Determinants of Uncontrolled Hypertension Among Hypertensive Patients in Kandahar, Afghanistan

Rahimy N

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OJHAS Vol. 19, Issue 2: (April-June 2020)

Original Article
Determinants of Uncontrolled Hypertension Among Hypertensive Patients in Kandahar, Afghanistan.

Authors:
Bilal Ahmad Rahimi, Associate Professor and Head, Department of Pediatrics, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan,
Mohammad Dawood Hemat, Department of Public Health, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan,
Najeebullah Rahimy, Assistant Professor, Department of Histopathology, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan,
Najibullah Rafiqi, Assistant Professor, Department of Surgery, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan,
Mohammad Azeem Zmarial Kakar, Assistant Professor, Department of Public Health, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan.

Address for Correspondence
Najeebullah Rahimy, Assistant Professor,
Department of Histopathology,
Faculty of Medicine,
Kandahar University,
Durahi, Beside Aino Mena Town, District 10,
Kandahar, Afghanistan.
E-mail: najeebrahimy@yahoo.com.

Citation
Rahimi BA, Hemat MD, Rahimy N, Rafiqi N, Kakar MAZ. Determinants of Uncontrolled Hypertension Among Hypertensive Patients in Kandahar, Afghanistan. Online J Health Allied Scs. 2020;19(2):7. Available at URL: https://www.ojhas.org/issue74/2020-2-7.html

Submitted: Apr 11, 2020; Accepted: Sep 2, 2020; Published: Sep 20, 2020

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This work is licensed under a Creative Commons Attribution-No Derivative Works 2.5 India License

Abstract: Background: Globally, hypertension is a major public health issue as well as one of the leading causes of cardiovascular diseases and deaths. To determine the risk factors of uncontrolled hypertension among adult hypertensive patients in Kandahar, Afghanistan. Methods: This was a cross-sectional study, conducted in Kandahar City, Afghanistan. Data of 12 months (May, 2018–April, 2019) was collected from outpatients who visited Mirwais Regional Hospital and Sidal Hospital in Kandahar City. Results: Among 1050 hypertensive patients, 651/1050 (62.0%) were females, 636/1050 (60.6%) living in rural areas, 816/234 (77.7%) married, 723/1050 (68.9%) uneducated, 918/1050 (87.4%) overweight or obese, 459/1050 (43.7%) having family history of hypertension, and 786/1050 (74.9%) of the patients with uncontrolled hypertension. Mean age of the patients was 51 years. Binary logistic regression revealed that living in rural areas (AOR [Adjusted Odds Ratio] 3.0, p-value 0.004), sedentary lifestyle (AOR 3.7, p-value 0.002), and poor adherence to antihypertensive medications (AOR 4.4, p-value 0.003) were the statistically significant risk factors for the uncontrolled hypertension in these patients. Conclusion: Uncontrolled hypertension is a major threat for the hypertensive patients in Afghanistan. Better strategies for the control of hypertension are required in Afghanistan to reduce the burden of disease as a result of complications of uncontrolled hypertension.
Key Words: Hypertension, Blood Pressure, Determinant, Kandahar, Afghanistan

Introduction:

Globally, hypertension (HTN) is one of the leading causes of cardiovascular diseases (CVD) and deaths.(1) It is a major public health issue with the global prevalence of 30.8%.(2) Globally, approximately 1.1 billion people are suffering from hypertension, with the expectation of increase in this number to more than 1.5 billion by the year 2025.(3) Hypertension may progress to further complications, such as the risk of heart failure, cerebral ischemia, cerebral hemorrhage, and chronic kidney diseases.(4,5,6) The recent rapid social and economic changes in the countries of Eastern Mediterranean Region have increased the number of patients with hypertension and other risk factors of cardiovascular diseases.(7) United Nations estimates the prevalence of HTN in Eastern Mediterranean countries to be 26.0%.(8)

Although knowledge about HTN is very important for health, many hypertensive patients in both developing and developed countries are not aware of their disease. A large multi-center study revealed that prevalence of awareness about HTN among hypertensive patients in high-, upper–middle-, low–middle-, and low-income countries was 49.0%, 52.5%, 43.6%, and 40.8%, respectively.(9) Main objective of this study was to determine the risk factors of uncontrolled hypertension among adult hypertensive patients in Kandahar, Afghanistan.

