International Journal of Environmental Research and Public Health Article Gaps in Hypertension Management in a Middle-Income Community of Quito-Ecuador: A Population-Based Study Patricia Ortiz 1,2,3, *, Yajaira Vásquez 1,2 , Esperanza Arévalo 1,2 , Patrick Van der Stuyft 2,4 and Esteban Londoño Agudelo 2,4,5,6,7 1 Facultad de Medicina, Pontificia Universidad Católica del Ecuador, Quito 170143, Ecuador; yajaira.vasquez@gmail.com (Y.V.); darevalo@puce.edu.ec (E.A.) 2 Consortium Latin-American Network for Multidisciplinary Research on Chronic Non-Communicable Diseases, Medellin 050010, Colombia; patrick.vanderstuyft@ugent.be (P.V.d.S.); elondono@ces.edu.co (E.L.A.) 3 Departamento de Pediatría, Obstetricia y Ginecología y de Medicina Preventiva, Universidad Autónoma de Barcelona, 08193 Barcelona, Spain 4 Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium 5 Department of Public Health, Institute of Tropical Medicine, 2000 Antwerp, Belgium 6 Grupo de Epidemiología, Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín 50010, Colombia 7 Facultad de Medicina, Universidad CES, Medellín 0510, Colombia * Correspondence: portizs@puce.edu.ec Abstract: Optimal hypertension care and control at population level significantly reduces cardio-  vascular morbidity and mortality. The study objective was to measure the gaps in the diagnosis,  care, and control of hypertension in residents of an urban community in Quito, Ecuador. A cross- Citation: Ortiz, P.; Vásquez, Y.; sectional population-based study with a sample of 2160 persons was performed using a survey and Arévalo, E.; Van der Stuyft, P.; direct blood pressure measurement. Logistical regression models were used for analyzing factors Londoño Agudelo, E. Gaps in Hypertension Management in a associated with the gaps, expressed as percentages. The prevalence of hypertension was 17.6% Middle-Income Community of [CI 95% 17.3–17.9%]. The diagnosis gap was 6.1% [CI 95% 5.9–6.2%] among the entire population and Quito-Ecuador: A Population-Based 34.5% [CI 95% 33.7–35.3%] among persons with hypertension. No access gaps were detected; whereas Study. Int. J. Environ. Res. Public the follow-up gap was 22.7% [CI 95% 21.8–23.6%] and control gap reached 43.5% [CI 95% 42.6–44.2%]. Health 2022, 19, 5832. https:// Results indicated that being male, older than 64 years, an employee, without health insurance, and doi.org/10.3390/ijerph19105832 not perceiving a need for healthcare, increased the risk of experiencing these gaps. Data showed Academic Editors: Carlos appropriate access to health services and high coverage in the diagnosis was due to the application G Santos-Gallego and of a community and family healthcare model. Notwithstanding, we found significant gaps in the Tomonori Okamura follow-up and control of hypertensive patients, especially among older males, which should warrant the attention of the Ministry of Health. Received: 20 January 2022 Accepted: 30 March 2022 Keywords: hypertension; primary health care; hypertension management; health systems; Ecuador Published: 11 May 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- 1. Introduction iations. Hypertension (HTN) is the most important risk factor for disease burden and prema- ture death worldwide [1,2]. It affects approximately one billion people, three-fourths of whom live in low- and middle-income countries (LMIC) [3], and it causes more than ten Copyright: © 2022 by the authors. million deaths per year, most of which are premature and preventable [4]. Licensee MDPI, Basel, Switzerland. HTN affects 20–40% of adults in the Americas Region and represents 6.6% of the This article is an open access article disability-adjusted life- years (DALYs) [5,6]. Fifty-nine percent of deaths due to ischemic distributed under the terms and heart disease and 63.2% of cerebrovascular events in Latin America are attributed to HTN conditions of the Creative Commons in people between 50 and 69 years of age [1,7]. In Ecuador, ischemic heart disease was Attribution (CC BY) license (https:// the main overall cause of death in 2018, accounting for 11.1% of all deaths in both sexes. creativecommons.org/licenses/by/ Hypertensive diseases, ischemic heart and cerebrovascular diseases caused 15,619 deaths, 4.0/). which represents 22% of total deaths in the country [8]. The death rate from cardiovascular Int. J. Environ. Res. Public Health 2022, 19, 5832. https://doi.org/10.3390/ijerph19105832 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2022, 19, 5832 2 of 13 diseases (CVDs) in Ecuador was 131.6 per 100,000 people in 2016, from which 39.7% were deaths occurred under 70 years of age [9]. Efficient and equitable health systems are required to decrease the HTN-related disease burden. Globally, health systems should guarantee universal coverage, promote