Adherence To Lifestyle Modifications As A First-Line Therapy In Hypertension Management In Primary Health Care Setting, Medina, Saudi Arabia

Introduction:

Adherence to lifestyle management is an important first-line step in hypertension management due to its benefits in reducing hypertension (HTN) 1 and delaying or avoiding the use of pharmacological medications 1. It can also play a major role in reducing the incidence of complications related to hypertension, such as atherosclerosis and stroke 1.

Lifestyle modifications are recommended for individuals with above optimal blood pressure, they are used as a first-line or initial step for management of patients diagnosed with stage 1 of hypertension 2. For patients who are treated with antihypertensive agents, they are used as adjunctive therapy along with medications 2. These modifications include weight reduction, dietary reduction of sodium intake, reduction of alcohol consumption, and following a Dietary Approaches to Stop Hypertension (DASH) diet.

Modifying a patient's lifestyle can play a major role in the management of hypertension and lower the incidence of complications1. Weight reduction can decrease Systolic Blood Pressure (SBP) by 5-20mmHg/10Kg 1. Adapting the (DASH) diet can lower SBP by 8-14mmHg. Reducing dietary salt intake can lower SBP by 2-8mmHg. Limiting alcohol intake can lower SBP by 2-4 mmHg 1. Maintaining aerobic exercises for 30 minutes/day can lower SBP by 4-9mmHg 1. With the provided benefits of cheap, easy, and simply understandable lifestyle modifications, the use of pharmacological medications can be minimized or delayed. This will reduce the occurrence of many problems associated with polypharmacy and spread the culture of having a healthy lifestyle in the community 1.

According to multiple studies, a population between 15-24 has a HTN prevalence of 3.2%, a Population between 55-64 has a prevalence of 51.2% and up to 70% in individuals above the age of 65 and older 3. The prevalence among men was 28.6% and 23.9% among women 4. In addition, 15.2% of adults in Saudi Arabia are hypertensive, 57.8% of those adults were unaware of their diagnosis and 78.9% of those who are aware of their diagnosis reported compliance with their medication 5.

We need to find out whether patients adhere to lifestyle modifications or not. We also need to determine the main factors and pitfalls to why some patients do not adhere to lifestyle modifications and which modifications are difficult to adhere to and why? By achieving this, we can assist healthcare providers to develop targeted self-management educational programs for people with hypertension. Covering these factors will ensure more success in enhancing the use of lifestyle modifications as the first-line management in hypertension.

This study aims to detect the adherence of hypertensive patients to lifestyle modifications in the management of their hypertension in Medina, Saudi Arabia. And to assess the adherence of primary care physicians to prescribing lifestyle modifications. It also aims to scan the current health care system in hope of identifying factors that affect hypertensive patients and their management negatively. We hope that this will help in guiding future studies, guidelines, or protocols related to the management of hypertension.

Materials and methods:

Study Setting: Medina is a province in western Saudi Arabia along with the Red Sea coast. It has a population of 2,239,923 according to the 2019 census. It is the third-largest region in the Kingdom in terms of surface area and is the fifth largest in terms of population 6.

Study design: This is an observational cross-sectional study. Data collection was conducted in the period from June 06, 2020, to July 06, 2020. The selection was done from 2,239,923 people live in Medina. The sample size was 1569 with a 95% confidence level and 2.48% margin of error.

Sampling Technique: An electronic survey questionnaire was given randomly to the targeted population. By experienced data collectors with a background in the medical field Through different social media platforms.

Inclusion criteria included patients with primary hypertension, aged 18 years and older from both sexes who are under follow-up by a family physician at PHC clinics.

Exclusion criteria included patients who have secondary hypertension and patients who have been diagnosed or are followed up at a secondary or tertiary care hospital.

Variables: The questionnaire has been formulated and designed with a consistent structure and relations between the questions to meet the study goal. It contains four main sections, the first section contains demographic data (gender, age, nationality, occupation status, residency, and educational level). The second section includes the current management plan of the patients, the compliance, and complications. The third section includes the patient’s awareness about the health benefits of lifestyle management and the doctor’s adherence to providing lifestyle modification advice. The last section assesses the adherence to non-pharmacological and pharmacological management of high blood pressure.

The criteria for awareness about lifestyle modifications in hypertension management were drawn from 5 questions designed on a five-grade scale starting from 0– 5 points which generally means that the higher the score, the higher the awareness toward lifestyle modifications in hypertension management. And by using the mean score as a cutoff point to determine the level of knowledge. A score above the mean was considered as good knowledge and a score equal to or below the mean was considered as poor knowledge.

