Awareness, treatment, and control of hypertension is low among adults in Aksum town, northern

16 Pages·2017·1.21 MB·English

RESEARCHARTICLE
Awareness, treatment, and control of
hypertension is low among adults in Aksum
town, northern Ethiopia: A sequential
quantitative-qualitative study
TeklayAredeheyGebrihet1☯,KebedeHaileMesgna2☯,YosefSibhatuGebregiorgis2☯*,
AlemayehuBayrayKahsay3☯,NegassieBerheWeldehaweria2‡,Meresa
GebremedhinWeldu2‡
1 DistrictHealthOffice,Aksum,Ethiopia,2 CollegeofHealthSciences,AksumUniversity,Aksum,Ethiopia,
3 CollegeofHealthSciences,MekelleUniversity,Mekelle,Ethiopia
a1111111111
a1111111111 ☯Theseauthorscontributedequallytothiswork.
a1111111111 ‡Theseauthorsalsocontributedequallytothiswork.
a1111111111 *[email protected]
a1111111111
Abstract
OPENACCESS Introduction
Citation:GebrihetTA,MesgnaKH,Gebregiorgis Hypertensionisamajorriskfactorofcardiovasculardiseaseswhicharetheleadingcauses
YS,KahsayAB,WeldehaweriaNB,WelduMG
ofdeathsfromchronicnon-communicablediseasesinEthiopia.However,littleisdocu-
(2017)Awareness,treatment,andcontrolof
mentedintheissue.Therefore,thisstudyaimedtoassesstheprevalence,associatedfac-
hypertensionislowamongadultsinAksumtown,
northernEthiopia:Asequentialquantitative- tors,awareness,treatmentandcontrolofhypertensionamongadults18yearsoldorabove
qualitativestudy.PLoSONE12(5):e0176904. inAksumtown,Tigrayregion,NorthEthiopia.
https://doi.org/10.1371/journal.pone.0176904
Editor:AftabAhmad,UniversityofAlabamaat Methods
Birmingham,UNITEDSTATES
Asequentialquantitative-qualitativestudywasconductedamongadultsaged18yearsand
Received:February13,2017 aboveinAksumtown.Amultistagesamplingprocedurewasusedtoselectthestudypartic-
Accepted:April19,2017 ipantsforthequantitativestudywhilstconveniencesamplingtechniquewasusedforthe
qualitativepart.Apre-testedandstructuredquestionnairewasusedtocollectquantitative
Published:May10,2017
data,andaninterviewguidewasusedtocollectthequalitativedata.Thelogisticregression
Copyright:©2017Gebrihetetal.Thisisanopen
modelwasfittedtoidentifyfactorsindependentlyassociatedwithhypertensionusingSPSS
accessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense,which Version20.P-valuesof<0.05wereconsideredstatisticallysignificant.Forthequalitative
permitsunrestricteduse,distribution,and data,iterativehearingofthediscussionsverbatiminterpretationwasfollowedbycategoriz-
reproductioninanymedium,providedtheoriginal
ingsimilarideasintothemesandfinallytriangulatedwiththequantitativeresults.
authorandsourcearecredited.
DataAvailabilityStatement:Allthedata Results
supportingthefindingsiscontainedwithinthe
manuscript. Theoverallprevalenceofhypertensionwas16.5%(95%CI:13.4,20.0).Awareness,treat-
mentandcontrolofhypertensionwere43%,2.1%and18.2%,respectively.Beingunableto
Funding:Theauthorsreceivednofunding;the
workwascoveredbytherespectiveauthors. readandwrite[AOR=4.73,95%CI:1.11,20.23],notconsumingfruit[AOR=4.31,95%
CI:1.74,10.66],beingphysicallyinactive[AOR=20.11,95%CI:8.75,6.20],notknowing
Competinginterests:Theauthorsdeclarethatthey
havenocompetinginterests. physicalinactivityisariskfactorofhypertension[AOR=3.57,95%CI:1.69,7.69]andbeing
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Awareness,treatment,andcontrolofhypertensionislowamongadultsinAksumtown,NorthEthiopia
overweight/obese[AOR=9.2,95%CI:4.54,18.67]weresignificantlyassociatedwithhyper-
tension.Remarkably,allidentifiedhypertensivecaseswerelinkedtothenearbyhospitalfor
confirmationofdiagnosis,careandfollow-upandallofthemwerefoundtobehypertensive.
