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 Table of Contents 
ORIGINAL ARTICLE
Year : 2002  |  Volume : 9  |  Issue : 1  |  Page : 25-32  

Quality of life in a sample of hypertensive patients attending primary health care facilities in Al-Khobar, Saudi Arabia


1 Baha Health Affairs, Baha, Saudi Arabia
2 College of Medicine, King Faisal University, Dammam, Saudi Arabia

Date of Web Publication30-Jul-2012

Correspondence Address:
Mohammed S Al-Ghamdi
Primary Health Care Department, Baha Health Affairs, P.O. Box 1063, Baha Region
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 23008659

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   Abstract 

Background: Hypertension is one of the most prevalent chronic conditions in Saudi Arabia. It is the leading risk factor for cardiovascular diseases and a major reason for visits to clinic and prescription of medications. Inspite of this, the degree of its control is not to the optimum. This could be due to its impact on patients' quality of life (QOL). Impaired physical and psychological well-being may lead to non-compliance or even the withdrawal of treatment . The aim of this study was to assess QOL of hypertensive patients registered in Al-Khobar.
Methods: The QOL of hypertensive patients was compared with QOL of a control group. A total of 404 subjects (202 cases and 202 controls) were interviewed. The cases and controls were matched for age and sex. Patients' self-assessment of QOL was measured with an Arabic version of SF-36, a 36-item Short Form Health Survey Questionnaire encompassing two main dimensions, physical and mental.
Results: The QOL of hypertensive patients was substantially impaired in comparison to the control group. The mean scores for the physical component summary scale (PCS) were 39.3 and 50.8 for cases and controls respectively. The mean scores for the mental component summary scale (MCS) were 43.7 and 50.8 for cases and controls respectively. The burden of hypertension was concentrated in the physical dimension of health. Older age, female gender, unmarried patients, patients with hypertension complications, comorbid DM, use of Aldomet and shorter duration of hypertension were independently related to poorer QOL. The variability of the two summary measures explained by selected demographic and clinical characteristics was 24.3% and 10% for the PCS and MCS respectively.
Conclusions and recommendations: The QOL of hypertensive patients was substantially impaired in comparison to the control group. Notably, the total explained variation of QOL by the selected characteristics was small, suggesting that the determinants of QOL are multi-factorial. Further research to explore the determinants and indices of QOL in hypertensive patients is warranted. From a clinical perspective, QOL should be considered in the monitoring of hypertensive patients to estimate the burden of hypertension and monitor their outcome.

Keywords: Quality of life, hypertension, primary health care, SF-36 questionnaire


How to cite this article:
Al-Ghamdi MS, Taha AZ, Bahnassy A, Khalil MS. Quality of life in a sample of hypertensive patients attending primary health care facilities in Al-Khobar, Saudi Arabia. J Fam Community Med 2002;9:25-32

How to cite this URL:
Al-Ghamdi MS, Taha AZ, Bahnassy A, Khalil MS. Quality of life in a sample of hypertensive patients attending primary health care facilities in Al-Khobar, Saudi Arabia. J Fam Community Med [serial online] 2002 [cited 2019 Dec 14];9:25-32. Available from: http://www.jfcmonline.com/text.asp?2002/9/1/25/98030


   Introduction Top


The impact of hypertension reaches far beyond the expectation of treating physicians by affecting physical function, psychosocial function, and other activities of daily living. Individuals with hypertension may have no symptoms of illness. The 'labeling effect' and the adoption of the sick role by people diagnosed to be hypertensive and therapeutic intervention, raises interest in QOL assessments. [1] WHOQOL group has provided a definition of QOL as the "individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns." [1] The measurement of QOL has become an emerging science in the last few decades when QOL is a reflection of symptoms and concerns. There is now recognition that meaningful measures of QOL should be used to monitor the health of the general population, estimating the burden of different conditions and monitoring outcomes. The paternalistic adage: "doctor knows best" is no longer valid. How the patient feels is as important as symptoms response and survival rates, particularly where patients are treated for a chronic condition like hypertension. Impaired physical and psychological well-being may lead to non-compliance or even withdrawal of treatment. [2] Physical well-being is likely to be affected by the side effects of treatment, while psychological well-being may be affected by anxiety and depression, which have been shown to be more likely to occur in hypertensive patients. [2] Since hypertension is a common health problem in Saudi Arabia and the level of its control is not at its optimum, [3] it is important to study its effect on QOL. The aim of this study was to assess QOL of hypertensive patients in Al-Khobar area, the Eastern Province of Saudi Arabia. The hypothesis of this study was that the QOL of hypertensive patients was lower than that of normotensive subjects.


