Abdul-Aziz F. Alkabbaa
Consultant Family Medicine,
Associate Dean for Academic Affairs,
Faculty of Medicine,
King Saud Bin Abdul-Aziz University for Health Sciences,
King Fahad Medical City, Riyadh,
Saudi Arabia

Hypertension is a chronic condition that causes serious morbidity and mortality in many countries, including Saudi Arabia. The associated socioeconomic burden on the individual, family, and community is tremendous. Worldwide surveys show that the prevalence of hypertension varies widely in different countries, ranging from 3.4% in men in rural India to 72.5% in women in Poland(1). The overall worldwide prevalence among the adult population is reported to be 26.4% (26.6% and 26.1% for men and women, respectively). Should the current trend continue, the prevalence is projected reach 29.2% (29.0% and 29.5% for men and women, respectively) by the year 2025, totaling about 1.6 billion cases. Two-thirds of cases will occur in developing countries(2).

Rapid socioeconomic development in Saudi Arabia, with extensive expansion of educational and health facilities programs (including environmental health), has led to a reduction in the incidence of communicable diseases. As a result, awareness of the public health importance of chronic non-communicable diseases, such as hypertension, has increased. Hypertension is responsible for a large proportion of outpatient consultations. Obtaining reliable information about the prevalence of hypertension and associated factors is crucial for developing a comprehensive strategy for preventing and controlling hypertension.

North West Armed Forces Hospital Program (NWAFH) in Tabuk was established by the Ministry of Defense and Aviation, and it is one of the most modern and well-equipped military hospitals in the kingdom of Saudi Arabia. Providing quality health care services as required for the optimal care and treatment for patients is within the scope of the Saudi Arabian Armed Forces Medical Services Directorate responsibilities. General practitioner services for the military community and hospital employees are provided on an outpatient basis by the Family Medicine Clinics.

The objectives of this study, the first of its nature and magnitude, were to determine the proportion and characteristics of adult patients (18 years of age and older) with hypertension who attended NWAFH Family Medicine Clinics in Tabuk City. The results of the study will help to develop appropriate health policies and programs for preventing, detecting, and controlling hypertension in the community.

The current study was a cross-sectional study, conducted from January 1, 2003 through to December 31, 2003. The study population was all patients 18 years of age and older who attended NWAFH Family Medicine Clinics in Tabuk, Saudi Arabia during the study period. Tabuk City is the Capital of the North West region of Saudi Arabia, and has a population of approximately 500,000.
Stratified systematic random sampling was used to select 10% (14,694) of the Family Medicine Clinic encounters during the study period from the tally sheets used for daily encounter registration. To ensure selection of a random representative sample, the strata included all working days of the week for the entire study period.

Physicians collected the following data from patients' medical records using a pilot-tested data collection form: age; sex; provisional and final diagnosis; referral to specialty clinics in the hospital and feedback; follow up appointments; health education documentation; chronic co-morbidities; smoking status, and the frequency of visits per year.
The study was approved by a research and ethics committee at North West Armed Forces Hospital in Tabuk; permissions were obtained from the appropriate related authorities.

Collected data was checked for completeness before being fed into a personal computer. A double entry method was used to decrease data entry errors. The International Classification of Health Care Problems in Primary Care (ICHPPC-2) was used for disease and health problem classification. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS-10) with the level of statistical significance set at P < .05.

Hypertension was defined according to WHO criteria: systolic blood pressure >140 mmHg or diastolic pressure > 90 mmHg or both, or currently receiving pharmacologic or non-pharmacologic treatment for hypertension.

Of the patient encounters selected (n = 14,694), 556 (3.8%) were excluded due to the incomplete information in some study variables. These patients did not differ significantly from the included patients in age or sex. All of the remaining 14,138 encounters were analyzed. This communication dealt only with subjects who are 18 years or above (n = 7644). The mean age of the adult patients (18 years of age and older) who attended the clinics during the study period was 33.48 years (SD, 13.10; range, 18-97 years).

Table 2: Age and sex distributions of patients with hypertension

Tables 1 and 2 show the age and sex distribution of all subjects and subjects with hypertension, respectively. Of the 7,644 adult patients, 557 had hypertension, giving an overall prevalence of 7.3%. The proportion of women in both groups slightly exceeded that of men (approximately 52%). For both sexes in both groups, more than 80% were younger than 45 years of age and less than 4% were older than 65 years of age. The mean age of all subjects was 33.48 years (SD, 13.10), with women being significantly younger than men (32.8 years versus 34.2 years). Patients with hypertension were significantly older than were patients without hypertension (53.6 versus 33.5 years, respectively). Women were more likely to have hypertension than were men, and women with hypertension were older than men with hypertension; however, these differences were not significant.