Thissuggeststhatimplementingprimaryhealthcareapproachintegratedwiththeurban
healthextensionpackagemaybeeffectiveinthepreventionandcontrolofhypertensionin
poorsettings.
Conclusionandrecommendation
Prevalenceofhypertensionamongadultswasveryhigh,butawareness,treatmentandcon-
trolofhypertensionwasverylow.Beingunabletoreadandwrite,notconsumingfruit,being
physicallyinactive,overweight/obesityandnotknowingphysicalinactivityisariskfactorfor
hypertensionwereindependentlyassociatedwithhypertension.Policymakersneedtocon-
siderintegratingpreventionandcontrolofhypertensionwithhealthextensionpackage.
Appropriateinformation,educationandcommunicationstrategiesshouldalsobedesigned
andimplementedtoavoidunhealthylifestylesandpromotehealthypractices.
Introduction
Chronicnon-communicablediseases(CNCDs)ingeneralandhypertensioninparticularwere
originallythoughttobeassociatedwithaffluentsocieties[1].Contrarytothecommonpercep-
tionofrelatingCNCDstothedevelopedworld,epidemiologicshifthasgivenrisetoan
increaseinhypertensionandotherCNCDsindevelopingcountries[1].Chronicnon-commu-
nicablediseasesaccountfornearlysevenintendeathsgloballyandabout40%ofthesedeaths
arepremature.Sadly,nearlythreefourthsofalldeathsfromCNCDs,andanoverwhelming
majority(>80%)ofprematuredeathsfromCNCDs,occurindevelopingcountries[2].Cardio-
vasculardiseasesaretheleadingcausesofdeathsfromCNCDswhichcontributefornearly
halfofthedeaths[2].
Hypertensionisthepresenceofachronicelevationofsystemicarterialpressureabovea
certainthresholdvalue.Specifically,hypertensionisdefinedassystolicbloodpressure(cid:21)140
mmHgordiastolicbloodpressure(cid:21)90mmHgorreporteduseofanti-hypertensivemedica-
tioninadultsaged18yearsandover[3–6].Itisamajorcardiovascularproblemriskfactorand
leadstocerebralstroke,congestiveheartfailure,chronickidneydiseaseandcoronaryartery
disease[1,7].Hypertensionplaysaroleinapproximately55%oftheglobalmortalitycausedby
cardiovasculardiseasesandin7%ofalldisability-adjustedlifeyears[8].Theglobalprevalence
ofhypertensioninadultsaged18yearsandoverisaround22%in2014[2].
Africaisoneoftheregionshighlyaffectedbyhypertension.MorerecentstudybyAdeloye
etal.showsthattheprevalenceofhypertensioninAfricais30.8%[9].Ethiopiaisalsooneof
themostaffectedcountriesintheregion.Accordingtoarecentmeta-analysisstudyinEthio-
piabyKibretetal.,theprevalenceofhypertensionamongEthiopianpopulationisestimatedto
be19.6%(95%CI:13.7%,25.5%)[10].Thisindicatesthathypertensionisapublichealthprob-
leminEthiopiatoday.
Beingpreventablewithsimpleandcosteffectiveinterventions[8,11],hypertensionshould
bepreventedbyimplementingappropriatepreventivemeasures.Furthermore,peoplewhoget
hypertensiveshouldbeearlydetected,treatedandtheraisedbloodpressurebecontrolled.