   Methodology Top


The study population was drawn from the registered hypertensive patients in the primary health care (PHC) centers in Al Khobar area during the year1420 H(1999 G). A two-stage random sampling technique was used. In the first stage, out of the ten PHC centers in Al Khobar, five were selected using simple random sampling procedure. In the second stage, within each selected PHC center, a systematic sampling of one-in-three was used to select hypertensive patients by means of their records. The total number of registered hypertensive patients in Al-Khobar in 1420H, was 1411, 212 (15 %) of whom were chosen. These were proportionally distributed among the five-selected PHC centers. A reserve sample of 5% was also selected in case that non-response rate might be high. Controls were defined as persons with no history of hypertension or other chronic diseases. They were randomly selected from non-hypertensive subjects registered in the same PHC center with trivial complaints or those who were just accompanying other patients. They were interviewed in a way similar to the cases, in the same place and by the same interviewers. Controls were matched with cases for age group, gender, and the number of cases from each center.

The hypertensive patients were individually interviewed in a quiet room within each PHC center using the Arabic version of SF-36.4 Patients who were not found or who refused to participate in the study were replaced by the next on the list. Demographic variables studied were age, gender, educational level, occupation, mari-tal status and nationality. Clinical characteristics comprised duration of hypertension, anti-hypertensive drugs used, compliance with drug therapy, hypertension-related complications, coexisting chronic diseases, drugs other than anti-hypertensives, and the last three blood pressure readings.

QOL was measured with an Arabic version of SF-36 after it had been validated. The SF-36 contains 36 items, which measure eight dimensions: physical funct-ioning (extent to which health limits physical activity), social functioning (extent to which physical or mental health interferes with normal social activities), role-physical (extent to which physical health interferes with daily activities), role-emotional (extent to which emotional problems interfere with daily activities), mental health (general mental health, including anxiety and depre-ssion), energy/vitality (feeling energetic and full of pep), bodily pain (intensity of pain and effect of pain on normal work, both inside or outside the home), and general health perception (personal evaluations of current health, health outlook, and resistance to illness).

The SF-36 scores of the cases were compared with the SF-36 scores of the controls. SF-36 scores were transformed to a scale of 0 to 100, a higher score indicating a better QOL state. The physical component summary (PCS) and mental component summary (MCS) were constructed and scored to reduce SF-36 from an eight-scale profile to two summary measures without substantial loss of information.

Scoring of the PCS and MCS involved three steps. [5] First, the eight SF-36 scales were standardized using means and standard deviations from the general population. Second, they were aggregated by means of factor score coefficients from the general population. Finally, aggregate PCS and MCS scores were standardized with a linear T-score transformation to give a mean of 50 and a standard deviation of 10, in the general population.

All collected data were checked and entered into a personal computer. QOL was scored from all related variables. Student t-test was used to differentiate between mean scores of QOL for both cases and controls. Chi-square test was used to measure associations among qualitative variables. The level of significance was set at < 0.05. The SPSS-PC was used for data entry & analysis.6


   Results Top


Out of a total of 404 participants interviewed, 212 were hypertensive subj-ects. Of the hypertensives, 8 refused to be interviewed and 2 were not found. The response rate was 95.3% for the hyper-tensive subjects. The socio-demographic characteristics of the study population are shown in [Table 1].
Table 1: Socio-demographic characteristics of cases and controls

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[Table 2] shows the clinical characteristics of the hypertensive cases. More than one-third of the hypertensives had their blood pressure controlled, with a mean + 1SD of 129.96 + 6.80 mmHg for SBP and 83.21 + 4.03 mmHg for DBP.
Table 2: Clinical characteristics of hypertensive patients

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The majority of the hypertensives (82.1%) were on a single anti-hypertensive drug. More than half of the hypertensives (55.4 %) were on Tenormin (atenolol). The use of Esidrex (hydrochlorothiazide) was reported by 6.9 %, while the use of both Tenormin and Esidrex was only reported by 3.5 % of patients. The use of ACE inhibitors namely, Capoten, Zestril or Renitec was reported by 14.5 % of the patients. The use of Adalat (nifedipine) and Aldomet (methyldopa) was reported by 9.4 % and 4.5 % respectively. Compliance with the anti-hypertensive drugs was reported by 81% of the patients. Coexisting DM was reported by 44 % of the hypertensive patients.

