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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 12  |  Issue : 2  |  Page : 81-84

Knowledge and attitude of general practitioners regarding diagnosis and treatment of hypertension in a Nigerian city


1 Department of Medicine, Lagoon Hospital, Lagos, Nigeria
2 Department of Medicine and General Outpatient, Lagoon Hospital, Lagos, Nigeria

Date of Web Publication30-Jul-2015

Correspondence Address:
Adedeji Kola Adebayo
Department of Medicine, Lagoon Hospital, 8, Marine Road, Apapa, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.152002

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  Abstract 

Background: Hypertension is highly prevalent in sub-Saharan Africa, underlying many of the fatal and non-fatal cardiovascular events.
Objectives: To examine the level of knowledge of primary care physicians in urban Nigeria, as regards to hypertension.
Participants: A cross-sectional survey of general medical practitioners in Lagos, Nigeria was undertaken in the months of July and August 2011 using self-administered semi-structured questionnaires.
Results: There were 74 respondents, 59.5% of whom were men and the bulk of the subjects, 41.9% were in the 30-39 years age range. Duration since graduation of 0-5 years, 56.8% and ≥21 years, 17.6% had the highest respondents. The bulk of the respondents, 90.5% were aware of the existence of guidelines on hypertension but 35.1% were not familiar with the details of any guideline. Majority, 97.3% agreed to the usefulness of guidelines and 93.2% correctly identified cut-off values for hypertension. All but one agreed to the need of referral of complicated cases to hypertension experts and would recommend lifestyle modification for all. About 44.6% of respondents generally attended 5 or more continuing professional development (CPD) per year.
Conclusion: Awareness of the existence of guidelines on hypertension and attendance at CPD programs is quite high among general medical practitioners in urban Nigeria. Knowledge of the details of these guidelines however is not as high. Focus on hypertension guidelines in most of the CPDs is recommended considering the public health importance of hypertension.

Keywords: Diagnosis, general practitioners, hypertension, knowledge, knowledge and attitude, treatment


How to cite this article:
Alli FO, Adebayo AK, Anebona A, Ohakume H, Etuwoma I, Soaga A. Knowledge and attitude of general practitioners regarding diagnosis and treatment of hypertension in a Nigerian city. Nig J Cardiol 2015;12:81-4

How to cite this URL:
Alli FO, Adebayo AK, Anebona A, Ohakume H, Etuwoma I, Soaga A. Knowledge and attitude of general practitioners regarding diagnosis and treatment of hypertension in a Nigerian city. Nig J Cardiol [serial online] 2015 [cited 2021 Jan 26];12:81-4. Available from: https://www.nigjcardiol.org/text.asp?2015/12/2/81/152002


  Introduction Top


Hypertension constitutes a global problem underlying many of the cardiovascular morbidity and mortality the world over. [1] Earlier appearance and more severe complications are well-known phenomena in blacks. [2],[3] In the developing countries, the problem is compounded by very poor and healthcare coverage, late diagnosis, and affordability of qualitative healthcare. The problem of under-diagnosis and under-treatment of hypertension is indeed a worldwide problem, [4],[5],[6],[7] but expectedly this may be more accentuated in sub-Saharan Africa because of the other confounding problems alluded to earlier. Although much of the information on hypertension complications and severity are derived from studies and observations of blacks in diaspora, it is known that the pattern is similar in sub-Saharan Africa. Major factors identified for under-treatment of hypertension are: Patients factors as it relates to poor drug compliance which many times is related to poor understanding of therapy and poverty; [5] and of course physicians inertia [8],[9] which may have its root in lack of familiarity with existing practice guidelines. The poverty of healthcare resources and low doctor to patient ratio in this region of practice may stretch the medical facilities and practitioners leading to very little time or resources to spare for continuing professional development. We believe strongly that the level of the knowledge and the attitude of medical practitioners to management of hypertension are pertinent to its accurate diagnosis and effective treatment. We therefore aim to explore the attitude and knowledge of primary care physicians in Urban Nigeria taking Lagos as example. This is particularly relevant since the medical regulatory bodies in this region have recently begun to or are planning to insist on evidence of attendance and participation at continuing professional development courses for renewal of practicing licenses of medical practitioners.