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Awareness,treatment,andcontrolofhypertensionislowamongadultsinAksumtown,NorthEthiopia
Otherwise,lowawareness,treatmentandcontrolofhypertensionleadtolifethreateningcom-
plications,whichimpactshealthandeconomicgains[11].
Differentfactorssuchassocio-demographiccharacteristics,behavioralfactors,bio-medical
characteristics,knowledgeandattitudecouldcontributetohypertension[12].Thesefactors
couldvarywithcontext.Therefore,researchbasedinformationregardingprevalence,associ-
atedfactors,awareness,treatmentandcontrolofhypertensionareurgentlyneededforpriori-
tizing,designingandinitiatinginterventionprogramsaimedatpreventionandcontrolof
hypertension.
However,previousstudiesarescarceinthestudyareaandeventhelimitedstudiesgave
emphasistotheprevalenceofhypertensionandlackcomprehensivenessinassessingaware-
ness,treatmentandcontrolofhypertensionandimportantvariablessuchasknowledgeasa
riskfactor.Thus,thisstudyisaimedatassessingprevalence,associatedfactors,awareness,
treatmentandcontrolofhypertensionamongadults18yearsoldoraboveinAksumtown,
Tigrayregion,northernEthiopiatoavailtheinformationrequiredforhealthcareproviders
andpolicymakerstodesignandimplementappropriateinterventions.
Methodsandmaterials
Studydesign,settingandpopulation
Asequentialquantitative-qualitativestudydesignwasemployedfromOctober1toDecember
30/2015amongadultslivinginAksumtown.Aksumtownislocatedinthenorthernpartof
Ethiopiabetween14,1297(147’46.920”N)latitudeand38,7158(3842’56.880”E)longitudeata
distanceof1010kmawayfromAddisAbaba.Administrativelythetownisdividedintofour
Kebeles(smalllocaladministrativeunits).Accordingtothe2007reportoftheCentralStatisti-
calAgencyofEthiopia,thetotalpopulationofAksumtownis60,766,with30,991(51.0%)
femalesand29,775(49.0%)males[13].Thereisonepublichospitalandtwohealthcentersin
thetown.Adultsaged18yearsormorelivinginAksumtownwerethesourcepopulationof
thestudy.
Samplesizeandsamplingtechnique
ThesamplesizewascalculatedusingOpenEpi.Theassumptionsforthesamplesizecalcula-
tionwere:20.1%prevalenceofhypertensionamongadultsfromastudybyMengistuetal.in
Mekelletown[14],95%confidenceinterval,5%marginoferror,designeffectoftwoand10%
non-responserate.Thefinalcalculatedsamplesizewas544.Atwo-stagesamplingapproach
wasusedtoselectstudyparticipants;wherefirst2kebeleswereselectedrandomlyfromthe
total5kebelesofAksumtown.Then,thetotalsamplesizewasallocatedtoeachoftheran-
domlyselectedkebelesbasedonprobabilityproportionaltosizeallocation.Secondly,544
householdswhofulfilledtheinclusioncriteriawereselectedbysystematicrandomsampling
technique.Thefirsthouseholdwasselectedbylotterymethodandthentherespondentsliving
ineverytenthhousewererecruited.Whenthereismorethanoneeligibleadultinthehouse-
hold,onlyoneindividualwasselectedusingthelotterymethod.Eventually,atotalof521
adultswereparticipatinginthisstudy.
Residentswhowerenotathomeduringtheinitialcontactwerere-visitedonthreeother
occasionsbeforeexcludingthemfromthestudy.Householdswereincludedif:1)theyhad
non-pregnantadultaged18yearsorolder,and2)theselectedadultwasapermanentresident
(wholivedintheareaatleastforsixmonths)andwillingtoprovideverbalconsent.House-
holdswereexcludedif:1)noadultresidentwasathomeonmorethan3visitsor2)ifthe
householdwasvacant.