Materials and Methods

Study Design, period, and questionnaire
This was a cross-sectional analytical study. Data was collected for a duration of 12 months (May 2018–April 2019). Expert-made questionnaire was used to collect the demographic, physical activity, diet, smoking, treatment, and follow up data of the patients with hypertension.

Study population and site
Study population was composed of all the adult patients with hypertension visiting the outpatient departments (OPDs) of either Mirwais Regional Hospital or Sidal Hospital in Kandahar City.

Research question
What are the risk factors of uncontrolled hypertension among adults in Kandahar, Afghanistan?

Main objective
To determine the risk factors of uncontrolled hypertension among adult hypertensive patients in Kandahar, Afghanistan.

Inclusion criteria
All male and female hypertensive patients who visited the OPDs of Mirwais Regional Hospital and Sidal Hospital.

Exclusion criteria
Patient who do not consent to take part in the study.

Sample size calculations
Sample size was calculated using the following formula:

Where n is the total sample size, p is the prevalence of outcome expressed as a proportion, E is the margin of error which is 0.05 in this case, 1.96 is the standard normal z-value, corresponding to the 95% confidence interval. The sample size and power calculations have been performed in Stata 15 (College Station, Texas, USA). Our sample size was 1050 patients.

Ethical considerations
Written informed consents were taken from all the participants prior to the study. Information of the participants will not be disclosed. Ethical approval was taken from Kandahar University Ethics Committee.

Data analysis
Data was analyzed with SPSS version 22 (Chicago, IL, USA). Descriptive statistics, such as percentages and proportions, were used to describe the sociodemographic and other variables of the study participants. Chi square test (using crude odd ratio [COR]) was used to study the association of different factors in uncontrolled hypertensive patients. All variables that showed statistically significant association were put in binary logistic regression (using adjusted odd ratio [AOR]) to determine the factors affecting uncontrolled HTN. P-value of <0.05 was considered statistically significant.

Results

In this cross-sectional analytical study, conducted during May 2018 to April 2019, a total of 1050 patients with hypertension were studied. Mean age of the patients was 51 years with 465/1050 (44.3%) of them with the age group of 45–54 years (Tables 1 and 2). Among these patients, 651/1050 (62.0%) were females, 636/1050 (60.6%) living in rural areas, 816/234 (77.7%) married, 723/1050 (68.9%) illiterate, 918/1050 (87.4%) overweight or obese, 459/1050 (43.7%) having family history of HTN, and 786/1050 (74.9%) of the patients with uncontrolled HTN (Table 2).

Table 1: Characteristics of the continuous data variables.
Variable	Frequency (n)	Mean ± SD	Range
Age	1050	51.0 ± 9.9	25–75
Systolic BP (mmHg)	1050	166.5 ± 17.0	100–210
Diastolic BP (mmHg)	1050	93.5 ± 10.2	70–131
Pulse rate (beats/min)	1050	83.8 ± 8.8	60–108
Height (cm)	1050	162.8 ± 10.0	105–180
Weight (kg)	1050	79.6 ± 14.1	45–115
BMI	1050	30.1 ± 5.6	17–79
Number of family members living in one house	1050	11.5 ± 5.6	2–50
Duration of smoking (years)	468	15.4 ± 11.0	1–40
Age of starting smoking (years)	204	21.6 ± 4.2	8–30
Number of packs of cigarettes used per week	231	5.7 ± 2.4	1–10
Age of starting smokeless tobacco or mouth sniff (years)	363	18.3 ± 11.5	2–50
Duration of using antihypertensive medications (years)	369	3.3 ± 3.3	1–15
BMI: Body Mass Index; BP: Blood Pressure; cm: Centimeter; kg: Kilogram; min: Minute; mmHg: Millimeter of Mercury; n: Number; SD: Standard Deviation.

