This study described the health-related quality of life of hypertensive patients and its associated factors among hypertensive patients attending the General Outpatient Clinics of the FMC Owo, South-Western Nigeria. It also ascertained the role of family support and its influence on the quality of life of hypertensive patients.
The demographic distribution of respondents in this study is characteristic of a middle-aged population (47.0%). This observation is in agreement with findings from most studies on
hypertension.18, 20, 154, This finding is however not surprising because most chronic medical conditions begin to creep in at the middle age period. The decline in endogenous oestrogen production after age 40 years and consequent atherosclerosis contributes to this occurrence in women.155 In addition, blood pressure especially systolic blood pressure rises with age.156, 157 Considering this, one would have expected modal population to be elderly in this study. However, the population structure in sub-Saharan Africa which typically has far more young than elderly people with about 44% of the population under age 15 years, and only about 36% over age 65 years due to low life expectancy157 may explain why patients with hypertension in our environment are middle aged.
The female preponderance (71.6%) in this study is in keeping with previous reports of more female attendees compared with their male counterparts in most hospital based studies on
hypertension.18, 159, 160, 161, 162 The higher number of hypertensive female participants in the present study may suggest that more females attended the General Out-patients Clinics, rather than an
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responsible for this observation. Firstly, in traditional African society, males are the major bread winners for their families and lacked the time to get to the hospital for screening or follow up.
Secondly, women seem to have better health seeking behaviour for chronic diseases than men.163 It is also possible that women are more likely to have their asymptomatic hypertension detected through blood pressure check due to more contact with health care facilities during their reproductive years.
A study in the South-West Nigeria154 however observed a strong male preponderance
(74.1%) among hypertensive workers attending the medical Centre of a research institute. The observed difference perhaps, reflected the gender distribution of the workers attending the medical Centre of this research institute. In all, (61.3%) of the respondents were married. This is expected considering the age range of the respondents (41-82) in this study. Essential hypertension affects adult population, 164 a stage in life when an individual is expected to have been married. Most of the study participants were employed (80.6%). As income rises, willingness to pay for health improvements increases as well.165 Unemployed people are more likely to be uninsured and thus have limited access to health care.166
Most of the respondents in this study were Yoruba’s (84.4%). The predominance of Yoruba respondents in this study was not surprising because the study was conducted in Owo, South West of Nigeria, where most of the residents were Yoruba’s. In this study, (84.1%) of the respondents practiced Christianity. Although traditional religion is part of the Nigerian culture, it had been largely taken over by Christianity and Islam. It was not surprising then that there were few respondents that practiced traditional religion.
In this study, most of the respondents between 50-59 years (middle aged) of age had good quality of life in all domains including the overall health. Some authors167, 70 also found good health related quality of life in middle aged hypertensive patients when compared to older patients. This had been attributed to the fact that during the aging process, health hazards may
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arise as a result of the physiological and functional changes, making individual more vulnerable to chronic diseases which can affect health-related quality of life and compromise
the physical aspect.167, 168
This finding is in contrast to another study which reported that middle aged hypertensive adults had lower scores in most of the domains of quality of life.168 The reason for this was that adults were able to develop more coping skills than the younger ones because of their experience in life. The relationship between age and health-related quality of life of the respondents was not statistically significant even though most of the middle age respondents had good quality of life in this study.
This study found that more women had good health related quality of life in all the domains including overall health domain in this study though there was no statistical significant relationship between sex and health related quality of life in this study. The reason for this finding may be because there are more women that presented in the clinic during the period of this study compared with men. It may also be because women, especially the older ones tend to stay with their children and grandchildren in our environment. They encourage them psychologically and this tends to improve their health status.