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Awareness,treatment,andcontrolofhypertensionislowamongadultsinAksumtown,NorthEthiopia
Forthequalitativepart,threefocusgroupdiscussionscomprisedof9–12participantswho
werenotinvolvedintheindividualinterviewwereconducted.Thefocusgroupdiscussants
wereselectedusingaconveniencesamplingtechnique.
Operationaldefinitions
Hypertension:hypertensionwasdefinedassystolicbloodpressure(cid:21)140mmHgand/ordia-
stolicbloodpressure(cid:21)90mmHgand/orreporteduseofanti-hypertensivemedication[15].
Controlledhypertension:bloodpressuremeasurements<140/90mmHgwhileontreat-
mentforhypertensionwereconsideredascontrolledhypertension.
Bodymassindex(BMI):iscalculatedasweightinkilogramsdividedbyheightinmeters
squaredandinterpretedasunderweight(BMI<18.5),normal(18.5–24.9),overweight(25.0–
29.9)andobese((cid:21)30.0)[15].
Physicalactivitylevel:physicallyactiveifhe/sheisengagedinmoderate-intensityphysical
activityforatleast150minutesperweekorinvigorous-intensityphysicalactivityforatleast
75minutesperweek,oranequivalentcombinationofmoderateandvigorousintensityactiv-
ity.Whereas,physicallyinactiveifhe/sheisengagedinmoderate-intensityphysicalactivity
for<150minutesperweek,orvigorousintensityphysicalactivityfor<75minutesperweek
[16].
Fruitintake:goodiffruitsintakeis(cid:21)3daysperweekandlowiffruitsintake<3daysper
week[17].
Vegetableintake:goodifvegetablesintakeis(cid:21)3daysperweekandlowifvegetablesintake
of<3daysperweek[17].
Knowledge:goodifthetotalknowledgescoreisabovethemeanscoreotherwiselow.
Datacollectionmethodandinstruments
AstructuredquestionnaireadaptedfromtheWorldHealthOrganizationinstrumentforstep-
wisesurveillance(WHOSTEPS)ofchronicdiseaseriskfactors[18]andotherrelevantlitera-
tures[14,19]wasusedtocollectthequantitativedatabyinterviewandbytakingphysical
measurements.Thequestionnairewascontextualizedtothelocalsituation(S1Table).The
questionnaireincludedsocio-demographicinformation,behavioralcharacteristics(dietary
habits,physicalactivity,alcoholconsumption,tobaccouse,familyhistoryofhypertension,
pastmedicalhistoryanddrughistory),physicalmeasurementsandknowledgeofhyperten-
sion.Thequantitativedatacollectionwasconductedbyeightclinicalnurses,whowereurban
healthextensionpackageworkersunderthesupervisionoftwoBScnursesandtheprincipal
investigators.Trainingandpracticaldemonstrationsoninterviewtechniquesandanthropo-
metricmeasurementproceduresweregiventodatacollectorsfortwoconsecutivedays.Prior
todatacollection,thequestionnairewaspre-testedon5%ofthetotalsampleofsimilarpopula-
tioninoneofthenon-studykebelesandnecessarymodificationsweremadebasedonthe
pretest.
Theparticipant’sbloodpressurewasmeasuredtwiceinasittingpositionusingastandard
mercurysphygmomanometerwiththeappropriatecuffsizethatcoverstwo-thirdsofthe
upperarmaftertheparticipantrestedforatleastfiveminutes.Participantswereinquired
whethertheyhadconsumedanyhotbeverage,suchasteaorcoffee,smokedcigaretteor
undertakenanyvigorous-intensityphysicalactivity30minutesbeforemeasurementotherwise
bloodpressuremeasurementwaspostponedfor30minutes.Thesecondmeasurementwas
takenfive-to-tenminutesafterthefirstmeasurement.Finallytheaverageofthetwoblood
pressuremeasurementswascomputedandusedtodeterminewhetherparticipantsarehyper-
tensiveornot.
