SQU Med J, August 2011, Vol. 11, Iss. 3, pp. 349-356, Epub. 15th aug 11
Submitted 4th Dec 10
Revision ReQ. 11th Apr 11, Revision recd. 10th May 11
Accepted 8th Jun 11

1Ministry of Health, South Batinah Region, Oman; 2Ministry of Health, Dakhliyah Region, Oman; 3Ministry of Health, North 
Sharqiah Region, Oman; Ministry of Health, Oman; 4Department of Family Medicine & Public Health, College of Medicine & Health 
Sciences, Sultan Qaboos University, Oman.
*Corresponding Author email: zakiya95@hotmail.com

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 
 

  18≤ 41150%
  3459
P < 0.05
 39%   95%
 P≤ 0.0016.4%44 34 95%
  58%P 0.02 18.5%
47%24% 
 56.3% 58.2%
 60%  



 :مفتاح الكلمات

aBstract: Objectives: This study aimed to estimate the prevalence of uncontrolled hypertension (HTN) 
among Omani hypertensive patients, on treatment and under primary health care (PHC) follow-up in Al Seeb 
Wilayat, Oman. Socio-demographic and clinical factors were explored for possible influence on blood pressure 
(BP) control. Methods: Based on an assumption of 50% prevalence of uncontrolled HTN, a retrospective data 
collection was conducted on the last three follow-up visits of 411 randomly selected Omani adults (≥18 years) from 
3,459 hypertensive patients. Adequate BP control was defined using criteria from 7th Report of the Joint National 
Committee on Prevention Detection Evaluation & Treatment of High Blood Pressure (JNC-7). A P value of <0.05 
and odds ratios with 95% confidence interval were used to assess for association. Results: The targets for adequate 
BP control were achieved in 39% of the studied patients (95% confidence interval [CI]: 34–44%). Lower BP control 
was found among hypertensives with diabetes (6.4%, P = <0.001) and renal disease (18.5%, P = 0.02); those with 
cardiovascular disease (CVD) showed relatively better control (58%). Age and gender had no impact on BP control. 
Most patients were only on one (24%) or two (47%) antihypertensive medications, the most frequently used being 
β-blockers (58.2%) and diuretics (56.3%). Conclusion: HTN is not adequately controlled in over 60% of treated 
patients; the presence of co-morbidity and less than aggressive treatment are significant contributors. Improving 
the quality of HTN care is a priority; effective efforts should be undertaken to improve BP control. 

Keywords: Hypertension; Primary care; Oman

Prevalence of Uncontrolled Hypertension 
in Primary Care Settings in Al Seeb Wilayat, 

Oman
Rashid Al-Saadi,1 Sulaiman Al-Shukaili,2 Suleiman Al-Mahrazi,3 *Zakiya Al-Busaidi4

CLINICAL & BASIC RESEARCH



Prevalence of Uncontrolled Hypertension in Primary Care Settings in Al Seeb Wilayat, Oman

350 | SQU Medical Journal, August 2011, Volume 11, Issue 3

Advances in Knowledge
1. Control of hypertension (HTN) among Omani adult hypertensive patients on treatment was significantly suboptimal.
2. Hypertensive patients who were obese, diabetic or had renal disease were at higher risk for uncontrolled HTN.
3. It is likely that the treatment of most hypertensive patients was inadequate and should have been more aggressive.
4. It seems that our primary care physicians have insufficient knowledge and experience in treating HTN to achieve international targets.

Applications to Patient Care
1. Improving the quality of HTN care in primary health care settings is a priority and effective efforts need to be undertaken in this regard.
2. Hypertensive patient who are also obese or diabetic should be targeted for a greater attention to blood pressure control.
3. Primary care physicians should be encouraged to become familiar with updated evidence-based HTN management guidelines.