  Materials and methods Top


A cross-sectional survey of general medical practitioners in Lagos was undertaken in the months of July and August 2011 using self-administered semi-structured questionnaires. Respondents were drawn mainly from attendees at enlightenment forum on hypertension for general practitioners in Lagos Nigeria and also practitioners at medical centers in the local government areas in Lagos. A total of 92 questionnaires were sent out, of which 74 (80.4%) was available for analysis. The questionnaire contained personal detail of respondents such as age range, gender, and year since graduation from medical school, nature of practice-private or public or mixed, ranges of average number of subjects with hypertension seen per week and average number of continuing professional development (CPD) sessions attended per year. Other details requested were: Awareness of availability of practice guidelines; familiarity with the details of any practice guideline; whether guidelines are useful in the treatment of hypertension; cut-off values for hypertension as ≥140/90 mmHg blood pressure (BP) value; need for counseling on lifestyle modification for all subjects with hypertension; need for referral of complicated cases to specialists; need for immediate pharmacologic treatment for subjects with established cardiovascular disease at diagnosis; initial choice of antihypertensive including calcium channel blockers and/or diuretics subjects with uncomplicated hypertension within this population group; goal of treatment in uncomplicated hypertension being ≤140/90 mmHg; whether anti-hypertensives should be discontinued when the goal of normal or near normal BP is achieved.

Statistical analysis

Data generated were entered into a standard profoma. Analysis was performed using the statistical package of social sciences (SPSS) software version 15.0 (SPSS Inc., Chicago Ilinois, USA). Proportions in the data are expressed as count (percentage). Knowledge of details of guideline in relation to age range and year since graduation from medical school was further examined with the chi square test for trends among the respondents. A two-tailed P value P < 0.05 was considered to be significant.


  Results Top


The baseline characteristics of the respondents are detailed in [Table 1]. One of the respondents did not indicate the gender. The bulk of the remaining 73 respondents, 59.5% were males and the age range of 30-39 years accounted for 41.9% of the respondents. More than half (58.1%) of the study population practiced in the private sector while a combination of practitioners in the public sector with others who had a mix of practice in the private and in the public sectors accounted for the remaining 41.9%.
Table 1: Baseline characteristics of the respondents

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Majority of the respondents, 97.3% and 90.5% agreed to the usefulness of practice guidelines for effective treatment of hypertension and were aware of the availability of practice guideline respectively. However, 35.1% were not familiar with the details of any of these practice guidelines.

The cut-off value of hypertension as ≥140/90 mmHg was agreed upon by 93.2% of the respondents while 1.4% were not sure of the cut value, another 1.4% disagreed with the suggested cut-off value, 4.1% submitted that cut-off value for hypertension would be dependent on the patient's age. All but one of the respondents agreed that complicated cases of hypertension should be referred to hypertension experts and that there is the need for counseling on lifestyle modification in all subjects with hypertension. All but one of the respondents agreed on the need for immediate pharmacotherapy for subjects with hypertension and established cardiovascular disease. Furthermore, 87.8% of the respondents concurred on Calcium channel blockers or diuretics being first choice medications for indigenous subjects with hypertension. On the other hand, 8.1% disagreed with the suggested initial choices while 4.1% were undecided. The same proportion of 91.9%, would continue their patients on antihypertensive medications even at normal or near normal blood pressure. However, 6.8% would discontinue antihypertensive medications and 1.4% was undecided. The suggested therapeutic target of <140/90 mmHg for uncomplicated cases of hypertension, was agreed to by 79.7% of respondents, while 18.9% disagreed and 1.4% was unaware of any treatment target.

Of all the respondents, 35.2% attended to up 20 or more subjects with hypertension per week, while all attend at least 1 CPD course per year. Amazingly, 44.6% attended at least five courses in a year. [Table 2] and [Table 3] shows that there is nothing to choose in the knowledge base of the respondents either based on duration since graduation from medical school or based on the type of practice.
Table 2: Awareness of the details of hypertension guideline by years from graduation

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Table 3: Awareness of details of hypertension practice guideline by type of practice

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  Discussion Top


In the study, more than half of the respondents are private medical practitioners with a combination of practitioners in the public medical facilities and those who combined public and private practice making the up the rest. The bulk of the respondents also fall within the age 30 to 59 years which could be taken as the likely age range of many of the active independent medical practitioners. Positive responses on issues like awareness of existence of practice guidelines, usefulness of guidelines, blood pressure cut-off values defining hypertension is high. The surprising findings are those of lack of awareness of details of hypertension practice guidelines by about a third of the respondents despite the high attendance rate at continuing medical education courses.

