KNOWLEDGE AND AWARENESS OF

HYPERTENSION AMONG PATIENTS WITH

SYSTEMIC HYPERTENSION
B. Oluranti Familoni, MBBS, FMCP; S. Abayomi Ogun, BSc (Hons), MBCh, (Ife), FWACP;
and A. Olutoyin Aina, BSc, MSc
Sagamu, Ogun State, Nigeria

Background: In Nigeria, systemic hypertension is the commonest noncommunicable disease,

and public awareness about hypertension and its determinants is poor. This study aims to assess
the knowledge and level of awareness of the disease among hypertensive patients attending the
medical outpatient clinic of Olabisi Onabanjo University Teaching Hospital (OOUTH).
Methodology: Hypertensive patients who attended the medical outpatient clinic during the one-
year study period and gave their consent were recruited into the study. Response to a question-
naire on various aspects of hypertension was analyzed using the STATA for Windows software.
Results: There were 254 hypertensive patients, of which 111 were males and 143 were females,
giving a male: female ratio of 1:1.3. The mean age (SD) of the patients was 51 years ± 12.2; 52.4%
of the participants were aware that hypertension was the commonest noncommunicable disease in
Nigeria. About one in 10 patients (11.4%) was aware that "nil symptom" is the commonest symptom
of hypertension, while 37% were not aware that hypertension could cause renal failure. Only about
one-third (35.4%) of the patients knew that hypertension should ideally be treated for life, while
58.3% believed that antihypertensive drugs should be used only when there are symptoms. The
remaining 6.3% believed that the treatment of hypertension should be for periods ranging from two
weeks to five years but not for life.
Conclusion: This study has demonstrated inadequate knowledge of hypertension in patients with
hypertension in our study population. Conscious efforts should be made and time set aside to
health educate hypertensive patients. Organization of "hypertensive club or society" could be
encouraged. These will reduce dissemination of false or inaccurate information by hypertensive
patients to the public and its attendant dangers. (JNatlMedAssoc. 2004;96:620-624.)

Key words: knowledge * awareness*
hypertension
INTRODUCTION
Hypertension is the commonest noncommuni-
© 2004. From the Department of Medicine, Olabisi Onabanjo Univer-
sity Teaching Hospital and the Center for Research in Reproductive
Health (CRRH), Sagamu, Ogan State, Nigeria. Send correspon-
dence and reprint requests for J Natl MedAssoc. 2004;96:620-624
to: O.B. Familoni, PO Box 29800, Secretarat Ibadan, Nigera; e-mail:
rfamiloni@justice.com
cable disease in Nigeria.' It has been estimated that
over 4.3 million Nigerians above the age of 15
years were hypertensive with systolic blood pres-
sure of 160 mmHg and above, and/or a diastolic of
95 mmHg and above.
Hypertension is recognized as a silent killer,2 as
it damages the target organs on a continuous and
progressive basis until symptoms are manifested.3
It contributes to cardiovascular morbidity and mor-
tality, and its control reduces significantly the end-
organ effects of the disease. Population-based stud-
ies have shown that hypertension accounts for up to

