analysis
Data are expressed as means + standard deviation (SD) or percentages as appropriate. Comparison of numerical data between patients who were aware and unaware of the presence of hypertension was performed with an un-paired student t test, whereas analysis of categorical data between the two groups was performed with Chi-square of Fisher's exact test. P <0.05 was considered statistically significant. SPSS software was used for the statistical analysis.

General findings
The general characteristics of the patients are shown in table 1. The median age of the patients was 63 years, with more males (n=365, 65.7%) than females (n=191, 34.3%). Current cigarette smokers were confined to male patients (126/365, 34.5%), with an overall smoking rate of 22.7% (126/556) of the entire patient population. Type 2 diabetes was present in 101 (18.2%) patients, and more than half of the patients (296, 53.2%) had dyslipidaemia. In addition, 82 (14.8%) patients had a history of coronary artery disease.
Among the 556 patients, 429 (77.2%) were aware that they had been previously diagnosed with hypertension, while 127 (22.8%) patients did not know they had hypertension, although their blood pressure was >140/90 mm Hg on two separate measurements in our clinics.

Management of hypertension
Patients who were unaware of the presence of hypertension at the time of this study did not receive any antihypertensive therapy. Their mean systolic and diastolic blood pressure was 167.3 ± 13.2 and 90.5 ± 7.8 mm Hg, respectively, which were higher than the mean systolic (159.3 ± 11.2 mm Hg, p = 0.001) and diastolic (81.2 ± 5.9 mm Hg, p = 0.017) blood pressure in the patients who were aware of the presence of hypertension (table 2).
In patients who were aware of the hypertension, 369 (86.0%) had a systolic blood pressure of 140 mm Hg or higher, and 166 (38.7%) had a diastolic blood pressure of 90 mm Hg or higher. The total number of the patients who had a blood pressure of less than 140/90 mm Hg in this group was 54 (12.5%) (table 2). The mean systolic and diastolic blood pressure the patients who were unaware of the presence of hypertension was 167.3 ± 13.2 and 96.0 ± 7.1 mmHg, respectively (table 2).

Patient related barriers to hypertension management
The potential barriers to optimal hypertension control in patients who were aware of the presence of hypertension are listed in table 3. Only 21 (4.9%) patients received formal counselling or education from health professionals since the first diagnosis of this disease. One hundred and twelve (26.1%) patients sought information on hypertension and related cardiovascular risk factors from social media, mostly the Internet. Only 74 (17.2%) of the patients were aware of the optimal level of blood pressure, and 86 (20.0%) could name two or more major risks or complications from hypertension, such as coronary heart disease, stroke or renal failure.
The access to a specialist doctor was assessed in two aspects. Difficulties in getting an appointment to see a cardiologist was reported by 126 (29.4%) patients, and financial concerns preventing them to see a specialist was found in 176 (41.0%) patients. In 279 (65%) patients, missing regular antihypertensive medications was reported in the 4week period prior to this study. Omitting prescribed antihypertensive drugs due to the costs was reported by 169 (39.4%) patients.

Discussion
The main findings of this study were: a) Approximately 23% of the patients from this rural population were unaware of the presence of hypertension, and received no antihypertensive therapy; b) In patients who were aware of the presence of hypertension, 48.0% were not using any antihypertensive medications at the time of this study, and only 12.5% achieved optimal blood pressure control; c) Less than 5% of the patients who were aware of the presence of hypertension received formal counselling on the disease from the health professionals; d)Less than 20% of the patients had adequate knowledge of the complications or therapeutic targets of hypertension; e) Poor adherence to prescribed antihypertensive medications was common; f) Financial constraints appeared to be a factor hindering doctor visits and adherence to prescribed antihypertensive drugs. Optimal blood pressure control in hypertension patients appears to be a long-standing challenge around the world. Earlier studies showed that less than 25% of patients who were treated for hypertension achieved the target blood pressure of less than 140/90 mm Hg. 9,10 In China, less than 5% of treated hypertensive patients had blood pressure below 140/90mm Hg. 2,11 The proportion of patients achieved optimal blood pressure in the present study was 12.5%, which was consistent with the abovementioned reports.
The suboptimal control of blood pressure is related to a number of factors. Failure to diagnose high blood pressure in clinics and hospitals is a major cause. Our earlier study on a rural Australian population showed that 56.7% of the patients with elevated blood pressure were unaware of the presence of hypertension 3 . In the present study on a rural population in China, the unawareness was 22.8%. Patients who were unaware of the hypertension received no antihypertensive therapy, and had a higher level of systolic and diastolic blood pressure than those who knew they had hypertension.
Structured education on the management of hypertension and life style modification has been shown to facilitate body weight reduction and pharmacological control of blood pressure. 12,13 Education and counselling on the nature of hypertension and its impact on health appeared inadequate in the present study, and this may have contributed to the overall poor control of hypertension. Only 4.9% of the patients received formal counselling from health professionals, and only 20% of the patients had adequate knowledge about the risks and complications from uncontrolled hypertension.
Patients' poor adherence to prescribed antihypertensive medications has been identified as one of the main reasons for uncontrolled hypertension. 13,14 The poor medication adherence can be due to a number of factors, such as multiple dose regimens, poor eye sights or hands disabilities in the elderly, 13,14 or in some countries, financial constraints 7 . In the present study, 65% of the patients reported poor medication adherence in the 4-week period prior to the interviews at our clinics. Although the specific causes of poor medication adherence in our patients were unclear, affordability of the medications played a part. In 39.4% of the patients, costs of the medications were a contributing factor for omitting the antihypertensive drugs. These results suggest that new strategies or policies need to be developed to reduce the costs of antihypertensive medications, and to ultimately improve the medication adherence.
It was important to note that 29.4% of our patients reported to have difficulties in accessing a specialist doctor due to unavailability of the doctors, and 41% reported costs were a hindering factor for the specialist visits. These results were somewhat surprising because in China in general, and in the city of Liaocheng where the study was conducted in particular, the health care system was based on a fee-for-service system, and the patients had the freedom of choosing specialist doctors at either municipal, district or community hospitals. 14 Access to specialists has not been perceived as a major problem for hypertension treatment in the past. However the results of this study clearly indicate that there is a need to addressing the accessibility to specialist care, by either enhancing the availability of the specialist services, or containing the costs of these services, or both.

Conclusion
The present study has found that in the majority of the patients with hypertension from this rural Chinese community, blood pressure was poorly controlled. The reasons for the suboptimal hypertension management are multifactorial. Potential barriers are inadequate education from health professionals, limited access to specialist care and poor adherence to antihypertensive medications. New strategies or policies are required to improve the patient's accessibility to specialist services, and to reduce the financial burden associated with the management of hypertension.