The results of the QOL questionnaire are shown in [Table 3]. The mean scores from the eight SF-36 Health Survey Profile and the two summary measures were found to be significantly lower in the hypertensives as compared to the controls. The difference was statistically significant.
Table 3: Comparisons of scores of QOL between cases and controls

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The demographic and clinical characteristics of hypertensive patients were regressed as independent variables with the two summary scales, PCS and MCS as dependent variables.

The independent variables were regressed with PCS as a dependent variable. R 2 was 0.243, with a standard error of 12.654. In other words, around 24% of the variability in PCS was determined by the variables in the equation [Table 4]. Significantly, the older subjects scored less than younger subjects. Married subjects significantly scored more than those who were divorced, single, or widow. Patients with comorbid DM just significantly scored less than those with hypertension only. Males scored significantly more than females. Patients who reported hypertensive complications significantly scored less than those who were without complications. The PCS of patients, who were only on Esidrex was positively affected, while that of those on Aldomet was negatively affected.
Table 4: Multiple linear regression model to predict QOL from PCS scale for hypertensive patients

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MCS scale as a dependent variable was regressed with the independent variables. R 2 was 0.102, with standard error of 10.535. This means that 10% of variability in MCS was determined by the independent variables in the equation [Table 5]. Patients with longer duration of hypertension scored more than those with shorter duration. However, the difference was not statistically significant. Male hypertensives scored significantly more than females. Patients who were on Adalat scored significantly more than patients who were on other anti-hypertensive medications.
Table 5: Multiple linear regression model to predict QOL from MCS scale for hypertensive patients

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The assessment of QOL indicated that QOL of hypertensive patients was significantly lower than that of the controls on all dimensions. These findings appear to support the previous study of Stewart et al, [7] which found that patients with chronic conditions including hypertension had marked decrement in SF-36 scores compared to patients with no chronic conditions. Moreover, Batterson et al [2] in their case-control community-based study assessed QOL in treated hypertension, they showed impaired QOL of hypertensive patients compared with controls. They had a lower health status index, more absence from work, greater symptomatic complaint, and impaired psychological well-being.

The large and significant decline in the levels of all domains of QOL among hypertensive patients might have been slightly exaggerated. The mean age of the controls (49.6 years) was lower than that of the hypertensives (51.7 years) and since SF-36 scores are negatively related with age, [8] this might have resulted in overestimation of the differences in QOL.

The multiple regression analysis revealed that older patients, females, unmarried patients, patients with complications of hypertension, comorbid DM, and the use of aldomet were the most important independent explanatory factors for poorer PCS, while shorter duration of hypertension and female gender were the most explanatory factors for poorer MCS.

Significant declines were observed for both PCS and MCS in female patients. That is to say females showed more impairment of QOL than male patients. These findings are in agreement with the conclusions of Wachtel et al, [9] in which they state that older age and female gender were associated with lower scores of QOL in several health dimensions. However, the difference between both sexes in terms of QOL might have been exaggerated because, at baseline, females tend to have lower QOL than males. [10],[11]

The finding of the negative influence of older age on the PCS in the absence of a significant influence on the MCS seems reasonable and in accordance with the previous study done by Wachtel et al. [9] Moreover, physical health tends to decrease with age but not mental health. [4] The negative influence of the complications of hypertension on the PCS in the absence of a significant influence on the MCS could be attributed to the additive effect of comorbid chronic conditions on the physical dimension of health.

Comorbid DM adversely affected the PCS, which could be due to the additive effects of the symptoms of diabetes, the side effects of treatment, or its complications. These data appear to support previous studies of Stewart et al [7] who found that patients with multiple chronic conditions had a greater decrement in QOL scores than those with one condition alone.

Large and significant improvement was observed among patients using Esidrex for the PCS scale. This improvement could be due to the low-dose and simple regimen. The finding of a positive influence of Esidrex is in accordance with former studies. [12],[13] However, there was a significant decline of the PCS scale among patients on Aldomet. This could be due to the side effects of the drug. Croog et al [14] found that captopril improved the QOL from the baseline whereas Aldomet worsened it. Bulpitt and Dollary [12] found an association between Aldomet and drowsiness. However, it is unsafe to draw conclusions about whether antihypertensive drugs offer pharmacologic advantages in terms of QOL without verification from randomized controlled clinical trials.