620 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 5, MAY 2004

35% of all atherosclerotic events, including 49% of
all cases of heart failure. It increases two- to three
times an individual's risk of various cardiovascular
consequences.4
In Nigeria, awareness about hypertension is poor,
as only 33.8% of those with elevated blood pressure
(BP) were aware of their condition.5 In a study of
patients, medical students, workers, and factory
hands in Sagamu, Nigeria, the level of information
about hypertension and its various determinants
ranged from 10-51.7%P6 Commonly in this environ-
ment, as well as in many other developing countries,
individuals with a chronic disease tend to assume the
role of "a source of information" on that disease in
the community and people in the community seek
such information from the patients. It is, therefore,
paramount that information concerning all aspects of
the disease be readily available to the general popula-
tion but particularly to patients with elevated BP.
We, therefore, sought to find out the level of
knowledge of hypertension and awareness of the dis-
ease among hypertensive patients attending the med-
ical outpatient clinic of Olabisi Onabanjo University
Teaching Hospital (OOUTH), Sagamu, Nigeria.
SUBJECTS AND METHODS
Hypertensive patients attending the medical out-
patient clinics of the OOUTH during the period of
study from June 2000 to May 2001 gave their con-
sent and were recruited into the study. These
patients have been followed up in the outpatient
clinic by the authors for periods ranging from five
years until time of study. They were taken through a
structured questionnaire asking for information on
personal data, such as age, sex, occupation, and lit-
eracy levels; knowledge of normal BP; their own
personal BP; and the place of hypertension as the
commonest noncommunicable disease in Nigeria.
Information relating to the severity of hypertension
between males and females, blacks and caucasians,
as well as the commonest symptoms of hyperten-
sion, target organ damage, and the duration of treat-
ment were also obtained.
Hospital records were reviewed to check the level
of control of BP. These patients have been followed
up by the authors over the last five years in the out-
patient clinics. Patients whose BP was <140/90
mmHg for the last three consecutive visits were clas-
sified as having good control, and all others as poor
control. Information was also obtained as to the
duration of hypertension in each patient. We recruit-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
KNOWLEDGE AND AWARENESS OF HYPERTENSION
ed all consecutive hypertensive patients who gave an
informed consent irrespective of the grade of hyper-
tension and control since our focus was on knowl-
edge of hypertension and its determinant.
A patient was adjudged as hypertensive if he
had BP >140/90 mmHg or a lower BP on antihy-
pertensive therapy.
Statistical Analysis
The STATA for Windows software was used for
the analysis. The log likelihood ratio test using the
logistic regression was used to test the univariate
significance of the association between the knowl-
edge of the determinants and some explanatory
variables, such as sex, duration of hypertension,
age group, and level of control. Multivariate analy-
sis was done to control for potential confounders
using the Mantel Haenzel method. The odds ratio
of the knowledge of the determinants was also
derived with its 95% CI. Significance was set at a p
value of <0.05. The chi-square test for trend was
also used to test if there was a significant trend in
the odds of the knowledge of hypertension strati-
fied by the explanatory variables.
RESULTS
The study group consisted of 254 hypertensive
patients, made up of 111 males and 143 females,
giving a male: female ratio of 1:1.3. The mean age
of the patients was 51.1 ± 12.2 years (Table 1), mean
age for male was 49.1 ± 13.0 years and female 52.4
+ 1 1.7 years. There was no difference in ages of the
two sexes.
One-hundred-thirty-three (52.4%) of the respon-
dents were aware that hypertension was the com-
monest noncommunicable disease in Nigeria.
Forty-six percent knew what "normal" BP was, and
52.4% had knowledge of their own BP at the time
of interview. One-hundred-twenty (47.2%) knew
that hypertension is generally more severe in blacks
than in caucasians, while 111 (43.7%) patients felt
that it is more severe in males than females. Of
note, only about one in 10 patients (11.4%) were
aware that hypertension is commonly a symptom-
less condition until effects of target organ damages
are manifested, while 116 (45.5%) and 77 (30.2%)
patients, respectively, believed that headache and
palpitation were the commonest symptoms of
hypertension. One-hundred-thirty-five (53.2%)
patients recognized stroke, and heart and renal fail-
ure as the main target organ damage in hyperten-
VOL. 96, NO. 5, MAY 2004 621
KNOWLEDGE AND AWARENESS OF HYPERTENSION