primary prevention, and provide quality secondary prevention, to assure HTN treatment and control [10,11]. Evidence shows that HTN control may significantly contribute to decreasing morbidity and mortality due to CVDs. Despite this, the global burden of HTN is currently increasing [12–14]. A significant proportion of people with HTN is not aware of their condition; among those who are aware, only a minority have been treated and controlled [15,16]. It is estimated that approximately 80% of people with HTN in the Americas and the Caribbean region do not have adequate control of their blood pressure (BP) [5,17]. Another combined international study on HTN care in Argentina, Brazil, Chile, and Colombia found that only 57% of hypertensive people were aware of their condition. Of these, 53% received treatment, and only 30% had their BP under control [18]. According to data from the STEPS survey (2018) [19], the prevalence of HTN in Ecuador was 20% nationwide. A total of 45.2% of people aged 18 to 69 years with HTN were not aware of their condition, and 12.6% were aware of their diagnosis but did not take antihypertensive medication. In Ecuador, chronic patient management is guided by the Integral Health Care Model (IHCM), which, based on the Primary Health Care strategy, strengthens the resolutive capacity of the first- and second-line health care services. This is complemented with the “Physicians in the Neighborhood” strategy, which is geared towards guaranteeing integral health care for priority groups, such as those with chronic non-communicable diseases [20]. There are Clinical Practice guidelines and protocols for professionals at the three levels of healthcare for the management of HTN [21]. Using a populational perspective, this study measures the existence, magnitude, and main determinants for the access, diagnosis, treatment, follow-up and control gaps affecting the health care of persons aged 35 to 70 years with HTN residing in an urban middle-income community in Quito, Ecuador. 2. Materials and Methods 2.1. Study Design A population-based, cross-sectional study, including adult population between 35 to 70 years of age, living in the urban area of the Conocoto community in the Metropolitan District of Quito, between July 2015 and June 2016. 2.2. Study Site and Population The Ecuadorian Health System is composed of a public and a private sector. The public sector provides health care to the non-insured population. It includes the Ministry of Public Health (MSP), the Ministry of Economic and Social Inclusion (MIES) and the municipalities. The social security institutions [Ecuadorian Institute of Social Security (IESS), Armed Forces Social Security (ISSFA) and the National Police Social Security (ISSPOL)] provide health care to affiliated workers and their families. In 2018, the population covered by the IESS was 27.3%, the special insurance schemes for the army and police force (ISSFA and ISSPOL) reached 1.7%, and private insurance companies covered 9%. This left more than 60% of the population not formally covered by any insurance scheme. This population is entitled to receive free healthcare services run by the Ministry of Health [22]. These theoretical figures contrast with the strong private offering, which allows patients to turn to private services (including pharmacies) whenever they want and at any level of care, so long as they can fully pay for it, regardless of the coverage scheme they belong to [23]. Information disaggregated at community-level could not be found on this issue. Conocoto is a middle-income community that forms part of the Metropolitan District of Quito. It is located 6.8 miles from downtown, with an area of 51.46 km2 . According Int. J. Environ. Res. Public Health 2022, 19, 5832 3 of 13 to the 2010 census [24], the total population was 82,072 inhabitants (52% women), with an average age of 29 for men and 31 for women. People older than 70 years account for 4% of the population and 82.7% of the population is within the category of working age. According to poverty indicators, there is a high percentage of people classified as above the poverty line (72%); 87% of the population consider themselves “mestizo”, while 4.98% self-identify as Afro Ecuadorians, indigenous or mulatto [25]. The selection criteria for the study site were urban setting, low- or middle-income population, health service functionally similar to that of health establishments nationwide, and a commitment by local health authorities to develop an intervention based on the study results. 