Hypertension (HTN) is a major  medical problem affecting more than 1 billion individuals worldwide.1 It is 
sufficiently common to represent a public health 
concern in Oman as well. According to preliminary 
data from the World Health Survey is 2008 
(currently in press), the community prevalence of 
HTN in the country was estimated to be 40% and 
a further 17% of the population had pre-HTN.2 
Three quarters of this hypertensive population were 
found to be unaware of their HTN. Solid data on the 
number of hypertensive patients under follow-up at 
different health facilities is limited.

Across the globe, it is well established that high 
blood pressure (BP) is a leading modifiable risk 
factor for cardiovascular disease, cerebrovascular 
disease, heart failure and renal disease.3,4 
Reviewed literature has shown a consistent, strong 
relationship between higher levels of both systolic 
and diastolic BP, as well as mortality from these 
diseases.5 Generally, the higher the BP, the greater 
is the risk. Cohort studies and randomised clinical 
trials have shown that the risks from raised HTN 
can be partially reversed if an optimal BP control is 
achieved.6,7

HTN has been considered to be a common  
reason for patients to be seen by primary care 
physicians.8 It is generally accepted that well organised 
healthcare can improve the outcome in hypertensive 
patients,9 and clinical trials have clearly demonstra- 
ted that adequate BP control can be achieved in most 
patients.10,11 Still, uncontrolled HTN is a challenge 
for primary health care (PHC) services all over the 
world. The direct reasons for this global epidemic 
of uncontrolled HTN are not well understood, but 
it seems that the barriers for adequate control of 
HTN are complex and arise from a combination 
of factors related to patients, physicians and health 
systems.12 Studies have shown the influence of 

socio-demographic factors, such as age, gender and 
co-morbidity, on HTN control was variable with 
contradictory findings.13‒16 Similar findings have 
been shown for the influence on BP of the number 
of antihypertensive medications taken by patients.

The prevalence of uncontrolled HTN in Oman 
and possible associated factors have not been 
adequately studied to date. Only a single small study 
was conducted between 1998 and 2002 in a tertiary 
hospital setting and it showed that BP control was 
35% for Omani hypertensive patients examined, 
versus 53% for non-Omani.17

The current study aims to obtain an insight into 
the prevalence of uncontrolled HTN among Omani 
hypertensive patients on treatment and follow-up 
at the PHC settings in an urban town in Oman. 
Furthermore, certain socio-demographic and 
clinical factors will be explored for their possible 
influence on BP control.

Methods
The study was conducted using a retrospective data 
collection of hypertensive patients seen in the six 
PHC centres serving Al-Seeb Wilayat, an urban 
area belonging to the Muscat governorate of Oman. 
Al-Seeb is the most populated wilayat (district) in 
Oman with more than 225,000 residents.18 A total 
of 3,459 patients were registered as hypertensive 
patients and were under-follow up at HTN 
Clinics in these six PHC centres by 1 June 2009. A 
hypertensive patient usually attends the clinic every 
one to three months for follow-up and on monthly 
basis for a repeat prescription.

The sample size based on the assumption of a 
50% prevalence of uncontrolled BP, α = 0.05, and 
permissible error of 5% on either side of the estimate 
to be around 400. To account for the inclusion 
criteria, a total of 500 patients were then selected 



Rashid Al-Saadi, Sulaiman Al-Shukaili, Suleiman Al-Mahrazi, Zakiya Al-Busaidi

Clinical and Basic Research | 351

randomly using computer-generated numbers. All 
adult Omani hypertensive patients aged ≥18 years, 
who had made at least three previous PHC visits 
and had been on antihypertensive medications for 
at least 6 months, were included. Newly diagnosed 
individuals, those having less than three previous 
BP readings and those without any follow-up 
in the previous 6 months were excluded from 
the study. Despite being at risk of inadequate 
BP control, hypertensive patients who were not 
on pharmacotherapy were also excluded as the 
majority of them were found to be either newly 
diagnosed, or not on the expected regular follow-
up. A total of 411 patients (82.2%) met the inclusion 
criteria. Figure 1 summarises the selection process 
of the patients in the study.