Table 2: Categorical data of the male and female hypertensive patients.
Variable		All patients, n (%)	Males, n (%)	Females, n (%)
Age (years)	25–34	24 (2.3)	6 (1.5)	18 (2.8)
	35–44	225 (21.4)	66 (16.5)	159 (24.4)
	45–54	465 (44.3)	180 (45.1)	285 (43.8)
	55–64	213 (20.3)	87 (21.8)	126 (19.3)
	≥65	123 (11.7)	60 (15.1)	63 (9.7)
	Total	1050 (100)	399 (100)	651 (100)
Gender	Male	399 (38.0)	399 (100)	0 (0.0)
	Female	651 (62.0)	0 (0.0)	651 (100)
	Total	1050 (100)	399 (100)	651 (100)
Place of living	Urban	414 (39.4)	156 (39.1)	258 (39.6)
	Rural	636 (60.6)	243 (60.9)	393 (60.4)
	Total	1050 (100)	399 (100)	651 (100)
Marital status	Single	21 (2.0)	3 (0.8)	18 (2.8)
	Married	816 (77.7)	363 (91.0)	453 (69.6)
	Divorced/separated	213 (20.3)	33 (8.2)	180 (27.6)
	Total	234 (100)	399 (100)	651 (100)
Literacy level	Illiterate	723 (68.9)	186 (46.6)	537 (82.5)
	Literate	327 (31.1)	213 (53.4)	114 (17.5)
	Total	1050 (100)	399 (100)	651 (100)
Occupation	Employed	558 (53.3)	246 (62.1)	312 (47.9)
	Unemployed	489 (46.7)	150 (37.9)	339 (52.1)
	Total	1047 (100)	396 (100)	651 (100)
Socio-economic status	Low	246 (51.2)	99 (39.3)	147 (64.5)
	Middle	123 (25.6)	72 (28.6)	51 (22.4)
	High	111 (23.1)	81 (32.1)	30 (13.1)
	Total	480 (100)	252 (100)	228 (100)
BMI	Underweight	6 (0.6)	3 (0.7)	3 (0.5)
	Normal	126 (12.0)	45 (11.3)	81 (12.4)
	Overweight/obese	918 (87.4)	351 (88.0)	567 (87.1)
	Total	1050 (100)	399 (100)	651 (100)
Family history of HTN	Yes	459 (43.7)	198 (49.6)	261 (40.1)
	No	591 (56.3)	201 (50.4)	390 (59.9)
	Total	1050 (100)	399 (100)	651 (100)
Relative with history of HTN	Father	231 (50.0)	84 (42.4)	147 (56.3)
	Mother	153 (33.3)	69 (34.9)	84 (32.2)
	Brother	63 (13.7)	45 (22.7)	18 (6.9)
	Sister	12 (2.6)	0 (0.0)	12 (4.6)
	Total	459 (100)	198 (100)	261 (100)
Currently smoking cigarette	Yes	231 (22.0)	165 (41.4)	66 (10.1)
	No	819 (78.0)	234 (58.6)	585 (89.9)
	Total	1050 (100)	399 (100)	651 (100)