2.3. Sample Size and Sampling Strategy The sampling frame for this study was derived from the VII Population Census and the VI Housing 2010 of Ecuador, and the updated mapping elaborated by the National Census and Statistics Institute (INEC), which contained a complete listing of occupied housing and population for the Conocoto community. The sample design was probabilistic by conglomerates, defined as the registered sectors (N = 172) and proportional to their population size. A two-stage sampling method was used. The primary sampling unit (PSU) was the census sectors (10 randomly selected). The secondary selection unit was an inhabited dwelling with people between 35 and 70 years of age, and the observation unit was the household (group of people who live together and share a “common pot” of meals and where biological reproduction and social processes take place; housing refers to the physical structure, where more than two households may live [26]. The PSU and housing were selected by simple random sampling, taking into account an average of 1.75 persons between 35 and 70 years of age in each household. A total of 2237 housings were selected from a sampling frame of 16,030 and four housing units per PSU as a replacement. Finally, all household members between the ages of 35 and 70 were surveyed. The sample size was calculated with an expected prevalence of hypertension of 25% among the population between 35 and 70 years of age, with a confidence level of 95%, a precision of 5%, design effect of 1.5, and a non-response rate of 4%, rendering a total of 2100 persons. 2.4. Study and Measurement Procedures Two trained surveying teams made door-to-door visits to all selected households and dwellings. The eligible subjects—individuals between 35 and 70 years of age—who gave their informed consent to participate in the study were interviewed using a previously validated structured questionnaire. If the person was not at home at the time of the interview, two further attempts were made to locate a person who met the inclusion criteria for age. Information was gathered by means of a “Survey form for the study of gaps in Hypertensive Care Management”. The survey included several sections covering general household and subject data, namely: sociodemographic data, use of health services, lifestyle: tobacco, alcohol consumption and physical activity, HTN diagnosis and treatment, and BP figures. BP was measured using a digital device. Following the Panamerican Health Organiza- tion (PAHO) recommendations for population-based studies [27], three BP measurements were carried out. The first reading was discarded, and an average was obtained between the second and third readings. A hypertensive person with a previous diagnosis was defined as a person diagnosed as hypertensive by a physician, regardless of the BP values at the time of the survey. A presumptive hypertensive person was defined as a person without a previous diagnosis of HTN, who at the time of the survey had systolic tension values of ≥140 or diastolic tension values of ≥90. Int. J. Environ. Res. Public Health 2022, 19, 5832 4 of 13 Persons with no evidence of HTN were defined as those who referred not having a previous diagnosis of HTN and who had BP values of <140/90 [28]. Box 1 shows the definitions used in the study as the basis to calculate gaps. Box 1. Definitions of Needs and Gaps Need for medical care: proportion of people who had an illness, health discomfort or accident, and who required medical attention. Search for medical care: proportion of people who took action to solve their health problem. Access Gap (AG): proportion of people who reached a health service provider and were not attended to in each subpopulation (persons with a previous hypertension diagnosis, presumptive hypertensive patients, and population with no evidence of hypertension). Diagnosis Gap (DG): proportion of people who did not report a previous hypertension diagnosis, and who presented average BP values ≥140 systolic or ≥90 mmHg after the two BP measurements at the time of examination, or when the survey was applied, among the total of surveyed people. Follow-up Gap (FG): proportion of people with a previous HTN diagnosis who reported that during the last year they have not attended health services for their HTN. Treatment Gap (TG): proportion of people with a previous HTN diagnosis who reported having received a prescription for anti-hypertensive medication but did not get or take the treatment. Population Control Gap (PCG): proportion of people ≤59 years with or without a previous hypertension diagnosis, who at the time of the survey presented BP values ≥140/90; or people ≥60 years with BP values ≥150/90; as well as people with a previous diabetes diagnosis, with BP ≥140/90 (regardless of age). Hypertension Control Gap (HCG): proportion of people ≤59 years with a previous HTN diagnosis, who at the time of the survey presented BP values ≥140/90, or people ≥60 years with BP values ≥150/90; as well as people with a previous diabetes diagnosis with arterial pressure ≥140/90 (regardless of age). 