sion. Ninety-four (37%) patients were not aware
that hypertension could cause renal failure.
Only about one-third of the patients knew that
hypertension should ideally be treated for life
(35.4%). One-hundred-forty-eight (58.3%) believed
that antihypertensive drugs should be used only when
there are "symptoms," while the remaining 16 (6.3%)
believed that the treatment should be for a period
ranging from two weeks to five years but not for life.
There was adequate control of BP <140/90
mmHg) in 83 (32.7%) of the patients.
The longer the duration of hypertension, the
more likely was the patient to know "normal" BP
[OR=1.80 (1.30-2.49), P<0.001], that hypertension
is commonly asymptomatic [OR=2.7 (1.63-4.49)
P=0.001], and that hypertension treatment is for life
[OR=2.33 (1.66-3.26) P<0.0001]. The longer the
duration of hypertension the more likely they are to
know about the target organ damage [OR=1.41
(1.02-1.95) P=0.313] though this did not reach sta-
tistical significance.
There was, however, no statistically significant
association between the knowledge of hypertension
as the commonest noncommunicable disease in
Nigeria [OR=0.97 (0.71-1.35) P=0.8731] or good
control of hypertension [OR=0.97 (0.69-1.37)
P=0.8748] and the duration of hypertension.
It was observed that the older the age group of
the patient, the more likely that they would achieve
good control [OR=1.35 (1.09-1.67) P=0.0056],
knew normal BP [OR=1.42 (1.16-1.73) P=0.0007]
and knew that treatment is life-long [OR=1.41
(1.14-1.73) P=0.004]. Although there was a tenden-
cy for the older patients to know hypertension is
commonly asymptomatic, this did not reach statisti-
cal significance [OR=1.23 (0.90-1.68) P=0.2023],
as is the knowledge of target organ damage
[OR=1.07 (0.87-1.3 1) P=0.5227].
In the multivariate analysis of a model consist-
ing of the duration of hypertension and age group
combined, it was found that the association of the
variables, knowledge of normal BP [OR=1.27
(1.00-1.6)] and symptoms of hypertension [OR=
0.87 (0.89-1.47)] became weaker but was statisti-
cally significant. The same effect was also
observed in the knowledge of target organ damage.
Adjusting for both age group and duration of
hypertension combined, there was no association
with good control of BP and knowledge of hyper-
tension as the commonest noncommunicable dis-
ease in Nigeria.
622 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
DISCUSSION
There have been several community studies
about awareness of hypertension7'8 in the general
population. Awareness of hypertension among
those affected by the disease tends to be generally
higher than in the general population in our envi-
ronment.6 This study evaluated the awareness
among hypertensive patients, whom the general lay
public regard as a repository of information on the
disease condition. Moreover, these patients are
regarded as being more knowledgeable than others
on the disease condition and, thus, disseminate
information, including treatment modalities, to
people in their neighborhood.
In this study, the knowledge about hypertensive
symptoms is particularly poor, as only about one in
10 patients knew that hypertension is a disease that
for most times runs a symptomless course. Most of
the symptoms are due to target organ damage.
Prompt and adequate treatment of hypertension
will delay onset of complications and might reverse
some end organ damage.9 Waiting for onset of
symptoms, as most of the local populace are likely
to do, could delay diagnosis and medical interven-
tion. It has been observed that over 75% of hyper-
tensive patients in this environment already have
cardiac hypertrophy at the time of diagnosis.'0
For a cohort of hypertensive patients-about half
ofwhich have been attending the clinic for more than
five years-it is worrisome that only about a third
were aware that treatment for hypertension should be
life-long. The majority believed that drugs should be
taken only when they have "symptoms" or for a peri-
od of time. This practice has sometimes resulted in
disastrous consequences.'0 Hypertension treatment
should ideally be for life. Though it has been suggest-
ed that it is sometimes possible to withdraw drug
therapy and continue lifestyle-modification after sev-
eral years,'2 the consensus is that almost all who are
hypertensive before treatment will become hyperten-
sive again if treatment is stopped.'3"4
The level of satisfactory control in a third of our
patients is comparable with figures for other devel-
oping countries.7'8 A study done in China reported
satisfactory control in only 10% of their patients,
and it was also observed that the male gender and
residence in a developing country were factors
associated with poor BP control.'" The Joint Nation-
al Committee (JNC) sixth report believed that only
about half of the patients who are diagnosed as
hypertensive are adequately controlled.'6
VOL. 96, NO. 5, MAY 2004
 KNOWLEDGE AND AWARENESS OF HYPERTENSION