Hypertension diagnosis, treatment, and adequate control continue to be a subject of concern the world over. We found that about 1 out of 3 of respondents attend to 20 or more subjects with hypertension per week. This is pointer to high burden of hypertension in the primary health care setting. In a study in Germany, it was estimated that up to 700,000 subjects with hypertension are seen daily by primary care practitioners with an abysmal control rate of about 19%. [10] In a household survey in Nigeria, hypertension was found to be highly prevalent in the community with poor awareness of high blood pressure status and a woeful 5% blood pressure control rate in men and 17.5% in females. [11] A hospital-based study documented a better rate of control of 35.8% in subjects with hypertension receiving care in a tertiary care facility. [12] This rate is however still very poor.

In a hospital-based study in Nigeria, it was shown that evidence of target organ damage was present at the time of first documented diagnosis of hypertension. [13] While ignorance, accessibly and affordability of medical care may be contributory, it is also likely that some of these people have actually had previous contacts with medical facilities. The study in question did not look into the issue of recent contact with any medical facility in the subjects. Treatment and follow up could have been hindered by lack of awareness on the part of medical practitioners. Previous studies have shown that compliance with antihypertensive medication is very poor among subjects suffering from hypertension and this is coupled with extensive use of complementary and alternate medications. [14] Affordability, patient attitude, and belief remain a major problem, but one study alluded to physician related factors as also playing a prominent role as per compliance with medications and BP control. [15] Furthermore, failure to intensify antihypertensive medications is another strong link in the chain of widespread poor BP control which is dependent almost entirely on physician's knowledge and attitude. [16] In our study, some respondents were unaware of the precise definition of hypertension. A few of the respondents were of the opinion that definition of hypertension was age dependent. Also of note is the fact that 6.8% of the respondents in our study would discontinue antihypertensive medications at normal or near normal blood pressure values. Hence, of the population that is controlled on treatment, some run the risk of having their medications discontinued by their primary care physicians. A region wide survey carried out in Italy with over a thousand respondents showed significant awareness of details of hypertension guideline in only 20.1% of respondents. [17] The self-reported value appear higher in our study but taken in the light of our study being limited to one of the most urbanized city in our country, much smaller study population, coupled with the fact that significant details were not requested in our questionnaires, we can only conclude that the jury is still out regarding the accurate figure for our environment.

Recently, a study in Dakar corroborated the high incidence of hypertension in native Africans especially in the older adults, 50 years and over. Only about half of the subjects with high BP were aware of their blood pressure status and of the 70% on treatment, the control rate was an appalling 17%. [18] Recent surveys in Nigeria have also reemphasized the persisting burden of hypertension in Nigerian communities. [19],[20] The glimmer of hope stems from a survey in the United States of America in which it was shown that with well motivated physicians and patients, an excellent BP control rate is achievable. [21] This finding is particularly important since the excellent control was achieved in much older adults in whom BP control is generally more challenging.

Limitation of the study

The relatively low sample size and the non random sampling method in this study are acknowledged as potentially capable of introducing bias and diminishing from the strength of the findings from this study. It would be desirable to follow-up with a randomized and possibly nationwide survey.


  Conclusion Top


Taking the public health importance of hypertension, the physician's role in patient education and treatment, and the identified gap in primary care physician's knowledge and attitude as identified in this study, it is would be desirable to devote some effort to physicians' training through incorporation of this training into the continuing professional development programs organized to update physicians and facilitate certification to continue to practice.


  Acknowledgment Top


We thank the secretariat staff of the department of Medicine for assisting with the typesetting of the questionnaires, also, the management of the hospital for general logistic support.