Smoking cigarette daily	Yes	216 (93.5)	162 (98.2)	54 (81.8)
	No	15 (6.5)	3 (1.8)	12 (18.2)
	Total	231 (100)	165 (100)	66 (100)
Age of starting smoking (years)	1–10	3 (1.4)	0 (0.0)	3 (5.3)
	11–20	117 (55.7)	93 (60.8)	24 (42.1)
	21–30	90 (42.9)	60 (39.2)	30 (52.6)
	Total	210 (100)	153 (100)	57 (100)
Number of cigarette packs per week	1–3	54 (23.4)	24 (14.5)	30 (45.5)
	4–7	138 (59.7)	108 (65.5)	30 (45.5)
	8–10	39 (16.7)	33 (20.0)	6 (9.0)
	Total	231 (100)	165 (100)	66 (100)
Patient ever tried to stop smoking	Yes	51 (22.1)	30 (18.2)	21 (31.8)
	No	180 (77.9)	135 (81.8)	45 (68.2)
	Total	231 (100)	165 (100)	66 (100)
Doctor has ever advised to stop smoking	Yes	48 (20.8)	33 (20.0)	15 (22.7)
	No	183 (79.2)	132 (80.0)	51 (77.3)
	Total	231 (100)	165 (100)	66 (100)
Using mouth sniff	Yes	363 (34.6)	201 (50.4)	162 (24.9)
	No	687 (65.4)	198 (49.6)	489 (75.1)
	Total	1050 (100)	399 (100)	651 (100)
Using mouth sniff daily	Yes	333 (91.7)	180 (89.6)	153 (94.4)
	No	30 (8.3)	21 (10.4)	9 (5.6)
	Total	363 (100)	201 (100)	162 (100)
Duration of using mouth sniff (years)	<5	54 (14.9)	15 (7.5)	39 (24.1)
	5–10	63 (17.4)	33 (16.4)	30 (18.5)
	11–15	60 (16.5)	36 (17.9)	24 (14.8)
	16–20	42 (11.6)	27 (13.4)	15 (9.3)
	>20	144 (39.7)	90 (44.8)	54 (33.3)
	Total	363 (100)	201 (100)	162 (100)
Days of eating fruits in one week	Daily	36 (3.4)	12 (3.0)	24 (3.7)
	1–3 days	756 (72.0)	267 (66.9)	489 (75.1)
	4–6 days	228 (21.7)	114 (28.6)	114 (17.5)
	None	30 (2.9)	6 (1.5)	24 (3.7)
	Total	1050 (100)	399 (100)	651 (100)
Days of eating vegetables in one week	Daily	33 (3.1)	24 (6.0)	9 (1.4)
	1–3 days	663 (63.1)	252 (63.2)	411 (63.1)
	4–6 days	315 (30.0)	117 (29.3)	198 (30.4)
	None	39 (3.7)	6 (1.5)	33 (5.1)
	Total	1050 (100)	399 (100)	651 (100)
Type of cooking oil used	Vanaspati ghee	957 (91.1)	366 (91.7)	591 (90.8)
	Vegetable oil	93 (8.9)	33 (8.3)	60 (9.2)
	Total	1050 (100)	399 (100)	651 (100)
