A Systematic Review of the Adequacy of Hypertension Treatment in Women Attending Azadi Teaching Hospital During Crises in Kirkuk, Iraq

Abstract

Background: Elevated intraocular pressure is a major, dangerous and modifiable risk factor, as the resulting deaths are primarily due to cardiovascular and cerebrovascular diseases worldwide. Control of this condition is particularly important in the context of the disruptions caused by humanitarian crises; it has been found that in the city of Kirkuk in Iraq, there have been prolonged periods of instability, and among the causes of this during the period from 2014 to 2017, during the time of ISIS’s control and the widespread displacement that occurred repeatedly. This has been a major cause of sustained pressure on Azadi Teaching Hospital, which is considered a key referral centre in that governorate. Women attending outpatient clinics for this condition have faced overlapping problems that have prevented them from receiving treatment. Ultimately, the evidence regarding the appropriateness of treatment for these women remains extremely limited, fragmented and incomplete. Objective: To systematically review the available evidence on the adequacy of hypertension treatment among women attending Azadi Teaching Hospital, Kirkuk, during periods of crisis, and to synthesize contextual, regional, and global data to inform recommendations. Methods: A systematic search of PubMed/MEDLINE, Google Scholar, regional journals (Kirkuk Journal of Medical Sciences, Eastern Mediterranean Health Journal), and grey literature was conducted (search period: inception to September 2026). Studies were eligible if they reported on hypertension prevalence, treatment, adherence, or control among adults attending Azadi Teaching Hospital, or among Iraqi/crisis-affected populations where data were relevant to that setting. The exposure of interest was treatment adequacy, defined by four domains: (1) proportion receiving antihypertensive treatment, (2) guideline-concordance of prescribed regimens, (3) medication adherence, and (4) achieved blood pressure control (<140/90 mmHg). Risk of bias was assessed narratively given the predominance of cross-sectional designs. Results: Seven studies met inclusion criteria. Only two studies were conducted directly at Azadi Teaching Hospital; the remainder provided Iraqi, Kurdistan-region, or crisis-setting contextual evidence. The prevalence and incidence of high blood pressure amongst patients attending Azadi Teaching Hospital reached a very high rate of 41 per cent, whilst treatment coverage was very low and control of the condition, where possible, was very poor. A 2018 Azadi study found 93% of hypertensive patients uncontrolled. Evidence from Baghdad and Erbil showed control rates of 38.7% and 22% (rising to 47% with intensive follow-up), respectively. Female sex appeared protective for control in Erbil but not in Baghdad. Crisis-related barriers medication supply disruption, cost, out-of-pocket purchase, and interrupted follow-up were consistent across settings. Evidence specific to women at Azadi during crises remains sparse, and no study disaggregated treatment adequacy fully by sex and crisis phase. Conclusions: Hypertension treatment adequacy among women attending Azadi Teaching Hospital during crises is likely inadequate across all measured domains, consistent with national Iraqi and crisis-affected regional data. Priority actions include sex-disaggregated prospective monitoring, medication supply-chain strengthening, adherence support, task-sharing with clinical pharmacists, and integration of hypertension into crisis-preparedness planning.