In contrast to this finding, several studies observed that, for men, the health related quality of life (HRQOL) was good in all the domains, including the physical and psychological
domains.169, 170
This study showed that marital status influences health related quality of life. In this study, a statistically significant relationship were observed between marital status and health related quality of life in the physical and social health domains of quality of life (p< 0.001) and (p=
0.013) respectively. In this study, more of those respondents who were married had higher score and therefore, had a good quality of life compared with those who were
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widowed/separated/single/divorced. This supported the previous study conducted in the southern part of Nigeria171, which suggested that married life created a sense of completeness and contendness. This result is also in tandem with that of previous studies in Vietnam172, Malawi173, and Indonesia174. Married people who are living with their partner are more likely to have stronger support, which is often lacking in the widowed, divorced and separated. The spouse usually encourages the partner to do everything possible to take care of his/her blood pressure. Psychosocial health problems and feelings of loneliness are more common among those who live alone, due to lack of emotional support within the family and society. The finding is consistent with number of studies which revealed that the married patients who are cohabiting with their partner had had higher scores in the quality of life.151, 175, 176
In this study, a statistical significance between occupation and health related quality of life was observed in the physical, psychological, social and overall health domains, and this was confirmed by logistic regression. The senior public servants/professionals/managers were approximately 3 times likely to have better quality of life than unemployed respondents. Those respondents that were employed are likely to have access to health insurance scheme and they may also have financial capability to cater for their own health thereby improving their health related quality of life. This agrees with the finding of a study that investigated the relationship between unemployment and health related quality of life.177 Studies found that among those with hypertension, unemployment had a poorer quality of life in all the domains including overall quality of life except in the spiritual domain. This finding agrees with the outcome of earlier studies that unemployment and low socioeconomic status were associated with poorer health related quality of life.170, 177 In this study there was a significant association between educational level and quality of life in the social and environmental health domains. Those respondents with higher education had higher scores therefore, had good quality of life. This finding agree with other similar studies conducted in Nigeria, Brazil and Pakistan which showed study participants with a higher educational level also had a higher health-related
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quality of life.71, 22 The possible explanation for this is that the level of education influences the ability to understand information, which favours knowledge on the disease and treatment adherence. Therefore, patients with a higher level of education may have good quality of life scores.178 In addition, it is a common observation that better educated people are less likely to develop complications to chronic conditions, or are often in the “controlled” status.66 In addition to pharmacotherapy, better educated patients are more likely to adapt to life style modification and preventive measures which result in an improvement in health-related quality of life.22 Also, persons with higher education often have better occupational positions, higher incomes, and better socioeconomic conditions.66 Financially, an educated person is more likely to have a better Job and income with easier and affordable access to diagnosis and treatment.179 Previous studies have also shown that education has been widely identified as a determinant of quality of life; people with higher levels of education often report better quality of life.179, 180
This study found that there was a statistical significant association between co-morbidities and health related quality of life. Evidence from this study showed co-morbidities as predictor of health related quality of life in psychological, social and overall health domains of quality of life. Respondents who had no co-morbidities had higher scores and good quality of life.
Respondents who had no co-morbidities were three times more likely to have good health related quality of life than those respondents that had co-morbidities. It has been suggested that patients with co-morbidities are prone to receive incomplete, inefficient and ineffective care.181 Co-morbidities are associated with greater health care needs, greater likelihood of disability, increased cost of care, higher likelihood of financial burden, and resulting socio-economic disadvantage.182 All of these can be associated with impaired quality of life. Similar study to assess the impact of co-morbidities in hypertensive patients has demonstrated that patients with no co-morbidities show significant higher scores in quality of life when compared with those who suffer from co-morbidities.180 This study also found that absence of comorbidities were associated with higher or good HRQOL in hypertensive patients. This
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finding is consistent with that of Wang et al.70, showing a greater increase in function than those with associated co-morbidities. Previous study have identified that cardiovascular comorbidities affected most of the domains in HRQOL negatively.93 It has impact on both physical and psychological domains.93 Another study by Aydemir et al. suggested that heart failure, previous stroke, myocardial infarction and peripheral arterial disease influenced the HRQOL in hypertensive patients. As expected, the presence of comorbidities was associated with lower quality of life in hypertensive patient.93 It should be stressed that co-morbidities can affect different aspects of the HRQOL to varying degrees. For examples, previous study suggested that comorbidities are important factors in declining health in hypertensive patients.95 In contrast to these findings, it had also been reported that there is no further impact on quality of life due to hypertension and comorbidity like diabetes mellitus.93
This study revealed Body Mass Index (BMI) as predictor of health related quality of life in the physical, psychological and environmental domains of quality of life. In this study, those respondents who were not overweight or obese had higher scores and good quality of life.