Active lifestyle	Yes	216 (20.6)	102 (25.6)	114 (17.5)
	No	834 (79.4)	297 (74.4)	537 (82.5)
	Total	1050 (100)	399 (100)	651 (100)
Doing regular exercise	Yes	111 (10.6)	63 (15.8)	48 (7.4)
	No	939 (89.4)	336 (84.2)	603 (92.6)
	Total	1050 (100)	399 (100)	651 (100)
Type of exercise	Walking	102 (91.9)	57 (90.5)	45 (93.7)
	Running	9 (8.1)	6 (9.5)	3 (6.3)
	Total	111 (100)	63 (100)	48 (100)
Number of days doing exercise per week	Daily	18 (16.2)	9 (14.3)	9 (18.7)
	1–3 days	18 (16.2)	6 (9.5)	12 (25.0)
	4–6 days	75 (67.6)	48 (76.2)	27 (56.3)
	Total	111 (100)	63 (100)	48 (100)
Good adherence to anti-hypertensive medications	Yes	699 (66.6)	288 (72.2)	411 (63.1)
	No	351 (33.4)	111 (27.8)	240 (36.9)
	Total	1050 (100)	399 (100)	651 (100)
Taking anti-hypertensive medications	Single	468 (95.7)	201 (93.1)	267 (97.8)
	Double/combination form	21 (4.3)	15 (6.9)	6 (2.2)
	Total	489 (100)	216 (100)	273 (100)
Duration of antihypertensive medications usage (years)	<1	60 (16.4)	36 (21.1)	24 (12.3)
	1–5	246 (67.2)	114 (66.7)	132 (67.7)
	6–10	45 (12.3)	21 (12.2)	24 (12.3)
	>10	15 (4.1)	0 (0.0)	15 (7.7)
	Total	366 (100)	171 (100)	195 (100)
Hypertension controlled	Yes	246 (25.1)	99 (24.8)	165 (25.3)
	No	786 (74.9)	300 (75.2)	486 (74.7)
	Total	1050 (100)	399 (100)	651 (100)
Presence of co-morbidities	Yes	687 (65.4)	270 (67.7)	417 (64.1)
	No	363 (34.6)	129 (32.3)	234 (35.9)
	Total	1050 (100)	399 (100)	651 (100)
Co-morbid disease	Peptic ulcer	144 (21.0)	60 (22.5)	84 (20.0)
	UTI	84 (12.2)	30 (11.2)	54 (12.9)
	Hepatitis	24 (3.5)	15 (5.6)	9 (2.1)
	Depression	219 (31.9)	75 (28.1)	144 (34.3)
	COPD	66 (9.6)	21 (7.9)	45 (10.7)
	DM	150 (21.8)	66 (24.7)	84 (20.0)
	Total	687 (100)	267 (100)	420 (100)
BMI: Body Mass Index; BP: Blood Pressure; CI: Confidence Interval; COPD: Chronic Obstructive Pulmonary Disease; DM: Diabetes Mellitus; HTN: Hypertension; n: Number; UTI: Urinary Tract Infection.

