Table 1.

Summary of studies on hypertension in Pakistan

Project Title	Authors	Study Design	Sample Size	Objectives	Results
Perceptions and Practices towards Medication Non-Adherence among Hypertensive Patients: An Observational Study	Khan M N, Soomro N, Ashraf T, et al.	Cross-sectional, single-center study	200 patients	To evaluate medication adherence and the contributing factors of HTN along with the assessment of common perceptions and practices related to its management.	• No association between medication adherence and educational level • Perceptions like ‘BP is mostly controlled’ and ‘BP medication necessity’ was also positively associated with adherence
Prevalence and contributing risk factors for hypertension in urban and rural areas of Pakistan; a study from second National Diabetes Survey of Pakistan (NDSP) 2016–2017	Basit et al.	Community-based epidemiological survey	10,800 adults	To assess the prevalence and its associated risk factors for hypertension in urban and rural areas of Pakistan	• Prevalence of hypertension in urban and rural areas was 44.3% and 46.8%, respectively • Age, female gender, married individuals, positive family history of hypertension, diabetes, and obesity were highly significantly associated with hypertension
Risk factors assessment for hypertension in a squatter settlement of Karachi	Siddiqui et al.	Cross-sectional survey	327 adults	To assess the risk factors for hypertension in adults (age more than 15 years) in a squatter settlement of Karachi	• Hypertensives were 9.7 times more likely to be diabetic • no significant difference was noticed for education, smoking status, family history and occupation
Prevalence and Risk Factors of Hypertension Among Children Attending Outpatient Department of a Tertiary Care Hospital in Karachi	Bilal et al.	Cross-sectional study	1000 children	To identify the risk factors and the prevalence of HTN among the pediatric age group attending the OPD (out-patient department) of a tertiary care hospital in Karachi	• Higher prevalence of HTN and pre-HTN among children of 4–7 years of age • Significant association of BMI, family history of HTN, and high-fat diet intake with the prevalence of HTN
Children in South Asia have higher body mass-adjusted blood pressure levels than white children in the United States: a comparative study	TH Jafar et al.	Cross-sectional study	18,135 children	To determine the prevalence of high blood pressure in children in Pakistan and study the correlates of systolic and diastolic blood pressure in South Asian children	• The mean BMI (SD) was significantly lower in children in Pakistan • High blood pressure in Pakistani children 5 to 14 years old was 12.2% compared to 5% in US
Factors associated with hypertension in Pakistan: A systematic review and meta-analysis	Riaz et al.	Meta-analysis	30 cross-sectional and 7 case-control studies	To conduct a thorough systematic review and meta-analysis of the literature to make valid inferences about the risk factors of hypertension in Pakistan and provide greater consistency and validity to the previous results	• Adults aged 30–60 years who were married, in urban areas, high incomes, used tobacco, positive family history, and positive comorbidities were positively associated with hypertension
Good knowledge about hypertension is linked to better control of hypertension; a multicenter cross-sectional study in Karachi, Pakistan	Almas et al.	Cross-sectional study across 3 centers	447 adults	To elucidate the knowledge about hypertension and compare the knowledge of those with uncontrolled hypertension and controlled hypertension	• Total mean (SD) Knowledge score was 20.97(4.93) out of a maximum score of 38 • Sufficient knowledge about hypertension in patients has been associated with greater medication adherence
Hypertension-related Knowledge and Its Relationship with Blood Pressure Control in Hypertensive Patients Visiting a Semi-private Tertiary-care Charity Hospital in Karachi, Pakistan	Nadeem, Mohammad Khurram et al.	cross-sectional study	355 patients	To ascertain the knowledge of hypertension and other sociodemographic variables and their impact on controlling blood pressures in the hypertensive population belonging to the low socioeconomic strata	• No significant association was observed between the levels of knowledge of hypertension and gender, blood pressure (BP) status, professional activity, and age groups
Determinants of Uncontrolled Hypertension in Rural Communities in South Asia-Bangladesh, Pakistan, and Sri Lanka	Tazeen H Jafar et al.	Cross-sectional study	1,718 individuals aged ≥ 40 years	To determine the cross-country variation, and the factors associated with uncontrolled BP among adults treated for hypertension in rural South Asia	• 58.0% had uncontrolled BP: 52.8% in Bangladesh, 70.6% in Pakistan, and 56.5% in Sri Lanka • The odds of uncontrolled BP were significantly higher in individuals with lower wealth index, not married, higher urine albumin-to-creatinine ratio, lower estimated glomerular filtration rate, lower adherence to antihypertensive, and in Pakistan vs. Sri Lanka
Better physician-patient communication; an important milestone in control of hypertension, a multicenter study from Karachi, Pakistan	Almas A, Bhamani F, Khan AH.	Control trial study	3 tertiary care hospitals	To compare physician encounter score in patients with controlled and uncontrolled hypertension.	• Mean physician encounter score in uncontrolled hypertensive was 7.25 ± 2.64 versus 7.83 ± 2.22 in controlled hypertensive. • Patient-physician encounter is an important milestone in control of hypertension in hypertensive patients and directly translates into better adherence to antihypertensives in these patients.
