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American Journal of  Medical 
Science and Innovation (AJMSI) 

Quality of  Counseling About Lifestyle Modifications and Complications of  
Hypertensive Patients, Sudan

Sahar Moawia Balla Elnour1*, Ziryab Zainelabdin Mohamed Elmahdi2, Fatima Hassan Salman Nasr2

Samar Moawia Balla Elnour3, Ibtisam Ali4

Volume 2 Issue 2, Year 2023
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v2i2.2115
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: September 17, 2023
Accepted: October 23, 2023
Published: October 27, 2023

Hypertension is a common chronic disease and an important public health problem. 
Effective hypertension control depends on patients being aware of  the necessary lifestyle 
modifications. This study aimed to assess the quality of  counseling received by hypertensive 
patients, the influence of  blood pressure control and complications of  hypertension. This 
cross-sectional study was conducted on hypertensive patients attending a private medical 
facility, a governmental facility and a PHC (Primary Health Care) center in Sudan. The 
patients were randomly selected, and their waist circumference, height and weight were 
recorded. The participants received counseling from family physicians and SHOs (Senior 
House Officers) about diet, mental relaxation, weight loss, exercise, smoking, and alcohol. 
The follow-up doctor vs. counseling showed a significant difference in counseling about 
diet, salt, fat intake, and smoking. The quality of  counseling depended on the doctor rather 
than the follow-up location. The quality of  counseling offered to hypertensive patients 
depends on the doctor rather than the location; almost half  of  the participants had to 
follow up with SHOs, including half  of  the participants with complications, and only a 
quarter received counseling about complications. For hypertensive patients, the quality 
of  counseling depends on the doctor rather than the location. Recommendations include 
prioritizing lifestyle modifications and ensuring doctors are sensitive and aware of  their 
counseling tactics with patients.

Keywords
Counseling Quality, Doctor 
Sensitization, Hypertension, 
PHC Hospitals

1 Ministry of  Health, Sudan Medical Specialization Board, Sudan
2 Sheikh Khalifa Medical City, United Arab Emirates
3 Ibn Roshd Educational Holding Company, Al Liwa ضايرلا, Saudi Arabia
4 Medicine and Cardiology, International University of  Africa & Ahmed Gasim Hospital, Sudan
* Corresponding author’s e-mail: shimlinjahan2208@gmail.com

INTRODUCTION
Hypertension is a global health challenge common 
in semi-urban, urban and rural areas and should be 
monitored and treated vigilantly across the lifespan 
(Lemogoum et al., 2018). It is caused by cardiovascular 
diseases associated with other serious miscellaneous 
illnesses and a high fatality rate.(Petrie et al., 2018) The 
rapid rate of  obesity and old age are the two major factors 
contributing to its common occurrence in the community 
(Mosha et al., 2017).
The rationale for this study stems from the fact that the 
prevalence of  hypertension in the general population 
is 30%-45%, increasing with age. (Kjeldsen, 2018) 
Hypertension is expected to rise by 60% by 2025 to 1.56 
billion adults (Akoko et al., 2017). Lifestyle changes may 
be an effective way of  preventing/delaying hypertension 
or evading pharmaceutical treatment in patients with 
grade 1 hypertension and reducing BP in patients who 
are already treated (Bogale et al., 2020; Ferdinand et al., 
2020).
Thus, this study aims to investigate whether effective 
hypertension solutions are impacted by the quality of  the 
doctor and the counseling received.

MATERIALS AND METHODS
Selection and Description of  Participants
Our study was a repeated cross-sectional hospital/PHC 
center-based study. The Cochran formula collected the 
sample size for 384 out-patients attending Alzaytouna 

Specialized Hospital, Alakadimiy Charity Hospital and 
Omer Ibn Elkhatab PHC center. Of  those 384, 250 
participants remained after excluding questionnaires 
with missing essential data such as weight and waist 
circumference, and the remaining participants were 
interviewed via questionnaire. Weight, height and waist 
circumference were recorded via weight scale and tape.

Sample Size 
After the patient’s voluntary informed consent was 
obtained in written form, 102 patients were interviewed 
at a governmental medical facility, 97 were interviewed 
at a private medical facility, and the remaining 51 were 
interviewed at a PHC center; the males were 139 (55.6%), 
and the females were 111 (44.4%), their ages ranged 
between 23-89 years. Participants who were married were 
82%, 13.6% were uneducated, the remaining participants 
received some education, and 57.6% were employed. 
We divided the population into three groups; the first 
group was properly diagnosed patients by a physician, the 
second group was patients on hypertensive drugs, and the 
third group had patients who suffered from hypertension 
for at least 1 year. The study was carried out between 
January and September 2017.

