Multicenter study of blood pressure control and its determinants in 1004 hypertensive patients followed in primary health care facilities in Settat/Morocco

Type and location of study

This is a cross-sectional analytical study conducted over a period of 11 months, from 01 March 2023 to 02 February 2024, in 12 urban health centers and 9 rural health districts in Settat city [2].

Study population

Inclusion criteria

Hypertensive patients diagnosed with essential hypertension for at least six months before the start of the study, aged 18 and over, on antihypertensive treatment and living in Settat city.

Exclusion criteria

Women with gestational hypertension and hypertensive patients with mental disorders.

Sampling method and sample size

The sampling adopted in this study is probabilistic. The survey was carried out among all hypertensive patients followed up in the PHCFs of the province of Settat as part of medical-nursing follow-up. Based on the Lorenz formula developed by Cochrane⁸ and Ardilly⁹:

Data collection tools

Structured questionnaire

Data were collected by face-to-face interviews with patients using a structured questionnaire based on the scientific literature and validated by experts in public health and cardiology. We contacted doctors and teacher-researchers who are members of the care and health of the population and the environment research team of the Health Sciences and Technologies laboratory at the Higher Institute of Health Sciences at Hassan First University.

To test the clarity and ease of understanding of the questionnaire, a pre-test was carried out with a representative sample of the target population consisting of 30 people¹⁰ excluded from the final study sample. The survey explored several aspects, including:

Socio-demographic and economic data

Age, sex, marital status, level of education, professional status and the presence of medical cover. For monthly household income, we used the classification proposed by the High Commission for Planning (HCP).¹¹

Patients’ knowledge of hypertension

This section was devoted to assessing patients’ knowledge of the signs of hypertension, the hygiene and dietary measures essential to its management, and its major complications.

Clinical and therapeutic characteristics of patients

Duration of hypertension and circumstances of diagnosis, family history and comorbidities. We assessed patients’ behavior and lifestyle, looking for tobacco and alcohol consumption, the presence of stress, whether they followed a low-salt diet, and whether they had self-measured blood pressure at home.

carrying out the biological tests requested

The check-up was considered ‘completed’ if it had been carried out within 3 months or less of the date of our interview. This deadline was chosen because it generally corresponds to the period recommended by doctors for follow-up appointments.

Accessibility and care offered by PHCFs

This section aimed to determine whether patients had benefited from therapeutic education within the PHCFs, particularly with regard to the definition of hypertension and its potential complications. We also explored the geographical accessibility of the various PHCFs, the availability of different antihypertensive drugs, the frequency of follow-up consultations and, finally, we assessed patients’ general satisfaction with the services offered in these health centers.

Physical activity measurement

The level of physical activity (PA) was determined using the Global Physical Activity Questionnaire (GPAQ), recommended by the WHO for population surveys. This tool includes 16 questions covering the following areas: activities at work, travel activities and leisure activities. The aim is to determine the PA profile of patients according to these three levels: low, medium and high.¹²

Assessing compliance with medication

Adherence to medication was assessed using the validated Girerd test, commonly used in primary care to measure adherence to treatment in chronic patients. This questionnaire consists of 6 closed questions on the likely difficulties associated with taking antihypertensive medication. Responses are dichotomous (‘Yes’ or ‘No’); a positive response to one or two questions indicates a minor adherence problem, while three or more positive responses indicate poor adherence.¹³

Anthropometric measurements

Weights were measured using an electronic scale accurate to 100g, and patients’ barefoot heights were measured using a wall-mounted scale accurate to one tenth of a centimeter. Waist and hip circumferences were measured using a tape measure graduated in millimeters. Patients’ nutritional status was assessed by calculating their body mass index (BMI) according to the WHO classification.¹⁴ Abdominal obesity (AO) was defined as a waist circumference greater than 88 cm in women and greater than 102 cm in men.¹⁵ The waist to hip ratio (WHR) was considered normal if it was <0.85 in women and <0.90 in men.¹⁶ By combining BMI and OA parameters, we classified hypertensive patients into two levels of cardiovascular risk: low or high.¹⁷

Blood pressure measurements

To measure blood pressure, we followed the recommendations of the European Society of Cardiology:

After 15 minutes’ rest, patients were placed in a seated position, with their backs resting against a chair, their arms at heart level and their feet flat on the floor, without crossing them. Patients were asked to remain calm and avoid talking during the measurement. Blood pressure was measured using an electronic blood pressure monitor (Microlife BP A2 Basic), fitted with a cuff suitable for adults and obese people. Two measurements were taken 2 minutes apart on the arm with the higher values, and the blood pressure was taken as the mean of the two values. To meet the objectives of the study, patients were classified in the ‘uncontrolled hypertension’ group if their systolic blood pressure (SBP) was greater than or equal to 140 mmHg and/or if their diastolic blood pressure (DBP) was greater than or equal to 90 mmHg.¹⁷ We then explored and compared the demographic characteristics, clinical and therapeutic data, behavior and lifestyle of patients in the two groups.