Non-Adherence to Prescribed Antihypertensives in Primary, Secondary and Tertiary Healthcare Settings in Islamabad, Pakistan: A Cross-Sectional Study	Mahmood S, Jalal Z, Hadi MA, Orooj H, Shah KU	Cross-sectional study	741 patients	To assess the prevalence and predictors of non-adherence to antihypertensive medication among patients with hypertension attending various healthcare settings in Islamabad, Pakistan	• Binary regression analysis revealed that old age, being educated, free medical care, treatment duration, number of medications, presence of any comorbidity and blood pressure control were significantly associated with good adherence • Main reasons for non-adherence to prescribed antihypertensive medication: ‘don’t feel need for regular use’ 24.7%), ‘Carelessness’ (13.4%) and ‘adverse effects’ (11.2%)
Medication Adherence and Its Association with Health Literacy and Performance in Activities of Daily Livings among Elderly Hypertensive Patients in Islamabad, Pakistan	Saqlain M, Riaz A, Malik MN, et al.	Cross-sectional survey-based study	262 adults	To investigate medication adherence and its associated factors among Pakistani geriatric hypertensive patients	• Self-reported moderate and good subjective health, adequate health literacy, and independence in performing activities of daily living were found to be independent predictors of medication adherence among older hypertensive patients
Out of pocket (OOP) cost of treating hypertension in Karachi, Pakistan	Aslam N, Shoaib MH, Bushra R, et al.	Cross-sectional prevalence-based study	350 adults	To determine the cost of treating hypertension form the patient’s perspective (out of pocket cost) in Karachi, Pakistan	• The average treatment cost of stage 1 was observed to be significantly lower (p = 0.006) than the cost of stage 2 HTN • Significant difference was observed in the average cost of drugs, consultancy fees and laboratory tests, but no variation was seen in cost of transport and loss of productivity through absenteeism from work
Awareness of hypertension among patients attending primary health care centre and outpatient department of tertiary care hospital of Karachi	Ashfaq T, Anjum Q, et al.	Cross sectional survey	202 patients	To compare awareness of hypertension among patients attending Primary Health Care Centre (PHC) and outpatient department (OPD) of a tertiary care hospital of Karachi.	• Majority of the patients attending tertiary care OPD (80%) and 56% from PHC group believed that hypertension could lead to cardiovascular disease (CVD) • 61% from tertiary care OPD group and 31% of PHC group said antihypertensives were taken only for few months • 77% of patient of tertiary OPD were not doing exercise and not avoiding oily and heavy food
Current trends in treatment of hypertension in Karachi and cost minimization possibilities	Hussain IM, Naqvi BS, Qasim RM, Ali N.	Three-pronged approach was used. Two randomized stratified surveys.	100 doctors 400 patients	To find drug usage trends in Stage I Hypertensive Patients without any compelling indications, deviations of current practices from evidence based antihypertensive therapeutic guidelines, and cost minimization opportunities.	• Majority of patients were prescribed Beta Blockers (33%), followed by Angiotensin Converting Enzyme (18%), Calcium Channel Blockers (13%) and Diuretics (8%) • For most cost-effective drug, 29% of the doctors opined Beta Blockers, followed by Angiotensin Converting Enzymes inhibitors (18%) and diuretics (12%)
Can community-based interventions control hypertension in developing countries? What is the evidence from Pakistan?	Majeed F, Kamal AK.	Cluster randomized controlled trial, in 12 randomly selected communities in Karachi	4023 between 5–39 years 1341 patients 40 years or older	To determine the impact of family-based home health education (HHE) on blood pressure in children, and adults at a community level over a 2 year follow up period	• In participants, aged 5–39 years analyses showed significant blood pressure reductions in the intervention arm which received home health education • In hypertensive patients over 40 years of age, there was a significant 10 mmHg improvement in systolic blood pressure in patients who were assigned to both home education and General Practitioner education
Enhanced hypertension care through private clinics in Pakistan: a cluster randomised trial	Khan MA, Khan N, Walley JD, et al.	A two-arm cluster randomised controlled trial	1138 patients in 13 clusters	To assess whether enhanced care at urban private clinics resulted in better control of hypertension, cardiovascular disease (CVD) risk factors, and treatment adherence	• mean intervention outcome was -25.2 mmHg; mean control outcome was -9.4 mmHg; and mean control–intervention difference was 15.8 • The findings support the scaling of an integrated CVD–hypertension care intervention in urban private clinics in areas lacking public primary care in Pakistan