2.5. Statistical Methods Data processing and analysis were carried out using the SPSS v24 software. Once raw data was entered into the program, the data entry assistants validated the incorrect and missing values, enumerated in an “observations log” to be delivered to the supervisors. Secondly, incorrect data and erroneously recorded and missing information were corrected using the validation grids established in SPSS. For the data entry validation, a random sample of the surveys entered was verified and contrasted with the forms. This resulted in a 2% error in data entry. Previous to the data processing and analysis, expansion factors were calculated to extrapolate sample data for the population (i.e., to expand the sample) [29]. These factors were calculated according to selection probability determined by the sampling design for each sample unit. The expansion factor was defined as the inverse of the probability of choosing a household and its members in a determined study domain [30]. Incidents registered during data gathering, such as lack of reply, rejection, no one home, were considered to adjust the expansion factors according to survey coverage. In both the descriptive and analytical phases, data analysis was carried out based on the population values. Gaps and socioeconomic characteristics were calculated, expressed in absolute frequencies and total percentages; continuous variables were expressed as means and standard deviation. 3. Results A total of 1583 surveys were performed in households from the Conocoto community. A total of 2160 people between the ages of 35 and 70 were found, which represented 78,591 individuals in the expanded population. Table 1 displays the sample and expanded population features within each sub-population: hypertensive with a previous diagnosis, presumptive hypertensive, and without evidence of HTN. Int. J. Environ. Res. Public Health 2022, 19, 5832 5 of 13 Table 1. Sociodemographic characteristics of the urban population of the community of Conocoto. 2016. Population without Evidence of Known Hypertensive Presumptive Hypertensive Total Hypertension 9060 240 11.5% 4766 115 6.1% 64,765 1805 82.4% 78,591 2160 100% Population Sample Population Sample Population Sample Population Sample % (N) % (N) % (N) % (N) (N) (n) (N) (n) (N) (n) (N) (n) Gender Male 2452 112 27.1% 3344 78 70.2% 26,275 855 40.6% 32,071 1045 40.8% Female 6608 128 72.9% 1422 37 29.8% 38,490 950 59.4% 46,520 1115 59.2% Who they Alone 842 16 9.3% 671 8 14.1% 3418 98 5.3% 4931 122 6.3% live with Accompanied 8218 224 90.7% 4095 107 85.9% 61,347 1707 94.7% 73,660 2038 93.7% Indigenous, Afro- Ethnicity 103 5 1.1% 29 1 0.6% 4176 62 6.45% 4308 68 5.48% Ecuadorian, Montubio Mestizo and 8957 235 98.9% 4737 114 99.4% 60,589 1743 93.55% 74,283 2092 94.52% Caucasian Employment Workers 4261 116 47.0% 3556 81 74.6% 40,997 1203 63.3% 48,814 1400 62.1% Non-worker 4799 124 53.0% 1210 34 25.4% 23,768 602 36.7% 29,777 760 37.9% Health insurance No 4656 106 51.4% 2772 57 58.2% 31,778 829 49.1% 39,206 992 49.9% affiliation Yes 4404 134 48.6% 1994 58 41.8% 32,978 976 50.9% 39,376 1168 50.1% Under 65 Age 7087 173 78.2% 3440 97 72.2% 58,392 1655 90.2% 68,919 1925 87.7% years Over 65 1973 67 21.8% 1326 18 27.8% 6374 150 9.8% 9672 235 12.3% years Means Age (SD) 59.07 ± 7.32 55.8 ± 9.7 50.2 ± 9.9 51.5 ± 10.1 Years Approved 11.0 ± 5.34 11.3 ± 4.6 12.1 ± 4.7 11.9 ± 4.8 (MeansSD) Means Systolic pressure 127.1 ± 16.4 142.9 ± 11.8 114.4 ± 10.3 117.6 ± 13.5 (SD) Means Diastolic pressure 76.4 ± 10.5 88.1 ± 7.1 71.9 ± 8.3 73.4 ± 9.4 (SD) Int. J. Environ. Res. Public Health 2022, 19, 5832 6 of 13 There were more females in all sub-populations, except for the presumptive hyperten- sive group. The average age was higher in the sub-population with a previous diagnosis of HTN (59.07 ± 7.32 years) when compared to the average age for the presumptive hy- pertensive sub-population (55.8 ± 9.7 years) and the sub-population without evidence of HTN (50.2 ± 9.9 years). The predominant self-described ethnic group was mestizo in all sub-populations. The proportion of unemployed people was higher in the group of those previously diagnosed as hypertensive. The proportion of those not affiliated with a health insurance system was higher in the known and presumptive hypertensive groups (Table 1). 