The following information was collected from 
the electronic records of the patients’ last three 
visits: age, gender, duration of follow-up, three 
most recent BP readings, presence of co-existing 
diseases, current smoking status, body mass index 
(BMI), prescribed regular medications, frequency 
of attendance at the outpatient clinic (in the 
last 6 months) and presence or absence of care 
continuity. The traditional definition of 'continuity 
of care' is the patient's experience of a “continuous 
caring relationship' with an identified health care 
professional”.19 In this study continuity of care was 
defined as any included patient having been seen by 
same physician in the last three visits.

Uncontrolled HTN was defined based on 
guidelines from 7th Report of the Joint National 
Committee on Prevention Detection Evaluation 
& Treatment of High Blood Pressure (JNC-7) as 
a BP of >140/90 mm Hg or >130 mmHg systolic 

and >80 mmHg diastolic with coexisting diabetes 
or renal disease.1 Uncontrolled HTN was based on 
the average of the collected three BP readings and 
it could be either uncontrolled in systolic, diastolic 
or both. 

Data were entered by authors 1 and 3, then 
analysed by author 2 using the Statistical Package for 
Social Sciences (SPSS, IBM, USA, Version 17.0). The 
chi-squire test was used to evaluate the association 
between qualitative variables (uncontrolled HTN 
and different independent variables). A P value of 
0.05 or less was considered statistically significant. 
In addition, variables with a P value of less than 0.25 
were included in a multivariate logistic regression 
model. Odds ratios (OR) with a 95% confidence 
interval for those variables was then estimated. 
Ethical approval was obtained from the Regional 
Research and Ethics Committee, Directorate 
General of Health Services, Governorate of Muscat.

Results
Data on a total of 411 subjects who met the inclusion 
criteria were analysed. The mean length of follow-
up in the same clinic for the studied population was 
5 ± 2 years. Their mean age ± standard deviation 
(SD) was 57 ± 12 years, and 68% (n = 281) were 
females. Only 39% (n = 160; 95% confidence 
interval [CI]: 34–44%) had a mean BP up to the 
goal. Table 1 describes the demographic and clinical 
characteristics of the patients with controlled and 
uncontrolled HTN. It can be observed that the age 
and gender of the subjects had no impact on BP 
control. Smoking was a measurable problem as 8% 
(n = 34) of subjects were documented as smokers; 

Total Hypertensive patients in Seeb Wilayat 
(n = 3459)

Representative sample (n = 500)

Eligible (n = 411) Not Eligible (n = 89)

-  More than 3 visits
-  Age >18
-  On antihypertensive medications for > 6 months
-  Omani
-  On medication 

-  Less than 3 visits
-  Age <18
-  On antihypertensive medications for < 6months
-  Non-Omani
-  Not on medication
-  No follow-up in last 6 months 

Figure 1: Selection of patients in the study.



Prevalence of Uncontrolled Hypertension in Primary Care Settings in Al Seeb Wilayat, Oman

352 | SQU Medical Journal, August 2011, Volume 11, Issue 3

however, they were equally divided between the 
controlled and uncontrolled groups (P = 0.59).

Around 23% of hypertensive patients in this 
study were diabetic; 47% were dyslipidemic; 9% 
had cardiovascular disease (CVD), and 6.5% were 
labelled as having kidney disease. The presence of 
diabetes mellitus or chronic kidney disease was 
associated with significantly poorer BP control, as 

more than 93% (n = 88/94) and 81% (n = 22/27) of 
these patients respectively had uncontrolled HTN. 
The presence of CVD, however, was associated with 
relatively better BP control, as 58% of hypertensive 
patients with CVD achieved their BP targets. 
The presence of dyslipidemia failed to show any 
association with the control of HTN. In addition, 
74% (n = 305) of the total subjects were overweight 
(27%) or obese (47%). Of those who were obese, 
69% failed to achieve their BP targets (P = 0.02). 
Being overweight was not a determinant of HTN 
control status, nor was normal weight.