Statistics
At the beginning of  this study, the researchers adhered 
to the STROBE guidelines. Statistical software packages 
(Excel and Access, Microsoft, Redmond, WA; SPSS 25.0, 



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Am. J. Med. Sci. Innov. 2(2) 164-170, 2023

SPSS Inc. Chicago, IL) were used for data management 
and analysis, respectively. The chi-square or Fisher 
exact test was used for comparisons of  proportions in 
two groups. Groups were assumed to statistically differ 
significantly when the probability level was less than 0.05, 
i.e. p < 0.05.

RESULTS
The most frequent age group was 60-69 years at 30.8%, 
followed closely by the age group 50-59 years at 29.6%, 
and the mean ± standard deviation was 58.77± 6.80 
years. Table 1 shows the demographic data of  the 250 
participants: the frequency and the percentage value 
of  the age groups, marital status, educational level and 
employment status of  the participants. 
Table 2 demonstrates the demographic data, and 
its association with blood pressure control adjusted 
OR (Odds Ratio) and 95% CI (Confidence interval) 
showed a statistically significant difference (p=0.005). 
Controlled blood pressure was most common in the age 
group of  50- 59 years (34.6%), followed closely by 60-
69 years (29.8%), and uncontrolled blood pressure was 
most frequent in the age group 60-69 years (33.9%). In 
contrast, the remaining demographic data did not show 
any significant association with blood pressure control: 
sex vs blood pressure control (p=0.338), marital status 
vs. blood pressure control (p=0.238), educational level vs. 
blood pressure control (p=0.368), employment vs. blood 
pressure control (p=0.548). 
Table 3 shows the demographic data vs. complications 
presence, age groups vs. complications presence 
demonstrated a statistically significant difference with 
an adjusted OR and 95% CI (p=0.043); the presence of  
complications was most frequent in the age group of  60-
69 years (29%), and none existed in the age group of  20-
29 years, the sex vs. complication presence adjusted OR 
and 95% CI showed a statistically significant difference 
(p=0.030), as 66.7% males and 33.3% females show 
complications presence. The remaining demographic 
characteristics vs. complications presence analysis were 
statistically insignificant: marital status vs. complications 
presence (p=0.405), educational level vs. complications 
presence (p=0.432), and employment vs. complications 
presence (p=0.436). 
The follow-up doctor vs. counseling offered can be seen 
in Table 4. The counseling offered about diet and the salt 
intake adjusted OR and 95% CI showed a statistically 
significant difference, (p=0.002) and (p=0.019), 
respectively. All participants following up with a family 
physician received counseling about diet as well as salt 
intake. The percentage of  participants following up with a 

physician and registrar who received counseling about diet 
as well as salt intake was 96.7% and 92.3%, respectively, 
while 82.4% of  participants following up with an SHO 
received counseling about diet whereas 86.6% received 
counseling about salt intake. The follow-up doctor vs. 
counseling offered about fat intake adjusted OR and 95% 
CI showed a statistically significant difference (p=0.013); 
96.4% of  participants following up with a family physician 
received counseling about fat intake while 96.7% of  the 
participants following up with a physician received the 
counseling. Participants following up with the registrar 
and receiving counseling about fat intake were 92.3%, 
while the percentage of  participants following up with an 
SHO who received the counseling was 84%. 
The follow-up doctor vs. counseling offered about 
mental relaxation adjusted OR and 95% CI showed 
a statistically significant difference (p=0.001), all the 
participants following up with a family physician or a 
registrar received counseling about mental relaxation, 
whereas 77.8% and 95% of  the participants following up 
with a physician and an SHO respectively, received the 
counseling. The follow-up doctor vs. smoking counseling 
(passive, active and cessation) adjusted OR and 95% CI 
showed a statistically significant difference (p=0.012), 
75.6% of  all the participants received counseling about 
smoking. A total of  67.9% of  participants following 
up with a family physician and 65.6% of  participants 
following up with a physician received counseling about 
smoking. Nearly 84.6% of  participants following up with 
a registrar received the counseling while the percentage 
that received counseling from an SHO was 84%. 
The follow-up doctor vs. counseling offered about 
alcohol consumption adjusted OR and 95% CI showed 
a statistically significant difference (p=0.001); 3.6% of  
all the participants received counseling about alcohol 
consumption, 50% of  the participants followed up with 
a family physician, 46.7% of  the participants following 
up with a physician, 76.9% following up with a registrar 
while 78.2% of  participants following up with an SHO 
received counseling about alcohol consumption. The 
remaining follow-up doctor vs. counseling offered 
analysis was statistically insignificant with (p>0.5) fruit 
intake (p=0.424), vegetable intake (p=0.787), weight loss 
(p=0.473), and exercise (p=0.230).
Table 5 shows the follow-up location vs. counseling 
offered about hypertension (p=0.872). Approximately 
45.5% of  the participants who received counseling about 
hypertension were followed up at a private medical facility, 
33.7% at a PHC center and 20.8% at a governmental 
facility.

