QUALITY OF LIFE AMONG HYPERTENSIVE PATIENTS ATTENDING PRIMARY HEALTHCARE CENTERS IN JEDDAH, SAUDI ARABIA

and Abdullah Mohammed Felemban 2 . 1. Al-Safa Primary Healthcare Center, Jeddah, Saudi Arabia. 2. King Fahad Hospital, Jeddah, Saudi Arabia. 3. Briman Primary Healthcare Center, Jeddah, Saudi Arabia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


Factors correlated with QOL:
Per domain analysis of factorsassociated with QOL is presented in detail in Table 3. Regarding physical health, lower scores were observed among older age category(p=0.000), widowed (p=0.000), retired and housewives (p=0.000), illiterate (p=0.000), low income (p=0.013), and high comorbidity participants (p=0.000), as well as those who are rigorously compliant with antihypertensive treatment (p=0.000). Regarding psychological health, lower scores were observed in older (p=0.001), widowed and divorced (p=0.026), retired (p=0.001), illiterate and primary educational level (p=0.000), high comorbidity participants (p=0.001), and who were fairly compliant with antihypertensive treatment (p=0.000); conversely, higher scores were observed in young single, employed and highly educated participants, as well as those without other comorbidities and in those who were moderately compliant with hypertension treatment. Regarding social relationships domain, lower scores were observed in older (p=0.039), divorced (p=0.000) participants, and in those who were fairly compliant with hypertension treatment (p=0.025). Low environmental health-related QOL scores were observed among participants with rented accommodation (p=0.0001), widowed (p=0.015), unemployed (p=0.000), illiterates (p=0.000), low income (p=0.000) and non-Saudi participants (p=0.001). Sleep quality was analyzed as a factor for QOL and showed significant correlation with all QOL domains, where related scores increased significantly with self-rated sleep satisfaction. In regression analysis, disease duration was significantly adversely correlated with lower QOL in all 4 domains ( Figure 1).

Predictors of QOL among hypertensive patients:
Predictive models for physical health showed that the number of comorbidities (0 versus 1 versus 2 or more; OR [95%CI]=0. 26 Table 4.