3.1. Gaps in the Process of Hypertension Care Management An overall hypertension prevalence of 17.6% [CI 95% 17.3–17.9] was found. Gaps in access to healthcare were not observed in any of the sub-populations. The lack of perceived need, as a requirement for healthcare demand, was lower in the sub-population of those previously diagnosed as hypertensive (6.2% CI 95% 5.74–6.7), as compared to the sub-populations of those presumptive hypertensive and without evidence of HTN (33.2% and 31.8%, respectively). The diagnosis gap was 6.1% [CI 95% 5.9–6.2] among the population surveyed and 34.5% [CI 95% 33.7–35.3] among the hypertensive population. The pharmacological treat- ment gap registered a proportion of 1.7% [CI 95% 1.37–1.95], while the gap in adherence— self-referenced, after the Morinsky test [31] was 59.5%. The follow-up gap obtained was 22.7% [CI 95% 21.8–23.6]; the control gap in the population with a previous HTN diagnosis was 13.7%. Meanwhile, the control gap on a population level was 43.5% [CI 95% 42.6–44.2]. 3.2. Factors Associated with Gaps in Diagnosis, Follow-Up, and Control Associated factors were analyzed separately for each gap. For the diagnosis gap, it was observed that males, those living alone, those with fewer years of schooling, and employees presented a greater gap. On the contrary, people under 65, the population self-identified as Afro-Ecuadorian, indigenous, or mulatto, and people with diabetes diagnosis showed a lower gap (Table 2). Not having health insurance seems to be a protective factor for the diagnosis gap, even though its OR value is close to 1. Table 3 shows associated factors related to the follow-up gap, revealing that people under 65 with no health insurance affiliation and with diabetes had a larger gap. On the other hand, males, people living alone, and those employed presented a lower gap. There was no indication that Afro- Ecuadorian, indigenous, or mulatto had a greater follow-up gap, probably because only a minimal proportion of the population of Conocoto self-identified with these ethnic groups. Concerning the factors associated with the population’s control gap, it was observed that males, people living alone, those employed, and those not affiliated with health insurance services presented a higher control gap. In contrast, people under 65 old years, with diabetes, and who do not exercise had a lower gap. No associations were found with tobacco and alcohol consumption or with ethnicity (Table 4). The logistic regression model (Table 5) indicates the predictive associated factors for the different gaps, like those observed in the bi-varied analysis. For the diagnosis gap, the main associated factors were men living alone, without health insurance affiliation, employed, and who avoided seeking medical attention. Being under 65 years of age constituted a protective condition. For the follow-up gap, the associated factors were being under 65, without health insurance affiliation, and with a diagnosis of diabetes. On the other hand, being a working male constituted a protective factor. Factors associated with the control gap were being male, without health insurance affiliation, employed, those who did not feel the need to seek out health care attention, and those who did not exercise. Together, these factors explain 62% of the control gap. People having a diagnosis of diabetes and adequate follow-up care had a smaller probability of uncontrolled HTN. Int. J. Environ. Res. Public Health 2022, 19, 5832 7 of 13 Table 2. Associated Factors to the Diagnostic Gap. Population = 78,591 Variable Category Population Gap % OR LB UB VALUE p (N) (N) DIAGNOSTIC GAP 78,591 4766 6.1 5.89 6.23 (People with undiagnosed HTN) Male 32,071 3344 10.4 Gender 3.692 3.464 3.935 <0.001 Female 46,520 1422 3.1 Under 65 years old 68,919 3440 5.0 Age groups 0.331 0.309 0.354 <0.001 Over 65 years old 9672 1326 13.7 Alone 4931 671 13.6 Who they live with 2.676 2.452 2.92 <0.001 Accompanied 73,660 4095 5.6 Afro-Ecuadorians, Montubio, 4308 29 0.7 Ethnicity Indigenous 0.1 0.069 0.144 <0.001 Mestizo, 74,283 4737 6.4 Caucasians Workers 4261 865 20.3 Employment 2.979 2.619 3.389 <0.001 Non-workers 4799 378 7.9 Health insurance No 4656 580 12.5 affiliation 0.804 0.713 0.9 <0.001 Yes 4404 662 15.0 Yes 2179 243 11.2 Diabetes diagnosis 0.738 0.636 0.857 <0.001 No 6882 1000 14.5 Standard N Means VALUE p deviation Education (years Yes Gap 1247 11.1 5.1 <0.001 passed approved) No Gap 7828 11.9 4.8 Lower and upper bounds (LB, UB) of the 95% confidence interval. Table 3. Follow-up gap, associated factors. Total Hypertensive Patients with Previous Dx Variable Category (N = 9060) Population Gap % OR LB UB VALUE p (N) (N) Follow-up gap 9060 2057 22.7 21.8 23.6 Male 2452 393 16.0 Gender 0.56 0.5 0.64 <0.001 Female 6608 1665 25.2 Under 65 years old 7087 1882 26.6 Age group 3.69 3.13 4.34 <0.001 Over 65 years old 1973 176 8.9 Alone 842 29 3.4 Who they live with 0.11 0.08 0.16 <0.001 Accompanied 8218 2029 24.7 Afro-Ecuadorian, 103 0 0.0 Ethnicity Montubio, Indigenous N/A N/A Mestizo, Caucasian 8957 2057 23.0 Worker 4261 577 13.5 Employment 0.35 0.32 0.39 <0.001 Non-worker 4799 1481 30.9 Health insurance No 4656 1413 30.3 2.53 2.28 2.8 <0.001 