Table 1: Demographic Data
Sex Frequency Percentage
Males 139 55.6
Females 111 44.4
Age Group Frequency Percentage
20-29 years 3 1.2



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30-39 years 9 3.6
40-49 years 40 16.0
50-59 years 74 29.6
60-69 years 77 30.8
70-79 years 36 14.4
80-89 years 11 4.4
Marital status Frequency Percentage
Single 6 2.4
Married 205 82.0
Divorced 9 3.6
Widowed 30 12.0
Educational level Frequency Percentage
Uneducated 34 13.6
Quran School (Khalwa) 10 4.0
Primary school 36 14.4
Secondary school 74 29.6
University 88 35.2
Postgraduate studies 8 3.2
Employment Frequency Percentage
Employed 144 57.6
Unemployed 106 42.4

Table 2: The demographic data vs. blood pressure control
Variable Frequency Controlled Blood Pressure

Sex
Male 139 (55.6%) 103 (53.9%) 36 (61.0%)
Female 111 (44.4%) 88 (46.1%) 23 (39.0%)
Age
20-29 3 (1.2%) 2 (1.0%) 1 (1.7%)
30-39 9 (3.6%) 4 (2.1%) 5 (8.5%)
40-49 40 (16%) 33 (17.3%) 7 (11.9%)
50-59 74 (29.6%) 66 (34.6%) 8 (13.6%)
60-69 77 (30.8%) 57 (29.8%) 20 (33.9%)
70-79 36 (14.4%) 22 (11.5%) 14 (23.7%)
80-89 11 (4.4%) 7 (3.7%) 4 (6.8%)
Marital Status
Single 6 (2.4%) 6 (3.1) 0
Married 205 (82.0%) 158 (82.7%) 47 (79.7%)
Divorced 9 (3.6%) 5 (2.6%) 4 (6.8%)
Widowed 30 (12.0%) 22 (11.5%) 8 (13.6%)
Educational Level
Uneducated 34 (13.6%) 24 (12.6%) 10 (16.9%)
Quran School (Khalwa) 10 (4.0%) 6 (6.3%) 4 (6.8%)
Primary school 36 (14.4%) 30 (15.7%) 6 (10.2%)
Secondary school 74 (29.6%) 55 (28.8%) 19 (10.2%)
University 88 (35.2%) 69 (36.1) 19 (32.2)
Postgraduate Studies 8 (3.2%) 7 (3.7%) 1 (10.7%)



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Employment
Employed 144 (57.6%) 113 (59.2%) 31 (52.5%)
Unemployed 106 (42.4% 78 (40.8%) 28 (47.5%)

Table 3: The demographic data and Complications presence
Variable Frequency Complications Presence

Yes No
Sex
Males 139 46 93

(55.6%) (66.7%) (51.4%)
Females 111 23 88

(44.4%) (33.3%) (48.6%)
Age Groups
20-29 years 3 0 3

(1.2%) (0.0%) (1.7%)
30-39 years 9 3 6

(3.6%) (4.3%) (3.3%)
40-49 years 40 10 30

(16.0%) (14.5%) (16.6%)
50-59 years 74 14 60

(29.6% ) (20.3%) (33.1%)
60-69 years 77 20 57

(30.8%) (29.0%) (31.5%)
70-79 years 36 17 19

(14.4%) (24.6%) (10.5%)
80-89 years 11 5 6

(4.4%) (7.2%) (3.3%)
Marital Status
Single 6 0 6

(2.4 %) (0.0%) (3.3%)
Married 205 57 148

(82.0%) (82.6%) (81.8%)
Divorced 9 2 7

(3.6%) (2.9%) (3.9%)
Widowed 30 10 20

(12.0%) (14.5%) (11.0%)
Education Level
Uneducated 34 9 25

(13.6%) (13.0%) (13.8%)
Quran School (Khalwa) 10 4 6

(4.0%) (5.8%) (3.3%)
Primary school 36 10 26

(14.4%) (14.5%) (14.4%)
Secondary school 74 23 51 (28.2%)