Most of the patients were aware that hyperten- Table 1. Distribution of Responses among
sion would cause stroke and heart failure, but a Hypertensive Patients about Knowledge and
third of the patients were not aware that it could lead Awareness of Hypertension
to end-stage renal disease (ESRD) and chronic
renal failure (CRF), which is an important cause of Variables n (%7)
morbidity and mortality in this environment'7',8 and Mean Age (Years ± SD) 51.1 ± 12.2
constituted 7.9% of all admissions to medical wards Age Distribution (Years)
in our hospital.'9 Hypertension is perhaps second <30 9 (3.5)
only to diabetes as a cause of ESRD in developed 30-39 33 (13.0)
countries of the world. It is a cause and conse- 40-49 79 (31.1)
quence of renal disease and a major determinant of 50-59 65 (25.6)
renal disease progression. One of the risk factors 60-69 51(20.1)
.70 17 (6.7)
that have been identified as predisposing hyperten-
sives to developing ESRD includes black race.20 Sex
Therefore, it is of concern that many of our hyper- Male 111 (43.7)
Female 143 (56.3)
tensive patients were ignorant of ESRD and CRF as
consequences of hypertension. The low level of Years of Diagnosis/Duration of Hypertension
awareness about hypertension in communities have <5 Years 131 (51.6)
sometimes been attributed to the quality of advice 5-10 years 78 (30.7)
> 10 years 45 (17.7)
given and the investment of time.2' In a developing
country, such as Nigeria, with a relative shortage of Knowledge of Normal BP
medical manpower and an overwhelming burden of Yes 117 (46.1)
communicable disease, adequate time and contact No 137 (53.9)
with patients are difficult. There are, however, con- Knowledge of Oneself's BP
certed efforts to improve this, and it has been sug- Yes 133 (52.4)
gested that patients with inadequate knowledge No 121 (47.6)
should be given a short clinic appointment to create Most Common Symptoms of Hypertension
more doctor-patient contact.22 Yes 29 (11.4)
In conclusion, this study has demonstrated inad- No 225 (88.6)
equate awareness of hypertension and its determi- Knowledge of Hypertension Being the
nants in patients with hypertension. Efforts should Commonest Noncommunicable Disease
be made on the part of the medical team to health in Nigeria
educate such patients as is done for other chronic Yes 133 (52.4)
illnesses, such as sickle cell disease and diabetes No 121 (47.6)
mellitus. Organization of "hypertensive club or Severity of Hypertension More in Black
society" with active participation should be en- than White
couraged, as this should diminish dissemination of Yes 120 (47.2)
inaccurate or false information by hypertensive No 134 (52.8)
patients to the community. Severity of Hypertension More in Male
than Female
REFERENCES Yes 111 (43.7)
1. Akinkugbe 00 (ed). Noncommunicable disease in Nige- No 143 (56.3)
ria-Final Report of a National Survey. Federal Ministry of Knowledge of the Target Organ's Damage
Health National Expert Committee on Non-Communicable Dis- Yes 135 (53.2)
eases Lagos. 1999 pp. 2-5. No 119 (46.8)
2. Hoel D, Howard RB. Hypertension-stalking the silent
killer. Postgrad Med J 1997;101:1 16-121. Hypertension Treatment Is for Life
3. Macmillan S, Peto R, Cutler J. Blood pressure, stroke, and Yes 90 (35.4)
coronary heart disease, part 1. Prolonged differences in blood No 164 (64.6)
pressure: prospective observational studies corrected for the Adequate Control of BP
regression dilutional bias. Lancet. 1990;335:765-774. Yes 83 (32.7)
4. Padwal R, Strauss SF, McAlister FA. Cardiovascular risk No 171 (67.3)
factors and their effects on the decision to treat hypertension. Evi-