Statistical analysis

The data were entered and analyzed using SPSS software (version 27). The normality of quantitative variables was verified using the Kolmogorov-Smirnov test. Variables with a normal distribution were expressed as mean ± standard deviation and compared using Student’s t test, while qualitative variables were analyzed in terms of numbers and percentages using the Chi-2 test or Fisher’s exact test. Risk factors for UBP were identified using univariable logistic regression, followed by multivariable analysis for significant variables (p<0.05), with a threshold of 5% for final variable selection.

Ethical considerations

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Biomedical Ethics Committee of the Faculty of Medicine and Pharmacy of Casablanca, Hassan First University under reference number 04/2023. Authorization to access and analyze patients’ medical records was also granted by the regional health authorities of the city of Settat. All data were anonymized prior to analysis to ensure confidentiality and respect for the privacy of participants. The patients surveyed were asked to give their verbal consent to participate in the study.

Results

The mean age was 60.08 (±12.85) with extremes ranging from 29 to 99 years and a marked predominance of women representing 75.1% (745) of the sample. 60.15% of participants were from urban areas. The majority of participants were married 71.30% (716), while 54.10% (543) of patients were illiterate, and 87.1% (874) were unemployed. A minority of patients (2.1%, 21) had no medical cover. More than half of the participants (51.90%, 521) reported receiving more than 2,000 dirhams per month (DHS/month). The distribution of patients according to their socio-demographic characteristics and blood pressure control status ( Table 1) revealed a significantly higher proportion of uncontrolled hypertension among patients living in urban areas, women, elderly subjects and those with a low socioeconomic level.

Most patients had a good understanding of the various aspects of hypertension. In fact, 94.30% (947) knew the signs of hypertension, 98% (984) were able to cite the essential dietary hygiene measures, and 82.40% (827) had knowledge of the potential complications of hypertension. The study of clinical and therapeutic data revealed that 68.60% (689) of patients had been hypertensive for 5 years or more, 57.80% (580) had a family history of hypertension, and 67.30% (676) were at cardiovascular risk. The nutritional status of the participants was in favor of overweight/obesity in 59.10% (594). With regard to the type of antihypertensive medication used, almost all patients 81.50% (818) were on monotherapy. The distribution of patients according to their clinical and therapeutic characteristics and blood pressure control status ( Table 2) showed a significantly higher proportion of uncontrolled hypertension in patients with a long history of the disease, diabetics, overweight subjects and those with associated heart disease.

The study of patients’ lifestyles revealed that only 4.4% (44) smoked and 1.4%¹⁴ drank alcohol, with the total absence of these two habits among the women surveyed. 74.40% (747) of participants reported stress, and 49.60% (498) did not follow a low-salt diet. Physical activity was lower than recommended in 46.40% (466) of participants, with a predominance of women in 73.61% (343). Almost all patients (908) did not have their blood pressure measured at home. The biological tests requested were not carried out by 68.80% (691) of participants, while more than half 59.60% (598) showed good adherence to treatment. 51.70% (519) of patients returned for a follow-up visit after 6 months ( Table 3).

Regarding accessibility and services offered at the PHCF, 54.10% (543) of patients confirmed that they needed 30 min to 1 hour to get to their follow-up center. 87.20% (875) of participants stated that they did not receive information on hypertension, while 56.20% (564) did not receive education on its complications. More than half of the respondents (59%, 592) expressed reluctance to discuss personal problems relating to hypertension with their doctor. The availability of antihypertensive in the PHCF was judged differently by hypertensive patients, 21% (211) said they had never found their medication, 55.80% (560) said they rarely found it, while 22.70% (228) often found it and 0.5%⁵ said they always found their medication available. Regarding patients’ satisfaction with the hypertension management services offered in the PHCF, 18.80% (189) were dissatisfied, 45.50% (457) were not very satisfied, 30.10% (302) were satisfied and only 5.6% (56) were very satisfied.

At the bivariable analysis stage, we retained sixteen variables significantly associated with UBP. Multivariable analysis of the previously selected variables revealed the following associated factors: rural residence (OR = 3.13; 95% CI = [2.06-4.74]); advanced age (OR= 1.39; 95% CI = [1. 09-1.63]); low monthly income (OR = 1.37; 95% CI = [1.21-1.56]); high BMI (OR = 1.39; 95% CI = [1.15-1.69]) and poor adherence to medication (OR = 7.24; 95% CI = [5.09-10.31]) ( Table 4).