Meanwhile, the criteria for the knowledge toward hypertension control and the knowledge provided by the doctor were drawn from 5 questions and 3 questions, respectively, and had been discussed in Table 2. Each question has a response of “yes” coded as 1 and “no/I don’t know” coded as 0. The total score had been generated by adding all questions related to the knowledge toward HTN control and related to the knowledge provided by the doctor. The total score of the knowledge toward HTN control has a score range from 0 – 5 points while the knowledge provided by the doctor has a score range of 0 – 3 points which generally means that the higher score, the higher the knowledge toward HTN control and information provided by the doctor. And by using the mean score as the cutoff points to determine the level of knowledge. A score above the mean was considered as good knowledge and a score equal to or below the mean was considered as poor knowledge.

Statistical Analysis: Quantitative data are presented using means, Standard Deviation (SD), and median (min-max) as appropriate. Qualitative data are presented using counts and proportions (%). In comparisons, the Chi-square test, Mann-Whitney U test, and Kruskal Wallis test were applied. Normality tests were conducted using the Shapiro-Wilk test as well as the Kolmogorov-Smirnov test. The data follow an abnormal distribution. Thus, non-parametric tests were applied. Furthermore, the correlation between the knowledge and practices score was also performed to determine each linear relationship. A p-value of <0.05 (two-sided) was used to indicate statistical significance. All data analyses were performed using the statistical package for social sciences, version 21, Armonk, New York, IBM Corporation, USA.

Ethical Consideration: A statement of ethical approval has been granted by the Scientific Research Ethics committee at Taibah University with the number (IORG0008716 – IRB00010413). The date of the decision was 2020/1/21. While collecting the data a message that explained the goal of the study and guaranteed the patient’s privacy after gaining their consent was included. The consent was for participation in the study and publication of data for research and educational purposes.

Results:

The data was collected from 1569 hypertension patients. 91.8% were Saudi and 8.2 were non-Saudi. Most of the participants were female (61.4%). The majority of patients were in the age group 41–60 years (54.7%), 27.1% of the patients were under 40. and 18.3% were older than 60%.

Regarding the level of education, 59% of the participants had a degree of higher education. 35% had a secondary school degree and 6% were illiterate. Employees represented 36.5% of participants, while 28% were housewives, 23.2% of the participants were retired, and 8.5% were students as shown in Table 1.

In figure 1, the age group 51 – 60 years old (31.1%) followed more advice from the doctor regarding lifestyle management of HBP than the other age groups while the advice to the <30 years old group was significantly less (11.2%).

Figure 2 depicted the different ways to control blood pressure. It was found that the most commonly known ways to control blood pressure were reducing salt intake (64.5%), followed by the use of one drug (40.6%) and regular exercise (33.8%) while the least of them was to quit smoking (12.6%).

Table 2 showed the assessment of knowledge toward lifestyle modifications in hypertension management and the knowledge provided by the doctor. It was shown that nearly all patients were aware that eating healthy food and reducing salt intake could help in controlling HBP (89.7% and 92.9%, respectively). Also, 86% and 88.1% were aware that weight reduction and regular exercises could further help in regulating HPB. 93.5% agreed that reducing exposure to stress levels could also help in controlling HBP.

With regards to the knowledge provided by the doctor, 73.2% reported that their doctor provided them with the general information about HBP, 70.3% indicated that their doctor provided them with information regarding the non-pharmacological treatment options to control HBP, while participation in a trial to lower down blood pressure before taking medication was lacking (41.7%).

According to the results of the assessment of practice toward hypertension management 24.9% had tried to take the recommended daily fiber intake all the time. However, the majority only did so sometimes 56%. Also, 54.7% of the participants were exercising some of the time, while 19.2% always exercised regularly. Besides, 71.4% of the patients had attempted to lose weight while 74.6% had tried to manage their stress levels.

The descriptive statistics of the knowledge and practices toward lifestyle modifications in HTN management have been described in Table 3 and Figure 3. Based on the results, it was found that the score of knowledge towards lifestyle modifications was 3.57 (SD 0.75) out of 5 points. Poor and good practice was identified among 9.6% and 90.4% of patients, respectively. In regards to the knowledge provided by the doctor; the mean score was 1.85 (SD 1.08) out of 3 points. Out of this score, 33.7% and 66.3% were classified into a poor and good level respectively. Finally, with regards to the practice of lifestyle modifications in HTN management, the mean score was 3.45(SD 1.55) out of 6 points. 46% and 54% were classified as poor and good levels of practices towards HTN control, respectively.

