Stroke and non-compliance with the therapeutic regimen among hypertensive men and women in Gaza Strip

The purpose of this study was to ascertain whether an association exists between non-compliance with the therapeutic regimen (anti-hypertensive medication, dietary restrictions of sodium, weight reduction, exercise program, follow-up health care, and smoking), and development of stroke among hypertensive patients, and to determine the risk factors which contribute to the development of stroke. Also to evaluate the differences in quality of life among the patients with stroke and history of hypertension (case group), and hypertensive patients without stroke (control group) one year before the study, and to assess the existence of seasonal pattern and the occurrence of stroke. The study described in this thesis aims: first, to understand the relationship between non-compliance with the therapeutic regimen and development of stroke among hypertensive patients in Gaza Strip; second, to provide reliable information that might help improving the quality of life among hypertensive patients. A pair-matched case-control study design was used involving a case group consisting of 112 subjects, who had been hospitalized for acute stroke with a history of hypertension in Gaza Strip during a 12 month period in 2001, and a control group consisting of 224 subjects (116 men and 108 women) who were matched by age, sex, period of duration of the therapeutic regimen, enrolment location, and with single history of hypertension (no other physical disease). A self-reported structured interview was used for data collection. Data and calculations were assessed using SPSS statistical system and SAS procedure PHREG. Descriptive statistics and frequency distributions were generated to make a comparison between the case and control group regarding compliance with the therapeutic regimen, and seasonal pattern. Single logistic regression models (crude odds ratio), and multiple conditional logistic regression models were used to determine potential risk factors, which contribute to the development of stroke (medication not taking as prescribed, using excessive salt at meals, eating diet high in fat, no involvement in a regular program of exercise, smoking, and high level of stress). In addition, the same model was used to determine the interaction between high level of stress (HLS) and using excessive salt at meals, and smoking and development of stroke. To investigate differences in quality of life among case and control groups an analysis of variance one-way ANOVA was carried out. We found that hypertensive patients who developed stroke (case group) were less compliant with the therapeutic regimen than the hypertensive patients who did not develop stroke (control group). Single logistic regression models (crude odds ratios) showed significant associations for stroke and several risk factors, such as medication not taken as prescribed (OR=7.13; 95 percent CI 3.32-15.32), excessive usage of salt at meals (OR=6.21; 95 percent CI 3.75-10.29), eating diet high in fat (OR=4.66; 95 percent CI 2.87-7.56), no involvement in a weight reduction program (OR=4.97; 95 percent CI 1.72-14.36), no involvement in regular exercise program (OR=4.94; 95 percent CI 3.80-8.73), no follow-up physician or clinic (OR=3.03; 95 percent CI 1.8-5.1), and smoking (OR=2.20; 95 percent CI 1.33-3.62). Multiple conditional logistic regression models showed a significant association between the development of stroke and medication not taken as prescribed (OR=6.07; 95 percent CI 1.53-24.07), using excessive salt at meals (OR=4.51; 95 percent CI 2.05-9.90), eating diet high in fat (OR=4.67; 95 percent CI 2.09-10.40), and high level of stress (OR=2.77; 95 percent CI 1.43-5.38). On the other hand no significant association between smoking and the development of stroke (OR=2.12; 95 percent CI 0.82-5.51) was found. Regular physical exercise appeared as a protective factor in our model (OR=0.26; 95 percent CI 0.12-0.57). The results of the multiple conditional logistic regression model based upon the backward selection procedure and considering interaction terms with two different stress levels showed significant interaction for using excessive salt at meals interacting with low level of stress (LLS) in relation to the development of stroke (OR=16.61; 95 percent CI 4.40-62.80). There was no significant effect of excessive usage of salt interacting with high level of stress (OR=1.76; 95 percent CI 0.58-5.33) in relation to the development of stroke. Smoking in interaction with low level of stress was a significant risk factor for stroke (OR=9.88; 95 percent CI 2.52-38.78), but a non-significant protective factor in interaction with high level of stress (OR=0.52; 95 percent CI 0.14-1.99). These results are discussed further.