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 5, MAY 2004 623
 KNOWLEDGE AND AWARENESS OF HYPERTENSION

dence-based review. BMJ 2001 ;322:977-980.
5. Akinkugbe 00. Current epidemiology of hypertension in
Nigeria. Arch Ibadan Med. 1999; 1:3-4.
6. Familoni OB. Hypertension-How much do our patients
know? Afr Health. 2002;24: 13.
7. Marques-Vidal P, Toumilehto J. Hypertension awareness,
treatment, and control in the community. Is "the rule of halves"
still valid? J. Hum. Hypertens. 1997; 1 1:213-220.
8. Jaddan HY, Bateiha AM, Ajlouni KM. Prevalence, awareness
and management of hypertension in a recently urbanized communi-
ty in Eastern Jordan. JHum Hypertens. 2000;14:497-501.
9. Liebeson RR, Serry RD. Significance of echocardiographic
left ventricular mass, part II. Left-ventricular remodeling, risk, and
therapeutic models for regression. Cardiol Inter 2001 ;2: 158-167.
10. Olubodun JOB, Cole TO, Falase AO, et al. Electrocardio-
graphic hypertrophic patterns in hypertensive Nigerians. Int J
Cardiol. 1991;30:97-102.
1 1. Familoni OB. High blood pressure. Med Dig. 1992; 18:54-55.
12. Salako LA. Treatment of hypertension. In: Cardiovascular
Diseases in Africa 1979. Ciba-Geigy. pp. 22-27.
13. Kaplan NM. The benefit of treating hypertension in the
elderly. In: Hypertension in the Elderly, 1999. Martin Dunitz Ltd.,
London. pp. 63.
14. 1999 WHO/ISH Guidelines for the management of hyper-
tension. Blood Press. 1999;(suppl 1)8:9-43.
15. Tao S, Wu X, Duan X, et al. Hypertension prevalence and
status of awareness, treatment, and control in China. Chi Med J
1995; 108:483-489.
16. JNC 6th report on prevention, detection, evaluation, and
treatment ofhigh blood pressure. Arch Int Med. 1997;157:2413-2446.
17. Adetuyibi A, Akinsanya JB, Onadeko BO. Analysis of the
causes of death on the medical wards of the University College
Hospital over a 14-year period (1960-1974). Trans Roy Soc Trop
MedHyg. 1976;70:466-473.
18. Oyediran ABO, Akinkugbe 00. Chronic renal failure in
Nigeria. Trop Geogr Med. 1970;22:41.
19. Ogun SA, Adelowo 00, Familoni OB, et al. Pattern and
outcome of medical admission at OSUTH Sagamu. A three-year
review WAJM. 2000;19:304-308.
20. Anderson S. Mechanisms of nephrosclerosis and glomeru-
losclerosis In: Izzo JL, Black HR (eds.) Hypertension Primer Dal-
las American Heart Association. 1993.
21. Pobee JOM. Community-based high blood pressure pro-
grams in Sub-Saharan Africa. Ethn Dis. 1993;3:538-545.
22. Kadiri S. Management of hypertension with special
emphasis on Nigeria. Arch Ibadan Med. 1999; 1: 19-21.

Department of Health and Human Services

t* 5 National Institutes of Health
Warren Magnuson Clinical Center
The Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda,
MD, is seeking a physician scientist or scientist with extensive clinical, and
management experience to serve as the Chief of the Positron Emission
Tomography Department. The PET Department presently has 3 cyclotrons, 4 PET
scanners, and supports numerous active protocols employing PET methodologies. The incumbent will be
responsible for the overall operation of the PET Department including staff supervision, the maintenance
of PET imaging equipment, and interactions with collaborating NIH Institutes. Familiarity with relevant
aspects of PET from cyclotron operation, to radiotracer production and clinical and pre-clinical
research studies is required. There are excellent opportunities for collaborative research associated with
the position. Salary and resources are negotiable and commensurate with experience.
Please submit your curriculum vitae, bibliography, and a letter describing your clinical, research,
and management experience to: Ms. Mariela Light, HR Specialist, OD, NIH, 6100 Executive Blvd.,
Rm. 3E01, MSC-7509, Bethesda, MD 20892-7509. Phone no. 301-496-6924. Email: MLight@mail.nih.gov.
For priority consideration, application packages should be submitted as early as possible, but no
later than June 30, 2004.
HHS and NIH are Equal Opportunity Employers. Selection for this
wksiRVIlCs.L, position will be based solely on merit, without discrimination for INL11\
non-merit reasons such as race, color, religion, sex, national origin,
politics, marital status, sexual orientation, physical or mental
, ijvi handicap, age or membership or non-membership in an
employee organization. EIs\'
624 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 96, NO. 5, MAY 2004