The multivariate analysis revealed a positive effect of the duration of hypertension on the MCS. That could be explained by the fact that these hypertensive patients might have had more time to adjust their lifestyle and emotional reactions. [8]

The variability of the two summary measures explained by selected demographic and clinical characteristics was 24.3 % and 10 % for the PCS and MCS respectively. It is reasonable to assume that the level of QOL is a result of a complex interaction of the outcome of disease, personal traits, ability to cope, social support, and quality of the care received. [8]

In conclusion, the present findings indicate that in hypertensive patients, QOL is substantially impaired. Notably, the total explained variation of QOL by the selected characteristics was small, suggesting that the determinants of QOL are multi-factorial. Further research to explore the determinants and indices of QOL in hypertensive patients is warranted. Perhaps there should be emphasis on the adverse effects of anti-hypertensive medications and disease-targeted indices. From a clinical perspective, QOL should be considered in the monitoring of hypertensive patients to estimate the burden of hypertension and monitor the outcome.

 
   References Top

1.Bowling A. Measuring Health: A review of quality of life measurement Scales. 2 nd ed. Milton Keynes: Open University Press; 1991.   Back to cited text no. 1
    
2.Betterson C, Hartley K, Fletcher A, Markow H, Styles W, Sapper H et al. Quality of Life in treated hypertension: A case-control community based study. J Hum Hpn 1995; 9:981-6.  Back to cited text no. 2
    
3.Khalil S, Elzubier A. Drug compliance among hypertensive patients in Tabuk, Saudi Arabia. J Hypertens 1997; 15(5):561-5.  Back to cited text no. 3
    
4.Ware J, Snow K, Kosinski M, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. Boston (Mass): The Health Institute, NEMC; 1993.  Back to cited text no. 4
    
5.Ware J, Kosinski M, Keller S. SF-36 physical and mental health summary scales: A user's manual. Boston Mass: The Health Institute, NEMC; 1994.  Back to cited text no. 5
    
6.Statistical Package for Social Sciences (SPSS\PC+) for Windows. Release 6.0(1993) {Computer Program}. SPSS Inc., 1989-93.   Back to cited text no. 6
    
7.Stewart A, Greenfield S, Hays R, Wells K, Rogers W, Berry S. Functional Status and well-being of patients with chronic conditions. JAMA 1989; 262(7): 907-13.  Back to cited text no. 7
    
8.Merkus M, Jager K, Dekker F, Boeschoten E, Stevens P, Krediet R. Quality of life in patients on chronic dialysis. AM J kidney Dis 1997; 29 (4):584-9  Back to cited text no. 8
    
9.Wachtel T, Piette J, Mohr V, stein M, Fleishman J, Carpenter C. Quality of life in person with HIV infection: Measured by the MOS SF-20. Ann Intern Med 1992;116:129-37.  Back to cited text no. 9
    
10.Richard H, Grimm J, Gregory A, Grandits M, Jeffrey A, Anita L et al. Relationship of Quality of Life measures to long-term lifestyle and drug treatment in the treatment of mild hypertension study. Arch Intern Med 1997; 157: 638-48.  Back to cited text no. 10
    
11.Anderson R, Appel L, Rosen R, Shumaker S. Baseline correlates with Quality of Life among men and women with medication-controlled hypertension. The Trial of Non-pharmacologic Interventions in the Elderly (TONE). J Am Geriatr Soc 1997;45:1080-5.  Back to cited text no. 11
    
12.Bulpitt C, Dollery C. Side effects of hypotensive agents evaluated by a self-administered questionnaire: BMJ 1973; 3: 485-90.  Back to cited text no. 12
    
13.Hurst D, Boswell D, Boogaard S, Watson M. The relationship of self-esteem to the health-related behaviors of the patients of a primary care clinic. Arch Fam Med 1996;6:67-70.  Back to cited text no. 13
    
14.Croog S, Levine S, Testa M, Brown B, Bulpitt C, Jenkins D et al. The effects of antihypertensive therapy on the quality of life. N Engl J Med 1986; 314:1657-64.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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