*P, P-value; **DF, Degrees of freedom; *** 2, P-value, Chi Square
Table 3: Characteristic of the study population

Table 3 compares the characteristic of patients with and without hypertension. Patients with hypertension received significantly more health education and follow up visits than did patients without hypertension; patients with hypertension were also significantly older. Patients with hypertension were more likely to have diabetes mellitus than were patients without hypertension. Women were affected more than males, but this difference was not significant. Among patients with hypertension, there were no significant sex-related differences for health education, co-morbid diabetes, or follow up visits (Table 4).

*P, P-value; **DF, Degrees of freedom; *** 2, P-value, Chi Square
Table 4: Characteristics of patients with hypertension

Hypertension is one of the most common non-communicable diseases worldwide, including in Saudi Arabia. Our data showed that more women than men attended the clinics during the study period, which follows the pattern typical for primary care clinics in Saudi Arabia(3).

The overall prevalence of hypertension in this study was about 7.3 %. In similar settings for the Ministry of Defense and Aviation and the Ministry of Health, the prevalence of hypertension among attending adult patients ranged from 3.1% to 10% and 2.4% to 30%, respectively(4-6). Recent community surveys showed that the overall prevalence among adults in different regions of the country was 26.1%(7). In other countries in the region, hypertension is estimated to affect 20-32.1 % of adult population(8,9,10,11). Various population-based studies conducted in other developing countries have shown that the prevalence of hypertension ranges from 9% to 30% among adults(12,13). In highly developed countries, the reported prevalence of hypertension among adults ranges from 38% to 55% in Europe and is 28% in North America(14). Making comparisons among these studies is problematic because of the difference in the definitions and methodologies used and the characteristics of the populations studied. Nonetheless, the message is clear: hypertension among adults is an important problem, and meaningful interventions are needed.

This study showed the significant relationship between hypertension and advancing age in both sexes. Cross-sectional surveys and prospective cohort studies have consistently demonstrated a positive relationship between age and blood pressure in the Kingdom of Saudi Arabia and in most populations regardless of geographical, cultural, and socioeconomic characteristics (3-7,15,16).

The association between sex and hypertension is less clear. Some studies have reported that hypertension was more prevalent in men, while others have reported the opposite. Many studies have reported that hypertension is more prevalent among men at younger ages and more prevalent among women at older ages. The association between hypertension and sex is complex and can be confounded by other factors such as socioeconomic status and education. Overall, no apparent sex predilection has been demonstrated (1-2).

Our data showed that patients with hypertension received more health education sessions during their clinic visits than did patients without hypertension. This finding was not unexpected: hypertension is associated with many risk factors and is itself a risk factor for many serious diseases and complications. In most cases, management of hypertension entails life-long pharmacologic and non-pharmacologic interventions. In order to encourage adherence to these life-long regimens, continuing education that promotes positive attitudes and behaviors is needed (17).

Patients with hypertension had more scheduled visits than did patients without hypertension. This finding was also expected for the same reasons discussed above. While follow up visits are necessary, the economic considerations must be revisited. Consultations for hypertension were shown to account for 67% of the direct costs of managing patients with hypertension in Eastern Saudi Arabia (18). It should be noted that patients with hypertension were offered the same health education and follow up services regardless of age, sex, or co-morbidity; this is a welcome finding.

The prevalence of diabetes mellitus in patients with hypertension was nearly 40% in our sample, in accordance with previously reported figures (19,20). The prevalence of multi-morbidity is high and increases significantly with age in both men and women. Patients with multi-morbidity who are seen in family practice represent the rule rather than the exception, and new health care models must be developed to meet the needs of these patients(21).

Hypertension is a common problem in patients attending NWAFH family medicine clinics in Tabuk City, Saudi Arabia. The prevalence of hypertension increases with age and hypertension is more common among patients with diabetes. Patients with hypertension receive more health education messages and follow up visits than do patients without hypertension, as is appropriate. The content and outcomes of these messages and follow up visits should be evaluated further in order to develop interventions that are more effective.

Our data indicates that hypertension affects a large proportion of adults in Tabuk and suggests that many patients known to have hypertension are not visiting the family clinics and that many individuals may have undiagnosed hypertension. Future intervention strategies should target primordial, primary, and secondary prevention. Guidelines for pharmacologic and non-pharmacologic management need to be developed and standardized. It is anticipated that implementation of such guidelines would lead to improved patient outcomes at a lower cost.