Difficulties in treating hypertension in resource-limited settings: A cross-sectional study of four district hospitals in Rwanda

Abstract

Hypertension is a common non-communicable diseases and the major risk factor for cardiovascular disease, stroke and chronic kidney disease. Methods We conducted a cross-sectional study in four rural Rwandan DH from April to July 2014 to review factors associated with adherence in population of low socio-economic status, cost and availability of antihypertensive drugs; knowledge of clinicians on antihypertensive drug prescription, cost and availability of these drugs in the hospitals and their communication to patients, all of which would contribute to poor BP control. The study targeted hypertensive patients, clinicians and registries for medication availability and costs. Results Of 112 study patients, 90 (80.4%) were female; 102 (91.1%) lived from subsistence farming, 95.5% are covered by community health insurance and 47 (42.3%) were illiterate. The median age was 61 years. Mean weight was 60.2 kg [SD 12.8], mean height of 159.1 cm [SD 10cm] giving a mean BMI of 23.5 kg/m2 [SD 4.4]. Mean systolic BP was 152.6 mmHg [SD 23.7] and mean diastolic BP was 90.9 mmHg [SD 14.2] and 63 (76.4%) did not meet BP goal value. High adherence was found in 86 (76.8%) patients and was associated with hospital in which patients were followed (p 0.001), to whether the patient received his medication in the hospital pharmacy (p 0.004) and education with ability to read (p 0.01). Antihypertensive drugs; Nifedipine, hydrochlorothiazide, furosemide, captopril, methyldopa, atenolol and spironolactone had been available in all hospitals for the previous four months and at affordable price considering community health insurance coverage. Half of clinicians (15/30, 50%) admitted to be non adherence to hypertension treatment guidelines and to constitute a key barrier to BP control of their patients. Loop diuretic was chosen as class of first choice to start to a newly diagnosed patient of hypertension without associated complications or other diagnoses by 36.7% clinicians and is most used in monotherapy to treat hypertension by 43.3%. Conclusions

Patients characteristics including adherence and health facility factors involving cost and availability of antihypertensive drugs are conducive at DH, despite, patients followed at DH have low level of BP control. Clinician factors including knowledge of standard of care of hypertension and communication are barriers to be improved. From this study, key interventions in Rwandan DH should be hypertension treatment guideline training for clinicians and initiating patient-centered care systems to improve BP control.