Only 29 individuals (7%) of the total 411 
analysed subjects experienced continuity of care in 
relation to their HTN management and follow-up. 
The statistical analysis did not  show any association 
between continuity of care and HTN control (P = 
0.89). Of 276 individuals with a history of non-
adherence to scheduled HTN clinic follow-up 
appointments, 72% had inadequate BP control. 

A total of 100 subjects (24%) were on a single 
anti-hypertensive medication, 193 subjects (47%) 
were on two medications, 96 subjects (23%) were 
on three medications, and only 18 subjects (4%) 
were on more than three anti-hypertensive drugs  
[Table 2]. Those on monotherapy were more 
likely to attain their BP control than those on 
two or more drugs (49% versus 37.8 and 31.3% 
respectively; P = 0.043). The most commonly 
prescribed antihypertensive agents were β-blockers 
and diuretics, 58% and 56% respectively. The class 
of antihypertensive agent had no influence on HTN 
control among those patients on monotherapy. 

Table 1: Demographic and clinical characteristics of the 
study stratified by blood pressure (BP) goal attainment 
as per the 7th Report of the Joint National Committee 
on Prevention Detection Evaluation & Treatment of 
High Blood Pressure (JNC-7) recommendations

Blood pressure Goal as 
per JNC-7

P 
Value

No  
(n = 251, 
61.1%)

Yes  
(n = 160, 
38.9%)

Demographic data (n, % unless indicated otherwise)

Age, mean ± SD, in 
years

56.40 ± 
12.17

57.43 ± 
11.87

 0.393

Female gender 173 (68.9) 108 (67.5) 0.762

Male gender 78 (31.1) 52 (32.5) 0.762

Smoking status 21 (8.3) 13 (8.1) 0.593

Clinical data (n, % unless indicated otherwise)

Dyslipidemia 101(40) 70 (44) 0.570

CVD 15 (6) 21 (13) 0.477

Diabetes mellitus 88 (35.0) 6 (4.0) 0.001

Stroke 5 (2.0) 6 (2.4) 0.416

Nephropathy 22 (8.8) 5 (3.1) 0.024

Retinopathy 1(0.4) 0 (0) 0.389

Thyroid disease 9 (3.6) 8 (5) 0.703

Asthma 11(4.4) 11 (6.9) 0.469

               Normal    

BMI     Overweight

               Obese

55 (22) 43 (26.9)  
 

0.02160 (24) 53 (33)

133 (53) 59 (36.8)

Length of follow-
up in the same 
clinic (mean 
± SD)

4.95 ± 2.18 5.01 ± 2.17 0.620

Non-adherence 
to scheduled 
follow-up 
appointments

200 (80) 76 (48) 0.696

Continuity of care 17 (7) 12 (8) 0.892

Legend: SD = Standard deviation; CVD = cardiovascular disease; 
BMI = Body Mass Index; BP control was defined as casual BP of <140 
(systolic) and <90 mmHg (diastolic) and <130 (systolic) and <80 mmHg 
(diastolic) for diabetic patients as per the JNC-7. 

Table 2: Patient and health care related factors and 
pharmaceutical characteristics of the study stratified 
by blood pressure (BP) goal attainment as per the 7th 
Report of the Joint National Committee on Prevention 
Detection Evaluation & Treatment of High Blood 
Pressure recommendations 

Blood pressure Goal as per 
JNC7

P 
Value

No  
(n = 251 
(61.1%)

Yes  
(n = 160 
(38.9%)

Level of Antihypertensive Therapy

Mono therapy 51 (20%) 49 (30%)  
 
 
0.043

Dual therapy 113 (45%) 80 (50%)

Triple therapy 61 (24%) 35 (22%)

More than three 
medications

10 (4%) 8 (5%)