Chi square test of HTN patients showed that statistically significant factors that may cause the uncontrolled HTN were living in rural areas (COR [Crude Odds Ratio] 1.4, 95% CI 1.0–1.8%, p-value 0.024), person who has not tried to stop smoking (COR 2.1, 95% CI 1.1–4.0%, p-value 0.034), using vanaspati ghee (COR 2.4, 95% CI 1.3–4.5%, p-value 0.004), sedentary life style (COR 1.4, 95% CI 1.0–2.0%, p-value 0.043), not doing regular exercise (COR 2.6, 95% CI 1.7–3.8%, p-value <0.001), poor adherence to antihypertensive medications (COR 4.2, 95% CI 2.9–6.2%, p-value <0.001), no family history of HTN (COR 1.4, 95% CI 1.1–1.9%, p-value 0.018), and not having co-morbidities (COR 2.1, 95% CI 1.5–2.9%, p-value <0.001) (Table 3).

Table 3. Univariate analysis of the factors affecting uncontrolled hypertension
Variable		Controlled HTN, n (%)	Uncontrolled HTN, n (%)	COR	95% CI	P-value
Age (years) (n=1050)	≤40 (n=165)	36 (21.8)	129 (78.2)	0.8	0.5–1.2	0.328
Age (years) (n=1050)	>40 (n=885)	228 (25.8)	657 (74.2)	1	0.5–1.2	0.328
Gender (n=1050)	Male (n=399)	99 (24.8)	300 (75.2)	1.0	0.7–1.3	0.884
Gender (n=1050)	Female (n=651)	165 (25.3)	486 (74.7)	1	0.7–1.3	0.884
Marital status (n=837)	Single (n=21)	3 (14.3)	18 (85.7)	0.5	0.2–1.8	0.437
Marital status (n=837)	Married (n=816)	198 (24.3)	618 (75.7)	1	0.2–1.8	0.437
Place of living (n=1050)	Urban (n=414)	120 (29.0)	294 (71.0)	1	1.0–1.8	0.024
Place of living (n=1050)	Rural (n=636)	144 (22.6)	492 (77.4)	1.4	1.0–1.8	0.024
Literacy level (n=1050)	Illiterate (n=723)	180 (24.9)	543 (75.1)	1.0	0.7–1.3	0.818
Literacy level (n=1050)	Literate (n=327)	84 (25.7)	243 (74.3)	1	0.7–1.3	0.818
Occupation (n=1047)	Employed (n=558)	150 (26.9)	408 (73.1)	1	0.9–1.7	0.133
Occupation (n=1047)	Unemployed (n=489)	111 (22.7)	378 (77.3)	1.3	0.9–1.7	0.133
Socio-economic status (n=480)	Low/Middle (n=369)	93 (25.2)	276 (74.8)	0.7	0.4–1.1	0.143
Socio-economic status (n=480)	High (n=111)	36 (32.4)	75 (67.6)	1	0.4–1.1	0.143
Currently smoking cigarette (n=1050)	Yes (n=231)	66 (28.6)	165 (71.4)	1	0.9–1.7	0.198
Currently smoking cigarette (n=1050)	No (n=819)	198 (24.2)	621 (75.8)	1.3	0.9–1.7	0.198
Smoking cigarette daily (n=231)	Yes (n=216)	60 (27.8)	156 (72.2)	0.6	0.2–1.7	0.376
Smoking cigarette daily (n=231)	No (n=15)	6 (40.0)	9 (60.0)	1	0.2–1.7	0.376
Age of starting smoking (years) (n=1050)	<18 (n=210)	57 (27.1)	153 (72.9)	1.1	0.8–1.6	0.477
Age of starting smoking (years) (n=1050)	≥18 (n=840)	207 (24.6)	633 (75.4)	1	0.8–1.6	0.477
Number of cigarette packs per week (n=1050)	≤7 (n=192)	51 (26.6)	141 (73.4)	1.1	0.8–1.6	0.646
Number of cigarette packs per week (n=1050)	>7 (n=858)	213 (24.8)	645 (75.2)	1	0.8–1.6	0.646
Patient ever tried to stop smoking? (n=231)	Yes (n=51)	21 (41.2)	30 (58.8)	1	1.1–4.0	0.034