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Awareness,treatment,andcontrolofhypertensionislowamongadultsinAksumtown,NorthEthiopia
Measurementofweightwasconductedusingastandardbeambalancethatisusedfor
weightmeasurementinthemedicalsetup.Thescalepointerwascheckedatzerobeforetaking
everymeasure.Eachparticipantwasaskedtoremoveheavyclothes.He/shestoodstraightand
unassistedatthecenterofthebalanceplatform.Weightmeasurementsweretakentothenear-
est0.1kg.
Heightwasmeasuredusingawoodenheight-measuringboardwithaslidingheadbarfol-
lowingstandardanthropometrictechniques.Theparticipantswereaskedtoremovetheir
shoes,stooderect,andpositionedintheFrankfertplanewithfeettogetherandkneesstraight.
Theheels,buttocks,shoulderbladesandthebackofthehead(occipital)wereintouchagainst
theverticalstandofthestadiometerandthevalueswererecordedtothenearest0.1cm.
Forthequalitativepart,asemi-structuredopenendedinterviewguidewasusedasaguide
forconductingthefocusedgroupdiscussion.Qualitativedatawerecollectedbytrainedand
experiencedprofessionalsusingtaperecordingandnotetaking.
Dataprocessingandanalysis
DatawereenteredandcleanedusingEpiInfoversion6.04,andtransferredtoSPSS20statisti-
calsoftwarepackageforanalysis.Descriptivestatisticswereusedtosummarizethestudyvari-
ables.Summarymeasuresandproportionsoftheindependentvariableswerecomputed
againsttheoutcomevariable.Inthisstudy,theoutcomevariablewashypertension,whichwas
dichotomizedbyassigning1forthosewhowerehypertensive(systolicbloodpressure(cid:21)140
mmHgand/ordiastolicbloodpressure(cid:21)90mmHgand/orreporteduseofanti-hypertensive
medication)and0forthosewhowerenothypertensive(systolicbloodpressure<140mmHg
anddiastolicbloodpressure<90mmHgandreportednouseofanti-hypertensivemedica-
tion)duringthedatacollectiontime.Bivariableanalysiswasusedtoseetheunadjustedeffect
ofeachfactoronhypertension.Finally,independentvariableswithap-value<0.05inthe
bivariableanalysiswerefittedintoamultivariablelogisticregressionmodeltoidentifytheir
independenteffectonhypertension.AdjustedOddsRatio(AOR)with95%confidenceinter-
valswasestimatedtoassessthestrengthoftheassociation,andap-value<0.05wasusedto
declarethestatisticalsignificanceinthemultivariateanalysis.Hence,variableswithp-
value<0.05inthemultivariatelogisticregressionanalysiswereconsideredassignificantand
independentdeterminantsofhypertension.
TheHosmer-Lemeshowgoodness-of-fitandOmnibustestsofmodelcoefficientstestswith
enterprocedurewereusedtotestformodelfitting.Theexplanatoryvariablesweretestedfor
multicollinearitybeforeenteringthemintothemultivariablemodel,usingtheVarianceInfla-
tionFactor(VIF)test,theTolerancetest,andvaluesofthestandarderror.
Thequalitativedatatranscribedandthentranslatedfromlocallanguage,Tigrignato
Englishinverbatimmanner.Aftertheinterviews,listenedtomanytimes,thetranscriptswere
reduced,codedandcategorizedintothemes,andfinallytriangulatedwiththequantitative
results.
Ethicalconsideration
EthicalclearancewasapprovedbytheInstitutionalResearchReviewBoardofCollegeof
HealthSciencesandReferralHospital,AksumUniversity.Permissionletterwasalsoobtained
fromAksumdistricthealthoffice.Moreover,allstudyparticipantswereinformedaboutthe
purposeofthestudyandverbalconsentwasobtainedfromeachstudyparticipantbeforedata
collection.Confidentialitywasensuredbyusingaquestionnaireidentificationnumberin
whichwasimmediatelydetachedandfiledseparatelyinaconfidentialmanner.Subjectswith
highbloodpressure(hypertension)werelinkedtohealthfacilitiesforcareandfollow-up.
