Methodology Results Discussion If you did not seek treatment for your illness,

251 Improving Blood Pressure Controls in Primary Care Settings ABSTRACT Improving Blood Pressure Controls in Primary Care Settings Zarina Baharin 1 , Fauziah Ahmad 2 , Syah Izaini Khalib 3 , Marina Kamaruddin 4 , Amar-Singh HSS 5,8 , Sondi Sararaks 6 , Ranjit Kaur Praim Singh 7 , Morni Fauziah Ahmad 1 , Asmah Zainal Abidin 7 1 Perak Tengah Health District Office 2 Kerian Health District Office 3 Manjung Health District Office 4 Gerik Hospital 5 Clinical Research Centre Perak 6 Institute for Health Systems Research 7 Perak State Health Department 8 Hospital Raja Permaisuri Bainun Ipoh Introduction Hypertension is a major public health problem with a high prevalence. There are many barriers to the effective management of patients with hypertension including specific physician and patient factors. In this study we reported a provider and community intervention to improve blood pressure control among essential hypertension patients in the primary care setting. Methodology This was a controlled community trial to assess the effectiveness of an intervention targeted at health care providers and patients. Health clinics that participated were from three semi-urban locations in Malaysia. In each district, 2 clinics were chosen for intervention and 2 clinics for control. 339 patients were interviewed and a focus group discussion held with paramedics and medical officers to identify basic knowledge of hypertension and problems in managing patients with hypertension. From this data an interventional package was developed. Multiple cross-sectional surveys on blood pressure control were done at baseline and monthly for 4 consecutive months post intervention. Results A total of 3,000 patients were sampled at baseline and 1 to 4 post intervention assessments. There was a significant improvement in the proportion of patients whose blood pressure was treated to target at 1 month post intervention as compared to baseline. This improvement was sustained over four consecutive months in the clinics with intervention. Blood pressure treated improved from 44 at baseline to 66 at 4 months post intervention. The percentage of blood pressure treated to target was significantly improved among females and those aged less than 60 years. 252 Improving Blood Pressure Controls in Primary Care Settings Conclusion The interventional package in this study has significantly improved the blood pressure controlled in patients with essential hypertension in a busy primary care setting. Keywords blood pressure to target, primary care, hypertension, community trial, health care provider 253 Improving Blood Pressure Controls in Primary Care Settings

1.0 INTRODUCTION

1.1 Background

Hypertension is a major public health problem due to its high prevalence with the lack of awareness amongst the general population and its poor control impacting on cardiovascular morbidity and mortality. Hypertension is common and is one of the causes that contribute to strokes, heart attacks and premature death. The rule of halves states that only half of the patient diagnosed with hypertension receives treatment, of which only half have well controlled blood pressure. There is also considerable evidence of deficiency in patient management. The National Health and morbidity Survey 1996 showed that 30 of Malaysians above 30 years of age have hypertension. The prevalence seen was similar to those in developed country, for example in US the prevalence of hypertension among non-institutionalized adults aged 20 and over was 30 . Among the people who are diagnosed with hypertension, only 18 of them with well-controlled blood pressure. Those detected to have hypertension, their blood pressure often remained uncontrolled because they failed to comply with or dropped out from treatment Lim TO 1991; Lim TO 1992. The primary goal in treating hypertension is to achieve optimal blood pressure levels, thereby reducing the risks of cardiovascular morbidity and mortality Hassan et al 2005. It is known that lowering blood pressure reduced stroke by 40; myocardial infarction by 25 and heart failure by 50. Compliance describes the extent to which a person’s behaviors coincided with medical advice. Compliance had been evaluated from a wide range of scientific and clinical perspectives since 1950s. Compliant patients are defined as those who accept their physician’s advice to start drug therapy and take their medication at least 80 of the time.

1.2 Problem Statement

From the results of the National Health and Morbidity Survey 1996, among the hypertensive, 33 were aware of their hypertension, 23 were currently on treatment, however only 6 had controlled blood pressure. The distribution of blood pressure based on JNC V classification showed that 17 had high normal, 20 had Stage 1, 8 had Stage 2 and 4 had Stage 3-4 hypertension. As we know that hypertension is a major risk factor for cardiovascular disease Kannel WB, 1996, it is greatly important to have adequate blood pressure control so as to prevent these complications. 254 Improving Blood Pressure Controls in Primary Care Settings To achieve this, concerted public health effort is required to detect, treat and control hypertension in the community, as shown by the experiences of many countries Henauw et al., 1998; Kastarinen et al., 1998; Burt et al., 1995.

1.3 Problem Analysis

Inadequate blood pressure control among essential hypertension patients is contributed by many factors Figure 1. The factors include: 1. Health care provider factors, such as lack of knowledge, attitude problem, time constraint and lack of staff. 2. Patient factors, such as age, lack of awareness, ignorance, financial, family support and compliance. 3. Lack of specific hypertension programmed, such as specific health education, hypertension resource centre, hypertension registry and screening for target organ damage. 4. Provision factors, such as lack of availability of certain drugs in health centers, lack of equipment and financial constraint. Figure 1. Problem Analysis Chart showing factors that affecting the blood pressure control in essential hypertension patients in primary care setting. Poor Understanding of illness Side effects of drugs Ignorance Polypharmacy Illiterate Logistics Family support Health education Age Lack of awareness Poor compliance Financial factor Patient factor Lack of equipment Financial constraint Wrong choice of drugs Health provider Time constrain Complicated CPG Personal factor Attitude problem New staff Lack of staff Availability of drugs in health centre Lack of knowledge Provision factor Lack of hypertension specific programme Screening for TOD TOC Hypertension resource centre Hypertension registry Lack of commitment Why BP control is inadequate in primary care setting?