Discussion:-
This study assessed different QOL domains among hypertensive patients attending primary healthcare centerswho showed impaired QOL, which was more remarkable in social and environmental domains. Population distribution showed good representativeness of both genders and all social classes, while non-Saudi individuals and those with low educational level (illiterate and primary level) were more weakly represented. The most typical respondent was a married, employed and highly educated Saudi male aged below 50, living in his own propriety with an average-tohigh income, and is followedfor at least one other disease.
The average ratings of overall QOL and health satisfaction were neutral to good (scores=3.42/5 and 3.04/5, respectively), indicating relative impaired QOL in hypertensive patients. Comparative studies demonstratedthe impact of hypertension on patients' QOL as compared to random population (13)(14)(15)(16).
In our study, the highest average scores were observed in physical (61.30) and psychological (61. 16 In contrast with other studies (12,14,18) that found female patients more prone to impaired QOL, we found no gender discrepancy in any of the 4 QOL domains. Concordantly, a Brazilian study by Melchiors et al. reported no difference between genders in the 4 QOL domains (17). Other significant demographic and socioeconomic factors included age category, marital status, professional status, educational level and income, with some inter-domain differences. Lowest QOL scores were observed in older age category (>60 years), especially in physical, psychological and social relationships domains; while high educational level and high income were associated with better QOL scores in physical and environmental health domains, in addition to psychological health for educational level. Furthermore, employed professional status showed the highest score in physical, psychological and environmental health domains. These observations are consistent with findings from a Lebanese study by Khalifeh et al., reporting negative relationship of QOL with age and positive relationship with educational level (14). Similarly, Vietnamese study showed that high education level and employed professional status were significantly associated with better QOL in the 4 domains; whilenormal-to-high economic status showed higher but not statistically significant scores than poor economic one (12). In Nigerian study, increased income was predictive for improved QOL (15).
Duration of hypertension was among significant clinical factors associated with QOL, and psychological health domain was the most significantly affected, as demonstrated by the adverse collinear relationship showing linear decrease in psychological health domain score with the increase of disease duration. This suggests thatpsychological impact of hypertension in a function of time and emphasizes the need for timelyscreeningof psychological disorders such as depression and anxiety, as theyare frequentlyassociated withhypertension (19)(20)(21), especially in patients with long disease evolution.Comparably, duration of hypertension did not have significant impact on psychological health in the study by Kalifeh et al. (14); whereas it impacted both physical and psychological health in the series by Ha et al. (12).
We demonstrated that the existence of comorbidities was associated with a significant reduction of QOL-related scores. Number of comorbidities more specifically affected physical and psychological health domains. Our finding are supported by several studies showing that the existence and number of comorbidities are associated with reduced health-related QOL indicators among hypertensive patients and that physical health domain was the most affected (14,16,22). The study from Brazil identified heart failure, arrhythmia, obesity and depression as having significant additional impact on QOL of hypertensive patients (17). Another study by Palharas et al. observed significant 2207 correlation between QOL and clinical and echocardiographic symptoms of heart failure in hypertensive patients (23).
Sleep quality showed to be a significant factor for QOL. Depending on the domain, patients who were very satisfied with their sleep quality had up to 50% higher scores as compared to those who were very dissatisfied. Sleep quality has been demonstrated to be a significant factor of quality of life either in healthy people or among patients with different chronic diseases (24)(25)(26). It was even proposed to be used as a screening tool for the QOL assessment (27). However, in hypertensive patients, poor sleep quality may be the direct consequence of apneic-hypoapneic disorders; which are highly associated to the occurrence of hypertension and the diagnosis and treatment of which are crucial factors of therapeutic success and QOL improvement among hypertensive patients (28).
The number of antihypertensive medications and level of compliance were adversely correlated with the QOL. Study from Lebanon showed daily frequency of antihypertensive medication to be significant predictor for impaired QOL (14). In Nigerian study, authors observed a correlation between drug use and impaired psychological health domain, which impacted the overall QOL (15). Other authors reported low QOL scores in hypertensive patients who are adherent to pharmacologic medication (29). Several explanations could be given to these observations, whereas most probably the use of more than one antihypertensive therapy is related to disease severity and duration, which constitute the bridge between the number of medications and QOL (30).This has also been explained byunsatisfactory treatment outcome motivating medication dose escalation;which also increasesadverse drug effects. It has been shown that the existence and severity of these adverse effectsare associated with differential levels of impact on patients' QOL (31,32); and are more likely to be prevalent in patients who are compliant to pharmacotherapy (1,4). Thesemedication-related issues not only impact physical and social health but also cause a plethora of emotion, with dissatisfaction and possible depression (7).
These observations highlight the importance of patient's education regarding treatments' adverse effects and emphasize systemic assessment by physicianof benefit/risk equationfor each prescribed treatment. On the other hand, appropriate management including pharmacotherapy and lifestyle changes improves QOL, in addition to improving blood pressure control.
Although investigatedfactors were significantly associated with QOL, other plausible factors were not assessed in this study; such asthe adequate control of blood pressure, which has been demonstrated to be highly associated with QOL (33). In addition, it constitutes a crucial issue as only up to 16.1% of hypertensive patients are reported to be adequately controlled (6). Similarly, regular exerciseshould be recommended to hypertensive patients as it was demonstrated to have positive impact on controlling hypertension and improving health-related QOL especially among those with moderate hypertension (14,29,34).
Because hypertension is a non-curable disease,afflictedindividuals should benefit from lifelong management including simultaneous lifestyle modifications and pharmacotherapy in addition to close monitoring of therapeutic outcome and adverse events, all being crucial factors for improving their QOL.

Conclusion:-
Hypertensive patients have impaired health-related QOL indicators, which interests all physical, psychological, social and environmental healthdomains. Old age, unemployment, low education, and low economic class are most significant adverse demographic and socioeconomic factors forQOL; whileadverse clinical factors includelong disease duration, existence of comorbidities and greater use of antihypertensive medications.
The association and interaction between various aspects of hypertension and its management and patients' demographic, socioeconomic and clinical factors further display the complexity of assessing the health-related QOL. Appropriate management of hypertensive patients should includea comprehensive assessment of all these aspects to implement targeted lifestyle modifications in association with pharmacotherapy; along with close monitoring of therapeutic outcome and adverse effects, all being crucial factors for improving patients' QOL.