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Awareness,treatment,andcontrolofhypertensionislowamongadultsinAksumtown,NorthEthiopia
Table1. Socio-demographiccharacteristicsoftherespondentsinAksumtown,Tigray,northernEthiopia,2015(n=521).
Characteristics Frequency %
Sex Male 203 39.0
Female 318 61.0
Agegroup 18–29 178 34.2
30–49 253 48.6
(cid:21)50 90 17.3
Educationalstatus Unabletoreadandwrite 90 17.3
Primary 192 36.9
Secondary 164 31.5
Abovesecondary 75 14.4
Ethnicity Tigray 516 99.0
Other* 5 1.0
Religion Orthodox 421 80.8
Muslim 99 19.0
Catholic 1 0.2
Maritalstatus Married 350 67.2
Single 89 17.1
Divorced 50 9.6
Widowed 32 6.1
Occupationalstatus Housewife 135 25.9
Merchant 125 24.0
Employed** 102 19.5
Dailylaborer 77 14.8
Student 49 9.4
Nojob 21 4.0
Farmer 12 2.3
Monthlyfamilyincome (cid:20)1000ETB*** 217 41.7
1001–2000ETB 207 39.
2001–3000ETB 37 7.1
>3000ETB 60 11.5
*=Amhara,OromoandGurage
**=indicatesemploymentinbothgovernmentalandnon-governmentalorganizations
***=EthiopianBirr
https://doi.org/10.1371/journal.pone.0176904.t001
Results
Socio-demographiccharacteristicsofstudyparticipants
Atotalof521respondentswasincludedinthisstudy,makingtheresponserateof96%.The
mean(±SD)ageofrespondentswas36.44(±12.4).Nearlyhalfoftherespondents(48.6%)
wereintheagegroupof30–49years.Morethanhalf(61%)werefemales.Ofthetotal
respondents,516(99%)wereTigrayinethnicity,421(80.8%)wereOrthodoxinreligion
and350(67.2%)weremarried.Majority282(54.2%)attendedatmostprimaryleveleduca-
tionornotatall.Aboutonefourth(25.5%)werehousewivesfollowedbymerchants
(24.0%)andemployed(19.5%).Themedianmonthlyfamilyincomewas1,000.00ETB,and
217(41.7%)ofrespondentswereinthefamilyincomecategoryof<1000.00ETBpermonth
(Table1).
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Table2. Behavioral,dietaryandbio-medicalrelatedcharacteristicsoftherespondentsinAksumtown,Tigray,northernEthiopia,2015(n=521).
Characteristic Frequency %
Smoking Never 505 97.0
Currently 7 1.3
Previous 9 1.7
Alcoholuse Never 312 59.9
Currently 154 29.6
Previous 55 10.5
Frequencyofdrinkingalcohol/week <3days 124 23.8
(cid:21)3days 30 5.8
Consumefruit Yes 428 82.1
No 93 17.9
Fruitconsumption/week <3days 339 65.0
(cid:21)3days 89 17.1
Consumevegetable Yes 500 96.0
No 21 4.0
Vegetableconsumption/week <3days 362 69.5
(cid:21)3days 138 26.5
Typeoffat/oilmostoftenused Unsaturated 79 15.2
Saturated 442 84.8
Physicalactivity Active 341 65.5
Inactive 180 34.5
BMI(kg/m2) Underweight 42 8.1
Normal 397 76.2
Overweight/obese 82 15.7
Familyhistoryofhypertension Yes 41 7.9
No 480 92.1
Familymemberwithhypertension Parents 21 4.0
Siblings 9 1.8
BMI=BodyMassIndex
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Behavioral,dietaryandbio-medicalrelatedcharacteristics
Ofthetotalrespondents,seven(1.3%)werecurrentsmokersand154(29.6%)werecurrent
alcoholusers.Fourhundredtwentyeight(82.1%)ofthetotalrespondentsreportedthatthey
eatfruits,butonly89(17.1%)eatsafruitatleastthreedaysperweek.Almostalloftherespon-
dents500(96%)reportedthattheyeatvegetableintheirservings,butonly138(26.5%)eats
threedaysormoreperweek.Majority442(84.8%)oftherespondentsreportedthattheyuse
saturatedfatandoilintheirdiet.Ofthetotalrespondentsincludedinthisstudy,341(65.5%)
werephysicallyactive.Regardingtobodymassindex,82(15.7%)ofrespondentswereobese/
overweight(BMI(cid:21)25kg/m2).Inaddition,41(7.9%)oftherespondentshadafamilyhistory
ofhypertension(Table2).