When measuring the association between the knowledge toward lifestyle modification in HTN Control and the practices toward lifestyle modification in HTN control in relation to the socio

demographic characteristics of the patients, we have found that being older than 50 years (P-value 0.021), having a high school degree (P-value <0.001), or being unemployed (P-value <0.001) are all significant factors that might decrease your practices towards lifestyle modification in HTN control as shown in Table 4.

Discussion:

Our study investigated the level of practice of lifestyle modifications (LSM) and the physician's adherence to giving LSM advice as a part of HTN management. We have found that 90.4% of our study population had good knowledge of LSM in HTN management, while 54.0% had a good level of practice towards LSM in HTN management. Nonetheless, Studies in Eastern and Southern Ethiopia showed a higher level of knowledge with a poor practice level regarding LSM in HTN management 7,8. Another study in Kuwait also reported, that more than 60% of their participants didn’t adhere to LSM advice 9. In Addis Ababa, a study found that only 23% adhered to LSM 10. Some of the studies that were held in Ethiopia 11 and Nigeria 12 found that more than 50% of their subjects had a good knowledge level of LSM in HTN management. Which is in line with the results of our study. On the other hand, a study held in Egypt showed that only 8.9% had a good level of knowledge about LSM 13.

Among the population of our study, people who were 50 years or less had better knowledge and practice towards LSM than people aged more than 50 years, this is contrary to the findings of the Ethiopian study which found that practice towards LSM among the old age population is six times higher than the younger age groups 10. This could be dependent on the other covariates and the demographical differences between people living in Saudi Arabia and Ethiopia. However, we believe that more access to online information and better flexibility of adapting new habits made it easier for younger age groups to have a better practice of LSM.

The results showed that employed people had a better practice of LSM than unemployed individuals and students, while students had better knowledge than employed and unemployed people. This also can be viewed in the Ethiopian study where they noticed that employed respondents were better at adhering to LSM 10.

People with a university degree or higher were found to have better knowledge and adherence to LSM than people with a high school degree or below. These findings are consistent with the study that was done in Taif 14. These results can be an indication that the higher the educational level, the better the knowledge about the importance of LSM in managing hypertension.

When patients were surveyed about how they manage their hypertension, (64.5%) reported that they are reducing dietary salt intake as a non-pharmacological measure to control hypertension, while (33.8%) used regular exercise to manage their hypertension. This can be compared with a study done in Baltimore, United States, where they found that 75% of participants reported that they reduced their salt intake, and nearly 50% committed to regular exercise 15. in Saudi Arabia, a systematic review of inactivity prevalence conducted in the year 2018 found that most Saudi children, youth, and adults were not active enough to meet the recommended guidelines 16.

It is clear that the number of participants who exercise regularly to manage their high blood pressure is low, therefore, primary health care physicians should emphasize the importance of physical activity as an essential method to control hypertension and prevent its complications.

The gap between knowledge and practice could be explained by cultural and environmental factors, such as excessive social events, increased dependency on maids and cars which lead to decreased daily activities. Also, lack of time, easier accessibility, and lower cost of fast food compared with healthier options in addition to long summers. These factors are like those found in a study held in Kuwait 9.

When patients were asked about physicians’ prescription of LSM, 66% of our sampled group had a good level of knowledge provided to them by a doctor which is low in comparison with a study held in Asser, and another held in Nigeria where most physicians (more than 80%) prescribed LSM 17,18.

This study has several strengths as it used an electronic questionnaire to collect the data needed to achieve its target. which facilitated acquiring a large enough sample to reduce the probability of the results being due to chance making them more accurate and valid. The questionnaire is also a reliable tool to collect data since the questions were standardized in their phrasing to provide easier understanding for participants. This study is limited to the PHC setting and PHC-related healthcare specialties. This study may not be helpful in other settings or specialties. The study methodology involves self-reported measures which are highly dependent on the participant’s memory and recall bias may occur.

Conclusion:

The study showed that there is a higher level of knowledge (90.4%) than practice (54.0%) towered lifestyle modifications among hypertensive patients, this gap could be due to cultural, social, and environmental factors. most of the participants managed their hypertension non-pharmacologically by reducing salt intake. physician’s adherence to prescribing lifestyle modifications was low in comparison to other studies. Multiple health disciplinary efforts are needed to improve adherence to lifestyle modification in hypertensive management.

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