(29.6%) (33.3%)
University 88 19 69

(35.2%) (27.5%) (38.1%)
Postgraduate studies 8 4 4



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Primary school (3.2%) (5.8%) (2.2%)
Employment Status
Employed 144 37 107

(57.6%) (53.6%) (59.1)
Unemployed 106 32 74

(42.4% (46.4%) (40.9%)

Table 4: Follow-up Doctor Vs. Counseling Offered
Follow doctor up 
counselling offered

Physician Family physician Registrar S.H.O
Yes No Yes No Yes No Yes No

Diet 96.7% 3.3% 100% 0.0% 92.3% 7.7% 82.4% 17.6%
Low salt intake 96.7% 3.3% 100% 0.0% 92.3% 7.7% 86.6% 13.4%
Low-fat intake 96.7% 3.3% 96.4% 3.6% 92.3% 7.7% 84.0% 16.0%
High fruit intake 84.4% 15.6% 92.9% 7.1% 92.3% 7.7% 80.8% 9.2%
High Vegetable Intake 84.4% 15.6% 89.3% 10.7% 92.3% 7.7% 84.0% 16.0%
Weight Loss 90.0% 10.0% 96.4% 3.6% 92.3% 7.7% 95.0% 5.0%
Exercise 90.0% 10.0% 82.1% 17.9% 92.3% 7.7% 94.1% 5.9%
Mental Relaxation 77.8% 22.2% 100% 0.0% 100% 0.0% 95.0% 5.0%
Smoking Counseling 65.6% 34.4% 67.9% 32.1% 84.6% 15.4% 84.0% 16.0%
Alcohol Counseling 46.7% 53.3% 50.0% 50.0% 76.9% 23.1% 78.2% 21.8%

*SHO- Senior House Officer

Table 5: Follow-up Location Vs. Counseling About The Nature Of  Hypertension
PHC Centre Private medical facility Governmental medical facility

Yes 33.7% 45.5% 20.8%
No 20.9% 45.2% 20.4%

DISCUSSION
In 2009, a paper reviewed many studies investigating 
adherence to medication among patients with chronic 
conditions in Middle Eastern countries, including Sudan. 
A comprehensive literature search yielded 19 relevant 
studies that focused on the extent and predictors of  
non-adherence to medication adherence across different 
conditions, including hypertension. Patients gave a wide 
range of  reasons for non-adherence to medications, 
which included a lack of  health education (Al-Qasem 
et al., 2011). According to the AHA (American Heart 
Association) paper on medical training to achieve 
competency in lifestyle counseling, “AHA emphasized the 
importance of  lifestyle in its 2020 goals for cardiovascular 
health promotion and disease reduction.” (Hivert et al., 
2016).
In Sudan, health services are provided at all three levels: 
primary, secondary and tertiary levels in both the private 
and governmental sectors.(Salim & Hamed, 2018) Most 
patients obtain medical treatment and counseling during 
their treatment, but sadly, many doctors do not have the 
knowledge and are not trained enough (Belaid et al., 2020). 
Consequently, this increases costs for investigations and 
treatment or even hospital admissions. Nonetheless, 
an educated doctor who has good knowledge about 
the significance of  counseling and its contents and 
consequences can provide suitable information to 

patients.
A slight modification in the lifestyle behavior of  the 
patient can positively impact the outcomes of  even 
chronic diseases such as hypertension just by appropriate 
counseling to the patient and motivating them to 
implement the plan set by themselves with the assistance 
of  their doctor to achieve the best possible control 
for the patient blood pressure and decreasing the risk 
for complications. A lifestyle modification such as diet 
(DASH) has significantly decreased SBP and DBP for as 
long as 18 months in patients with good adherence in a 
randomized control trial (Poggio et al., 2019).
Patient counseling is a process that involves doctors, 
pharmacists or healthcare personnel who advise about 
the method of  intake of  medicine and precautions, either 
in the form of  prescription or verbally, to patients, their 
family members or caretakers (Mináriková et al. 2019). 
In this study, the focal aim was to study the quality of  
counseling about lifestyle modifications received by 
hypertensive patients and assess and compare the quality 
offered by SHOs, registrars, family physicians and 
physicians concerning the location (Arija et al., 2018). 
In 25 of  the 35 interviews conducted, only one lifestyle 
modification counseling was offered. In 7 visits, counseling 
about 2 topics was given: 3 times weight loss and diet 
combined, 3 times diet and exercise; and 1 time exercise 
and smoking. In 3 visits, advice on 3 topics was combined 