Rashid Al-Saadi, Sulaiman Al-Shukaili, Suleiman Al-Mahrazi, Zakiya Al-Busaidi

Clinical and Basic Research | 353

Discussion
Inadequate control of HTN appears to be a 
significantly prevalent problem challenging the 
PHC system in Oman, as is the case globally. In 
this practice-based study, the majority (61%) of 
hypertensive patients failed to reach the targeted 
BP goals. This can potentially make a significant 
impact on the morbidity and mortality associated 
with cardiovascular disease, stroke and other 
HTN-related diseases. Almost 20% of the national 
total hospital deaths in adults aged ≥45 yrs are 
collectively due to HTN-related diseases (ischaemic 
heart disease 9.7%, cerebrovascular disease 6.8%, 
and heart failure 3.1%), while direct hypertensive 
diseases are estimated to account for 3.6% of total 
deaths.20 Inadequate control of HTN not only 
has significant consequences in terms of patient 
morbidity and mortality, but also in terms of health 
care costs.21

The high prevalence of uncontrolled HTN 
suggests that a substantial number of cardiovascular 
events can be prevented by improving BP control. 
Using data from the Third National Health & 
Nutrition Examination Survey (NHANES III), 
Wong et al. estimated that control of HTN to 
levels recommended by the JNC could prevent  
19–56% of coronary heart disease events in men and  
31–57% of coronary heart disease events in women, 
depending on the BP achieved.22

The level of HTN control found in our study 
(39%) was similar to that reported in a smaller 
hospital-based study conducted 8 years earlier in 
Oman (41%).17 The situation of HTN control in the 
Arabian Gulf region is no better. Reports from Saudi 
Arabia and Bahrain showed a control rate of 25% 
and 16.5% respectively.23,24 Globally, HTN control 
rates vary from one country to another, from as low 
as 5.4% in Korea to as high as 58% in Barbados, with 
a worldwide average of around 30%,9 which clearly 
demonstrates the worldwide difficulty in achieving 
satisfactory BP control.

As shown in Table 1, only half of those 
24% who were on a single antihypertensive 
medication achieved their BP targets. Research 
has demonstrated that BP targets will be reached 
in only 40–50% of patients taking any single 
antihypertensive agent.25 The HTN management 
and control guideline by JNC-71 has recommended 
that most patients with HTN will require two or 

more antihypertensive medications to achieve goal 
BP (<140/90 mmHg, or <130/80 mmHg for patients 
with diabetes or chronic kidney disease). Several 
previous studies26,27 have shown that primary care 
physicians may not be managing HTN aggressively 
enough, and the majority was satisfied with the 
existing BP values.

On the other hand and despite the fact that 
three quarters of our patients were on two or 
more antihypertensive medications (the majority 
taking two drugs), the control of HTN in this 
group was relatively worse than in those taking 
a single drug. Similar findings were reported in a 
neighbouring country.23 These findings contradict 
what is concluded by major clinical trials that 
effective BP control is better achieved with 
two or more antihypertensive drugs for most 
patients.28‒30 The association between BP control 
and level of management is not so self-evident. 
Patient characteristics may contribute a significant 
influence. Our patients who were on monotherapy 
were likely to have been diagnosed more recently 
and have less complications and co-morbidities, 
be younger in age and more involved in their care, 
and hence probably complied better with the 
recommended lifestyle adjustments.

The current study has also shown that diabetes, 
dyslipidemia and obesity were common co-
morbidities among hypertensive patients. The 
relatively low prevalence (23%) of diabetes among 
the study population is likely not a representative 
figure of diabetics with co-existing HTN. This is due 
to the fact that in those PHC centres involved in the 
study most diabetic patients with HTN were seen 
and followed-up in the Diabetic Clinic rather than 
in the HTN Clinic.