Patient ever tried to stop smoking? (n=231)	No (n=180)	45 (25.0)	135 (75.0)	2.1	1.1–4.0	0.034
Doctor has ever advised to stop smoking (n=231)	Yes (n=48)	15 (31.2)	33 (68.8)	1	0.6–2.3	0.720
Doctor has ever advised to stop smoking (n=231)	No (n=183)	51 (27.9)	132 (72.1)	1.2	0.6–2.3	0.720
Using mouth sniff (n=1050)	Yes (n=363)	96 (26.4)	267 (73.6)	1	0.8–1.5	0.501
Using mouth sniff (n=1050)	No (n=687)	168 (24.5)	519 (75.5)	1.1	0.8–1.5	0.501
Using mouth sniff daily (n=363)	Yes (n=333)	90 (27.0)	243 (73.0)	1	0.6–3.7	0.519
Using mouth sniff daily (n=363)	No (n=30)	6 (20.0)	24 (80.0)	1.5	0.6–3.7	0.519
Eating fruit daily (n=1050)	Yes (n=36)	9 (25.0)	27 (75.0)	1.0	0.5–2.1	1.000
Eating fruit daily (n=1050)	No (n=1014)	255 (25.1)	759 (74.9)	1	0.5–2.1	1.000
Eating vegetables daily (n=1050)	Yes (n=33)	6 (18.2)	27 (81.8)	0.7	0.3–1.6	0.420
Eating vegetables daily (n=1050)	No (n=1017)	258 (25.4)	759 (74.6)	1	0.3–1.6	0.420
Type of cooking oil (n=1050)	Vanaspati ghee (n=957)	252 (26.3)	705 (73.7)	1	1.3–4.5	0.004
Type of cooking oil (n=1050)	Vegetable oil (n=93)	12 (12.9)	81 (87.1)	2.4	1.3–4.5	0.004
Active lifestyle (n=1050)	Yes (n=216)	66 (30.6)	150 (69.4)	1	1.0–2.0	0.043
Active lifestyle (n=1050)	No (n=834)	198 (23.7)	636 (76.3)	1.4	1.0–2.0	0.043
Regular exercise (n=1050)	Yes (n=111)	48 (43.2)	63 (56.8)	1	1.7–3.8	<0.001
Regular exercise (n=1050)	No (n=939)	216 (23.0)	723 (77.0)	2.6	1.7–3.8	<0.001
Type of exercise (n=111)	Walking (n=102)	48 (47.1)	54 (52.9)	1	0.4–0.6	0.005
Type of exercise (n=111)	Running (n=9)	0 (0.0)	9 (100)	0.5	0.4–0.6	0.005
Doing daily exercise (n=111)	Yes (n=18)	9 (50.0)	9 (50.0)	1	0.5–3.8	0.607
Doing daily exercise (n=111)	No (n=93)	39 (41.9)	54 (58.1)	1.4	0.5–3.8	0.607
Good adherence to anti-hypertensive medications (n=1050)	Yes (n=699)	228 (32.6)	471 (67.4)	1	2.9–6.2	<0.001
Good adherence to anti-hypertensive medications (n=1050)	No (n=351)	36 (10.3)	315 (89.7)	4.2	2.9–6.2	<0.001
Number of anti-hypertensive medications used (n=489)	Single (n=468)	159 (34.0)	309 (66.0)	0.2	0.1–0.5	0.001
Number of anti-hypertensive medications used (n=489)	Double/combination form (n=21)	15 (71.4)	6 (28.6)	1	0.1–0.5	0.001
Family history of HTN (n=1050)	Yes (n=459)	132 (28.8)	327 (71.2)	1	1.1–1.9	0.018
Family history of HTN (n=1050)	No (n=591)	132 (22.3)	459 (77.7)	1.4	1.1–1.9	0.018
Presence of co-morbidities (n=1050)	Yes (n=687)	204 (29.7)	483 (70.3)	1	1.5–2.9	<0.001
Presence of co-morbidities (n=1050)	No (n=363)	60 (16.5)	303 (83.5)	2.1	1.5–2.9	<0.001
BMI (n=1050)	Overweight/obese (n=918)	240 (26.1)	678 (73.9)	1	1.0–2.5	0.053
BMI (n=1050)	Not overweight/obese (n=132)	24 (18.2)	108 (81.8)	1.6	1.0–2.5	0.053
BMI: Body Mass Index; CI: Confidence Interval; COR; Crude Odds Ratio; HTN: Hypertension.