affiliation Yes 4404 645 14.6 Yes 2178 1028 47.2 Diabetes diagnosis 5.08 4.56 5.65 <0.001 No 6881 1029 15.0 Lower and upper bounds (LB, UB) of the 95% confidence interval. Int. J. Environ. Res. Public Health 2022, 19, 5832 8 of 13 Table 4. Associated factors to the Control Gap at the population level. Known Hypertensive + Presumptive Hypertensive Variable Category Population Gap % OR LB UB VALUE p (N) (N) Control gap 13,826 6008 43.5 42.6 44.3 Male 5796 4066 70.20 Gender 7.37 6.83 7.95 <0.001 Female 8029 1942 24.20 Under 65 years old 10,526 4379 41.60 Age group 0.73 0.68 0.79 <0.001 Over 65 years old 3299 1629 49.40 Who they live Alone 1513 751 49.60 1.32 1.19 1.47 <0.001 with Accompanied 12,312 5257 42.70 Afro-Ecuadorians, 132 58 43.90 Ethnicity Montubio, Indigenous 1.02 0.72 1.44 0.91 Mestizo, Caucasian 13,695 5951 43.50 Workers 7817 4421 56.60 Employment 3.63 3.37 3.90 <0.001 Non-workers 6008 1587 26.40 Health insurance No 7428 3352 45.10 affiliation 1.16 1.08 1.24 <0.001 Yes 6399 2657 41.50 Diabetes yes 2824 888 31.40 diagnosis 0.53 0.48 0.58 <0.001 No 11,002 5120 46.50 No 9066 3878 42.80 Exercise 0.92 0.86 0.99 0.03 Yes 4760 2130 44.70 Cigarette yes 6428 2490 38.70 1.01 0.91 1.12 0.85 Consumption No 2047 788 38.50 Alcohol Yes 0.00 0.00 0.00 NA Consumption No 13,825 6008 43.50 Lower and upper bounds (LB, UB) of the 95% confidence interval. Table 5. Logistic regression model of risk factors for gaps in diagnosis, monitoring and control of hypertension. OR Gaps Risk Factors Confidence Intervals Significance Adjusted Gender (male) 3.14 2.910 3.406 0.001 Age < 65 years 0.26 0.239 0.283 0.001 Live alone 2.49 2.229 2.786 0.001 Diagnostic gap Affiliation (No) 2.61 2.418 2.821 0.001 Employment (workers) 3.08 2.813 3.387 0.001 Not Attention seeking 2.15 1.686 2.761 0.001 Gender(male) 0.7 .655 0.900 0.001 Age < 65 years 3.95 3.246 4.814 0.001 Follow-up gap Affiliation (No) 2.19 1.936 2.496 0.001 Employment (workers) 0.715 0.617 0.829 0.001 Diabetes diagnosis (yes) 4.16 3.625 4.785 0.001 Gender (male) 4.8 4.34 5.4 0.001 Affiliation (No) 1.62 1.46 1.81 0.001 Employment (workers) 1.63 1.45 1.84 0.001 Control gap Need for attention (No) 6.68 5.55 8.05 0.296 Diabetes diagnosis (yes) 0.39 0.32 0.42 0.001 Exercise (No) 1.63 1.43 1.43 0.01 Follow-up gap 0.15 0.12 0.19 0.001 Int. J. Environ. Res. Public Health 2022, 19, 5832 9 of 13 4. Discussion This study revealed an HTN prevalence of 17.6%, the non-existence of access gaps to healthcare among the Conocoto community residents, and a relatively small diagnosis gap (6.1%). On the other hand, the follow-up gap (27.7%) and the control gap at a populational level (43.5%) should both warrant the attention of the Ministry of Health. This HTN prevalence value is similar to that reported in the STEPS survey performed in 2018 [19], with a nationwide prevalence of 20%. However, this data differs from results reported in different country areas, which showed large differences in the HTN prevalence [32–36]. This variability can be explained by the various definitions and measurement methods used [2,37,38]. Our results suggest that the diagnosis of HTN in Ecuador has improved over the last decade. Nevertheless, the prevalence of HTN among the researched population is relatively low compared to the average reported for Latin American countries [39]. The inexistence of access gaps could at least partially result from the implementation of integral health reforms undertaken by Ecuador during the past decade and the existence of a public policy aimed at regulating health care [40]. The 2008 Constitution [41] recognizes health as a human right and the State as a guarantor of this right. Since then, a series of socially focused policies, plans and programs have been formulated, directed toward providing ongoing and timely universal access to integrated health care. To comply with the Organic Health Law (2006) [42], the Ministry of Public Health (MSP) mandates free healthcare at all levels of the public healthcare network [41]. Granda and Jimenez [43] found that between 2006 and 2014, there was a decrease in inequity in access to healthcare. This could be attributed to the reform of the Ecuadorian health system, evidenced by broader use of public healthcare service’s curative care by the first and third socioeconomic quintile of the population. Nevertheless, obstacles that cause insufficient care in health services persist, preventing the delivery of consistent, adequate and high-quality care to achieve long-term control of chronic diseases [44]. The diagnosis gap in the population was significantly lower (6.1%) than those re- ported in other countries, such as India [45], Korea [46], The United States, Canada, and England [18]. Even in high-income countries, 37% of hypertensive patients do not