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(weight loss, diet and exercise), but the counseling never 
accommodated all the lifestyle modifications.
A significant statistical difference was noted in the 
distribution of  participants (PHC center, private medical 
facility or governmental facility) vs. the doctor they 
followed up with (physician, family physician, registrar or 
SHO). In contrast, the counseling about the nature of  
hypertension vs. location of  follow-up was statistically 
indifferent; almost half  of  all the participants who 
received counseling about hypertension followed up at 
a private medical facility. However, the same is true for 
half  of  the participants who did not receive counseling. 
Considering that all the doctors were available at the three 
locations, we can assume that the quality of  counseling 
depends on the doctor rather than the location.
Approximately a quarter of  all participants had 
complications, half  of  whom followed up with an SHO, 
of  which only a quarter received counseling about 
complications. We may consider the reason behind this 
fallout is that SHOs have limited knowledge because of  
a lack of  years of  experience. Also, this might be due to 
their limited time to see each patient and the fact that 
hypertensive patients with complications should follow 
up with a specialist.(Hernandorena et al., 2017) The 
participants who had complications followed up at a 
PHC center and a private medical facility equally, while 
the remaining followed up at a governmental facility. 
Through these findings again, we can assume that the 
quality of  counseling depends on the doctor rather than 
the location. However, unfortunately, there is a prevalent 
belief  among the Sudanese people that patients receive 
better health care services in private facilities.(Salim & 
Hamed, 2018) Approximately half  of  the participants 
who had complications had hypertension for 11-20 
years, while most complication-free participants had 
hypertension for 5 years or less. 
The location of  the follow-up showed an association, 
with almost half  of  the participants with controlled blood 
pressure followed up at a private medical facility. Blood 
pressure control vs. age group was statistically significant 
(p=0.005), where the controlled blood pressure was most 
observed in the age group 50-59 years, uncontrolled 
blood pressure was most frequent in the age group 
60-69 years in consensus with a study carried in which 
individuals aged ≥60 years had significantly lower rates 
of  blood pressure (Mente et al., 2018). Blood pressure 
control among sexes was close to equal; 55.6% were 
males, and 44.4% were females, which agreed with the 
same research study performed in the USA; women had 
lower blood pressure control rates than men (Alabousi 
et al., 2017). However, in another study, the females had 
higher attainment of  controlled blood pressure levels, 
where 75.7% of  males and 90.0% of  females attained 
their target blood pressure (Ademe et al., 2019).

CONCLUSIONS
The current study has concluded that the quality of  
counseling offered to hypertensive patients depends on 

the doctor rather than the location; in almost half  of  the 
participants who followed up with SHOs, including half  
of  the participants with complications, only a quarter 
received counseling about complications that may arise 
from hypertension. The counseling was for above-
average, hypertensive patients with complications who 
tended to follow up either at a PHC center or a private 
facility, especially given that private facilities have the 
largest amount of  participants with controlled blood 
pressure. Counseling a patient about lifestyle modification 
is a priority according to the 2014 Sudanese guideline for 
managing hypertension in adults; lifestyle modification 
should be recommended for all people with hypertension 
and pre-hypertension.

RECOMMENDATIONS
The current study recommends educating doctors and 
especially SHOs through brief  lectures about different 
aspects of  lifestyle modification counseling and its 
importance for hypertensive patients. Exploring the 
barriers to achieving a 100% in all lifestyle counseling 
categories, such as social habits cessation, can be sought 
out by physicians to know their reasons for the lack 
of  asking. Creating and handing out simple brochures 
about lifestyle modifications and their importance 
to hypertensive patients in clinics, PHC centers, and 
hospitals would also be a helpful initiative.
 
Acknowledgments
The corresponding author is grateful to her mentors and 
teachers at the Sudanese Society of  Hypertension and 
my college at the Young Investigators Office for their 
supervision, guidance and continuous support throughout 
this work. The author paid her earnest gratitude to the 
participating patients, without whom this work would not 
have been prosperous in the first place.

Ethical Approval
Permission from the Hospital/PHC center administration 
was obtained. The study also received its ethical clearance 
from SIRB (SUMASRI Institutional Review Board, 
University of  Medical Sciences and Technology). The 
study’s protocol, aims and benefits were explained to all 
the participants, and written voluntary informed consent 
was obtained from each participant.  

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