Binary logistic regression of the above-mentioned statistically significant factors revealed that living in rural areas (AOR [Adjusted Odds Ratio] 3.0, 95% CI 1.4–6.4%, p-value 0.004), sedentary lifestyle (AOR 3.7, 95% CI 1.6–8.3%, p-value 0.002), and poor adherence to antihypertensive medications (AOR 4.4, 95% CI 1.7–11.7%, p-value 0.003) were the risk factors for the uncontrolled HTN in these patients (Table 4).

Table 4: Binary logistic regression for estimating the factors affecting uncontrolled hypertension.
Variable	AOR	95% CI	P-value
Using vanaspati ghee	0.1	0.01–0.2	<0.001
Sedentary lifestyle	3.7	1.6–8.3	0.002
Poor adherence to antihypertensive medications	4.4	1.7–11.7	0.003
Living in rural areas	3.0	1.4–6.4	0.004
Person who has not tried to stop smoking	2.0	1.0–4.2	0.060
Having a co-morbidity	1.7	0.8–3.7	0.182
Family history of HTN	1.4	0.7–2.7	0.400
AOR: Adjusted Odds Ratio; CI: Confidence Interval; HTN: Hypertension.

Discussion

This was a cross-sectional analytical study conducted on 1050 hypertensive patients in Kandahar, Afghanistan. In this study 74.9% of the patients had uncontrolled HTN. A study conducted in 17 countries showed that 81%, 84.4%, 90.1%, and 87.3% of the hypertensive patients in high-, upper–middle-, low–middle-, and low-income countries had uncontrolled BP.(9) Similarly, uncontrolled HTN was observed in majority of the patients in Turkey (93.5%),(10) Pakistan (71%),(11) Sri Lanka (57%),(11) Bangladesh (53%),(11) Iran (62.3%),(12) Lebanon (51.1%),(13) Oman (61%),(14) Ethiopia (53.4%),(15) and USA (54.4%).(16) Higher prevalence of uncontrolled HTN can be due to decreased adherence to antihypertensive treatment. In contrast, decreased prevalence of uncontrolled HTN has been reported from Uganda (20.2%),(17) Spain (44.6%),(18) UK (48%),(19) and USA (49.9%).(20)

The traditional risk factors of hypertension are old age, diabetes mellitus, overweight, obesity, and family history of HTN.(21) In our study, main risk factors of uncontrolled hypertension were living in rural areas, sedentary lifestyle, and poor adherence to antihypertensive medications. Main risk factors of uncontrolled HTN were being male and BMI >25 in Iran;(12) obesity and adding salt to food at the table in Zimbabwe,(22) lack of awareness of hypertension-related complications, nonadherent to smoking and alcohol abstinence, overweight, middle age, and old age in Ethiopia;(23) older age, multi-drug regimens, lack of knowledge by the patient of their target systolic BP, and report of antihypertensive drug side effects in USA;(24) while obesity and sedentary lifestyle in Belgium.(25)

In this study, mean age of the hypertensive patients was 51 years. Mean age reported in other studies were 61.1 years in Iran,(12) 57 years in Oman,(14) 56.4 years in Ethiopia,(23) 58.6 years in France,(26) 66.1 years in Spain,(18) and 65 years in USA.(24)

Sedentary lifestyle was a statistically significant risk factor for uncontrolled HTN in our study. Similar result has been reported from China,(21) Thailand,(27) Ethiopia,(28) Spain,(29) Belgium,(25) and Brazil.(30) Physical activity may prevent increase in blood pressure through beneficial alterations in insulin sensitivity, autonomic nervous system function, and vasoconstriction regulation.(28) Also, it decreases hypertension by decreasing body weight and increasing renal function.(31)

Most (89.7%) of the patients in our study had poor adherence to antihypertensive medication. Poor medication adherence has also been observed in India (66.6%),(32) China (65%),(33) Pakistan (51.7%),(34) Lebanon (47%),(13) and USA (77%).(35) The poor medication adherence can be due to insufficient patient knowledge, inaccurate perception about hypertension,(36) poverty,(37) multiple dose regimens, poor eye sights or hands disabilities in the elderly.(38, 39) Studies have demonstrated that low adherence to antihypertensive treatment is associated with increased risk of stroke and other cardiovascular diseases.(40, 41)
Main limitations of this study were being cross-sectional and only in hospitals situated inside the city. In addition, BP fluctuates during different hours of the day and night, but we determined the presence or absence of HTN based on a single visit (with collecting only two readings of BP) during the day.

Conclusions

This study revealed that BP was poorly controlled in majority of the patients as well as a major threat for the people of Afghanistan. The main reasons for this suboptimal HTN management are living in rural areas, sedentary lifestyle, and poor adherence to antihypertensive medications. In Afghanistan, better strategies for the control of hypertension are required to reduce the burden of disease as a result of complications of uncontrolled HTN. Future studies, especially prospective, are needed to better understand the determinants of uncontrolled HTN in Afghanistan.

Conflict of Interest: All the authors have no competing interests.

Acknowledgements

We are sincerely thankful of the authorities of Ministry of Higher Education of Afghanistan, Kandahar University, and Kandahar Public Health Department for their kind support. We are thankful of all the patients who took part in this study.

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