acknowl- edge their disease [47]. The notable results regarding diagnosis coverage may be rooted in the previously mentioned health system reforms, but they should be explored in future studies. Findings on the sociodemographic factors associated with this gap are consistent with those of other studies [45]: males face multiple barriers in accessing healthcare, which, added to the lack of routine BP control and few support networks, prevent proper diag- nosis. The traits traditionally considered inherent to masculinity, such as self-sufficiency, self-dependence and/or strength, make men more prone to not seek healthcare, to seek it out following a delay, and to develop complications associated with these delays [48,49]. Although no specific explanations were found for the influence of living alone on the diagnosis gap, some studies show an association between the absence of support networks, whether friends or family and an increase in systolic BP [50]. On the contrary, support networks have been positively associated with treatment compliance and better self-care behavior in patients with HTN [51,52]. The follow-up gap in this study was 27.7%. It was larger for females under 65, with no social security affiliation, unemployed, and having a diabetes diagnosis. Follow- up constitutes an opportunity to make a clinical decision based on BP values, provide counseling, and evaluate treatment adherence [53]. The absence of follow-up may result in poor disease control, greater risks for hospitalization, decreased clinical efficiency and higher mortality [54,55]. Several barriers have been identified for optimal follow-up. However, the evidence contradicts [54]. In the first level of the Ecuadorian public health system, appointment scheduling does not allow for the health care professional to be selected. The resulting frequent change in physicians hampers care continuity, obstructing adequate follow-up for patients with chronic diseases. Despite women’s unquestionable progress in participation in work, politics and edu- cation, inequity nonetheless persists; women, particularly those who are poor, have less Int. J. Environ. Res. Public Health 2022, 19, 5832 10 of 13 access to health care resources within and outside of their families and less decision-making power over their own health. Furthermore, women frequently engage in informal em- ployment and are responsible for their dependents’ care [56]. This limits their ability to access social security benefits, which may constitute a barrier to continuing with follow-up consultations. The control gap in people with previously diagnosed HTN and the overall population (13.7% and 43.5%, respectively) showed significantly lower values than those reported in a study performed in 2017 in Cuenca, Ecuador. In the latter, 51.1% of the individuals with HTN diagnosis had adequate control [33]. Conversely, the STEPS (2018) [19] survey reported that 26% of those who knew their diagnosis and took medication had their blood pressure under control. Likewise, the PURE study showed that the rate of non-controlled hypertension in South America was 81.2% of the population previously diagnosed with HTN [18]. In a systematic review [15], this data corresponded with 66.8% for Central America, South America, and the Caribbean. North America had values of 49.9% for men and 44.1% for women. While HTN control has increased substantially since 2000 in high-income countries, from 18% to 28% in 2010, it remains insufficient [46]. The apparent contradiction between the results obtained regarding the gap of follow- up and the gap in population control may be explained due to the fact that the patients could have a scheduled appointment available for the follow-up (definition of follow-up gap), however the quality of the consultation is not always the best due to the lack of application of the GPC recommendations, such as appropriate counseling about habits and healthy styles, treatment standardization, adherence to treatment evaluation, as well as the lack of fulfillment of the recommendations on behalf of the patients, which finally affect arterial pressure control. The diagnosis, follow-up, and control gaps of the population with HTN require primary and secondary prevention actions to avoid complications or major cardiovascular injuries and decrease quality of life [57]. In addition, strategies are required to improve healthcare-seeking behavior; although mainly driven by individual decision, this behavior is mediated by an effective response from the health services. Examples of the latter are the availability of medical appointments in a timely fashion and at a convenient time for patients who work, a sustained accompaniment on behalf of the health professionals to improve self-care, and support for identifying