Respondents that were not overweight or obese were three times more likely to have good quality of life than those respondents that were overweight or obese. The possible explanation for this is that various co-morbidities and functional limitations associated with obesity can adversely affect physical quality of life. Dissatisfaction with body image, low self-esteem, poor health, depression, and employment-related as well as other forms of social discrimination can add to the psychological distress in obese individuals.152 Overweight and obesity also carry a considerable health burden and will have a significant impact on health expenditures. Obesity has a strong association with the occurrence of chronic medical problems, impairment of health-related quality of life, and increasing the health care and medication spending.184 Previous studies showed that the overweight and obese subjects suffer from poor quality of life as the increase in BMI had lowered the domains of quality of life.184,
185 Another study also found that overweight and obesity leads to decrease in physical activity
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and increase in co-morbidities and depression, so resulted in poor quality of life.186 A study by Egyptians supported the findings in this study that obesity doesn’t only affect the physical health but also leads to psychological impairment.187 Contrary to finding in this study, hypertensive patients who have higher body mass index have a better state of physical and psychological health. A previous study showed that the class 1 obese was significantly associated with better HRQOL scores in the psychological component than the normal weight in adults of the Chinese general population.188
This study found a statistical significant relationship between perceived social support and health related quality of life. Majority of the respondents had higher scores and good quality of life in overall health domain which showed strong perceived family support. This corroborates the fact that Africans have a strong social support network.189 This result is comparable to the findings of Okumabga et al190 in Nigeria who reported that 84.6% of the geriatric population studied received support from families and friends. A number of reasons may be adduced for this observation. Firstly, the influence of the extended family system in Nigeria makes the family closer to each other. It is known that in family-centered societies, people tend to gain major support from family as noted in a research work in Nigeria.190 Furthermore, 61.3% of the respondents were married. Marriage thought to hold significant potential for affecting an individual perception of family support, and therefore be inclined to report good family support perceptions than their unmarried counterparts.137, 191 Also, studies on family support in Nigeria have focused on chronic diseases such as diabetes and depression due to paucity of studies on the relationship between family support and health related quality of life in Nigeria and Africa.137, 192 Results from these studies indicated positive relationship between family support and health outcomes. Possible explanations attributed to the positive relationship between family support and blood pressure control are several. First, a good social support network can attenuate the accompanying increase in blood pressure.193 Second, the reduced level of family support could lead to the adoption of fewer habits related with a healthy
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lifestyle.137 It has also been reported that those who had support from family members had better compliance with treatment than those who did
not.116, 125, 121
This study reported 89.4% of the respondents were from functional family. This shows that family functionality most likely played a significant role in the overall quality of life. The WHO characterized the family as the primary social agent in the promotion of health and well-being.194 Family measures the extent to which a family works as a unit; it denotes the family’s ability to cope and adjust to different situations based on five components: adaptation, partnership, growth, affection and resolve. This is called the family APGAR, an instrument that was used in this study to assess family functionality.
This study stressed the influence of family support on HRQOL among hypertensive patients.
This study found that those who had a good relationship with the family had a good overall quality of life. It had been suggested that social support from family was strongly associated with hypertension treatment compliance110, and better survival, lower depression and higher compliance to medication.195 Social support is the complex network of how a person gets and gives information and aid, as well as how they meet their emotional needs.110 A good relationship with family may enhance the social support and improve quality of life.
CONCLUSION
There is significant association between marital status, level of education, occupation,
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senior public servants/professionals/managers, absence of co-morbidities, and BMI< 25kg/m2. There is statistical significant association between perceived family support and health related quality of life in this study. Occupation, body mass index and co-morbidity were independent predictors of health related quality of life. On the other hand, education, marital status, perceived family support and family APGAR were not independent predictors of health related quality of life among hypertensive patients.
.
LIMITATIONS
1. This study was a hospital based study and hence the results may not be generalized to the
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2. The study design was cross-sectional in nature; hence causal relationships could also not be ascertained for the findings identified in this study.
3. WHOQOL-BREF instrument measures quality of life within two weeks prior to the interview, the information provided may be influenced by recall bias.
RECOMMENDATIONS
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1. More aggressive approaches should be taken to educate obese patients about the benefits of lifestyle modifications in enhancing the effects of prescription drugs, their merits of reducing risks of other chronic conditions and diseases.
2. Public health approach on health seeking behaviour, early diagnosis and effective health interventions to ensure maintenance of desirable HRQOL as well as controlling of blood pressure in order to prevent or reduce co-morbidities of hypertension.
3. Patients’ education and enhanced information to improve quality of life among hypertensive patients.
4. The need for Family Physicians to reflect on the available family support when managing hypertensive patients.
Recommendation for further studying.
1. More studies on quality of life of hypertensive patients that utilizes the WHOQOL- BREF should be employed to determine those factors that affect HRQOL.
2. Further research on appropriate and targeted intervention in efforts to improve HRQOL of patients with hypertension is also recommended.
3. Further research on motivations for behaviour change would be important in combating the obesity epidemic.
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