It is well accepted that patients who have 
both diabetes and HTN are at a greater risk for 
cardiovascular events compared to non-diabetic 
hypertensive patients.31 Despite this, research 
by Abbott et al. has shown poor BP control in 
diabetic patients with only 11% of the diabetic 
patients treated for HTN reported as having 
achieved the systolic BP goal of <130 mmHg.32 A 
similar percentage was found in a national study 
where the BP control in diabetics was (10%).17 Our 
study demonstrated remarkably poor control of 
HTN among hypertensive patients with diabetes 
mellitus (6%, P = 0.001) as well as those with renal 
insufficiency (18%, P = 0.02). These findings could 



Prevalence of Uncontrolled Hypertension in Primary Care Settings in Al Seeb Wilayat, Oman

354 | SQU Medical Journal, August 2011, Volume 11, Issue 3

be related to the strict definition of controlled BP 
in diabetic and kidney disease patients (i.e. <130/80 
mmHg) used in this study. It is likely that such a 
target might not yet be fully employed or accepted 
in routine practice.

In this study, CVD was found to be relatively 
associated with better BP control. Such a positive 
effect was observed by other studies as well.15,33 The 
mechanism of this effect is not clear, but it might be 
a result of  improved compliance in these patients 
or more aggressive treatment by a specialist rather 
than by a PHC physician.

Another potentially important observation 
was the relationship between poor BP control 
and the presence of obesity (P = 0.02), in addition 
to the high prevalence of obesity (47%) among 
the studied population. These remarkable figures 
make it necessary for the health care providers 
in PHC settings to be aware of the importance of 
emphasising the treatment of obesity as part of the 
management of HTN, if better HTN control is to 
be achieved.

Although this study failed to show any 
statistically significant association between the 
control of HTN and continuity of care (as defined in 
this study), the importance of this aspect in the long 
term management of chronic diseases like HTN is 
beyond doubt. The absence of such an aspect from 
the care provided for hypertensive patients in all 
PHC centres in this study was a significant defect 
which needs to be addressed.

Several limitations of this study deserve 
mention. As this is a retrospective study, no 
information was available on how BP was measured 
and recorded which might question the accuracy 
of the BP readings obtained. The absence of some 
data from patients' electronic records could also 
have affected the findings and their ability to be 
generalised. A possible bias in this study is related to 
hypertensive patients who were also diabetics and 
whose HTN was followed-up in the diabetic clinic; 
they were thus not registered as hypertensive and 
so not included in the study. Another possible bias 
might also arise from the exclusion of hypertensive 
patients who were not on anti-hypertensive 
medication. However, such biases, if true, could 
contribute to further supporting our findings 
of poor HTN control since the excluded group 
could be expected to have even worse BP control. 
This study was conducted in PHC centres where 

family physicians were available, which is not the 
case in other PHC centres in rural parts of Oman. 
This limits the generalisation of the results to the 
whole of Oman. The lack of a global assessment of 
cardiovascular risk for each patient was another 
limitation.

Conclusion
The present study concluded that HTN is not 
adequately controlled in over 60% of treated 
patients, and that is explained by different factors 
including co-existing conditions like diabetes and 
obesity, as well as insufficient pharmacological 
treatment in many patients. Moreover, it seems that 
our primary care physicians have little training and 
experience in treating to target, as we have observed 
with the results of hypertensive patients with 
diabetes and renal disease. Improving the quality 
of HTN care is a priority and effective efforts need 
to be taken in order to improve BP control among 
hypertensive patients. Clinical experience affords 
sufficient reason not to delay aggressive treatment 
in patients with uncontrolled HTN. Obese patients 
and diabetics should be targeted for even greater 
attention to BP control. Any effort to decrease any 
degree of BP which is above the normal range is 
beneficial.

Further improvements in HTN control will 
require changes in physician behaviour which 
should be associated with more awareness of and 
familiarity with updated evidence-based practice 
guidelines. Further research is needed to explore in 
depth different underlying factors influencing the 
appropriate HTN control.

a c k n o w l e d g e m e n t

The authors also would like to thank Dr. Abdullah 
Al-Muniri for his generous help with the statistical 
part of the study.

c o n f l i c t o f i n t e r e s t
The authors reported no conflict of interest.

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