adequate solutions for the problems. A healthcare plan developed with the user, and the definition and monitoring of the fulfilment of goals could help in this endeavor [58]. Undisputedly, health care alone is not enough to formulate a complete approach on HTN since many of the implicated factors extend beyond health systems’ scope. By tackling some socio-economic determinants, they might better impact the population health [59,60]. To control HTN, it is necessary to account for an integrative response based on inter-sectoral collaboration and integrated methods of caring for persons with chronic conditions. Self- care strengthening, redefinition of roles and responsibilities of doctors, nurses, and social workers, and incorporating adequate financial models, represent fundamental elements of this integrative care model [47,61]. Methodological limitations in the current study are related to HTN measurements carried out on a single day, which might cast false positive or negative results. In order to reduce this possibility, three serial BP measurements were made, observing PAHO’S recommendations for population studies [27]. The selection criteria of including only participants aged between 35 and 70 years of age, excluded an important part of the population. People over 70 years most likely live in worse socio-economic and health conditions and might exhibit larger gaps regarding medical care and control of their hypertension. Nevertheless, this age group is relatively small and represents less than 4% of the total country’ population [25,29]. It is relevant to acknowledge that this study did not explore factors related to the frequency nor quality of follow-up. The values found in this study cannot be generalized to the entire Quito Metropolitan District population, let alone on a national level. It must be considered that Ecuador is a heterogeneous country, Int. J. Environ. Res. Public Health 2022, 19, 5832 11 of 13 not only in its geographical, ethnic, and cultural diversity, but also due to the pronounced social and economic imbalance and the availability and organization of its health services. 5. Conclusions This study demonstrated the existence of good access and coverage for diagnosis and treatment and problems with the follow-up and control of persons with HTN. This could be explained by the persistence of a healthcare model focused on acute diseases’ clinical management. The absence of a follow-up system that guarantees healthcare continuity in patients with chronic diseases, especially diabetes and hypertension, indicates this situation. A lack of follow-up is also associated with deficiencies in scheduling appointments and a healthcare service wherein organization of ongoing care is focused on freedom of choice. The gaps identified by this study expose the current limitations of the national healthcare system and its model. Author Contributions: Conceptualization: P.O., E.L.A. and P.V.d.S., Data curation: P.O. and Y.V., Formal analysis: P.O. and Y.V., Investigation: P.O., Y.V. and E.A., Methodology: P.O., Y.V., E.A., E.L.A. and P.V.d.S., Visualization: P.O. Project administration: E.A, Supervision: E.A. and Y.V. Writing— original draft preparation: P.O., Writing—review & editing: P.O., Y.V., E.A., E.L.A. and P.V.d.S. All authors have read and agreed to the published version of the manuscript. Funding: Research execution was finance with funds from the Pontifical Catholic University of Ecuador (Project PUCE—L13345). Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and the Ethics Committee for Research in Human of the Pontifical Catholic University of Ecuador provided ethical authorization for this study (Reference: 099-CEI-2015). Informed Consent Statement: A written consent was obtained from each participant for the applica- tion of the survey and the measurement of his/her blood pressure. Data Availability Statement: Data associated with this study are available upon request from the corresponding author. Acknowledgments: The authors thank Karen Pesse-Sorense and Monserrat Martin for reviewing the draft of the manuscript, offering their comments and contributions. We also thank Tullia Battaglioli, Rubén Darío Gómez and Armando Rodríguez-Salvá for their contribution in the initial analysis of data and preliminary results. This study is part of a joint research project within the Latin-American Network for Multidisciplinary Research on Chronic Non-Communicable Diseases, a regional network of partner academic institutions supported by the Antwerp Institute of Tropical Medicine and the Belgian Directorate-General for Development Cooperation. Conflicts of Interest: The authors declare no conflict of interest. References 1. GBD 2017 Risk Factor Collaborators. 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