 
  References Top

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Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: Analysis of worldwide data. Lancet 2005;365:217-23.  Back to cited text no. 1
    
2.
Aviv A, Aladjem M. Essential hypertension in blacks: Epidemiology, characteristics, and possible roles of racial differences in sodium, potassium, and calcium regulation. Cardiovasc Drugs Ther 1990;4:335-42.  Back to cited text no. 2
    
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Flack JM, Ferdinand KC, Nasser SA. Epidemiology of hypertension and cardiovascular disease in African Americans. J Clin Hypertens (Greenwich) 2003;5:5-11.  Back to cited text no. 3
    
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Abdulle AM, Nagelkerke NJ, Abouchacra S, Pathan JY, Adem A, Obineche EN. Under- treatment and under diagnosis of hypertension: A serious problem in the United Arab Emirates. BMC Cardiovasc Disord 2006;6:24.  Back to cited text no. 4
    
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Wagner EH, Slome C, Carroll CL, Warner JT, Pittman AW, Pickard CG, et al. Hypertension control in a rural biracial community: Successes and failures of primary care. Am J Public Health 1980;70:48-55.  Back to cited text no. 5
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Wang TJ, Vasan RS. Epidemiology of uncontrolled hypertension in the United States. Circulation 2005;112:1651-62.  Back to cited text no. 7
    
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Gil-Guillen V, Orozco-Beltran D, Perez RP, Alfonso JL, Redon J, Pertusa-Martinez S, et al. Clinical inertia in diagnosis and treatment of hypertension in primary care: Quantification and associated factors. Blood Press 2010;19:3-10.  Back to cited text no. 8
    
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Asai Y, Heller R, Kajii E. Hypertension control and medication increase in primary care. J Hum Hypertens 2002;16:313-8.  Back to cited text no. 9
    
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Sharma AM, Wittchen HU, Kirch W, Pittrow D, Ritz E, Goke B, et al. HYDRA Study Group. High prevalence and poor control of hypertension in primary care: Cross-sectional study. J Hypertens 2004;22:479-86.  Back to cited text no. 10
    
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Ekwunife OI, Udeogaranya PO, Nwatu IL. Prevalence, awareness, treatment and control of hypertension in a Nigerian population. Health 2010;2:731-5.  Back to cited text no. 11
    
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Salako BL, Ogah OS, Adebiyi AA, Adedapo KS, Bekibele CO, Oluleye TS, et al. Unexpectedly high prevalence of target-organ damage in newly diagnosed Nigerians with hypertension. Cardiovasc J Afr 2007;18:77-83.  Back to cited text no. 13
    
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Osamor PE, Owumi BE. Complementary and alternative medicine in the management of hypertension in an urban Nigerian community. BMC Complement Altern Med 2010;10:36.  Back to cited text no. 14
    
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Amira CO, Okubadejo NU. Factors influencing non-compliance with anti-hypertensive drug therapy in Nigerians. Niger Postgrad Med J 2007;14:325-9.  Back to cited text no. 15
    
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Ferrari P, Hess L, Pechere-Bertschi A, Muggli F, Burnier M. Reasons for not intensifying antihypertensive treatment (RIAT): A primary care antihypertensive intervention study. J Hypertens 2004;22:1221-9.  Back to cited text no. 16
    
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Cuspidi C, Michev I, Meani S, Severgnini B, Sala C, Salerno M, et al. Lombardy Regional Section of the Italian Society of Hypertension. Awareness of hypertension guidelines in primary care: Results of a regionwide survey in Italy. J Hum Hypertens 2003;17:541-7.  Back to cited text no. 17
    
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Macia E, Duboz P, Gueye L. Prevalence, awareness, treatment and control of hypertension among adults 50 years and older in Dakar, Senegal. Cardiovasc J Afr 2012;23:265-9.  Back to cited text no. 18
    
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Ogah OS, Madukwe OO, Chukwuonye II, Onyeonoro UU, Ukegbu AU, Akhimien MO, et al. Prevalence and determinants of hypertension in Abia State Nigeria: Results from the Abia State Non-Communicable Diseases and Cardiovascular Risk Factors Survey. Ethn Dis 2013;23:161-7.  Back to cited text no. 19
    
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Andy JJ, Peters EJ, Ekrikpo UE, Akpan NA, Unadike BC, Ekott JU. Prevalence and correlates of hypertension among the Ibibio/Annangs, Efiks and Obolos: A cross sectional community survey in rural South-South Nigeria. Ethn Dis 2012;22:335-9.  Back to cited text no. 20
    
21.
Fletcher RD, Amdur RL, Kolodner R, McManus C, Jones R, Faselis C, et al. Blood pressure control among us veterans: A large multiyear analysis of blood pressure data from the veterans administration health data repository. Circulation 2012;125:2462-8.  Back to cited text no. 21
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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Introduction
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