Knowledgeofrespondentsonhypertension
Themostcommonriskfactorsofhypertensionidentifiedwerehighsaltintake318(61%),
highfatintake270(51.8%),obesity253(49.1%),andphysicalinactivity189(36.3).About480
(92.1%)reportedthathypertensionispreventableandthecommonlyreportedprevention
methodsweredecreasingsaltintake371(71.2%),physicalactivity318(60%)anddecreasing
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Table3. KnowledgeonriskfactorsandpreventionmethodsofhypertensionamongadultsinAksumtown,Tigray,northernEthiopia,2015
(n=521).
Characteristic Frequency %
Everheardabouthypertension Yes 491 94.2
No 30 5.8
Knowledgeonriskfactorsofhypertension* Highsaltintake 318 61.0
Highfatintake 270 51.8
Obesity 256 49.1
Physicalinactivity 189 36.3
Alcoholism 157 30.1
Stress 106 20.3
Advancinginage 84 16.1
Smoking 40 7.7
Coffee 30 5.8
DiabetesMellitus 8 0.4
Knowsthathypertensionispreventable Yes 480 92.1
No 41 7.9
Knowledgeonpreventionmethodsofhypertension* Decreasingsaltintake 371 71.2
Doingphysicalactivity 318 61.0
Decreasingfatintake 257 49.3
Notusingalcohol 218 41.8
Notsmoking 39 7.5
Others** 18 3.45
Compositeknowledgescore Low 269 51.6
High 252 48.4
*=thepercentagesdonotaddupto100%duetomultipleresponses
**=reducingsugarintake,coffeeandstress
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fatintake257(49.3%).Generally,morethanhalf(51.65%)oftherespondentshadlowknowl-
edgeofriskfactorsandpreventionmethodsofhypertension(Table3).
Qualitativefindingsconcerningknowledgeonhypertension
Thesocio-demographiccharacteristicofthediscussantswas,14(46.7%)werewomenandthe
rest16(53.3%)weremales.Allwereolderthan18yearsinageandresidentsofAksumtown.
Twomainthemes,namelyriskfactorsofhypertensionandpreventionmethodsofhyperten-
sionwereidentifiedinthethematicframeworkanalysis.Accordinglythefindingsarepre-
sentedasfollows.
Knowledgeonriskfactorsofhypertension
Thefocusgroupdiscussionidentifiedlackofknowledgeonriskfactorsofhypertension.Con-
cerningriskfactorsofhypertension,feedinghabitwasmentionedbymostofthediscussants.
However,theyfailedtonameriskyfeedinghabit.Forinstance,a42yearsoldwomanclaimed:
“...Eatingtoomuchfoodofanytypeisthemostcommonriskfactorwhichexposespeopleto
hypertension..............”
Lackofknowledgeonriskfactorsofhypertensionwasalsosubstantiatedbyanother50
yearsoldmanwhostated:
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Awareness,treatment,andcontrolofhypertensionislowamongadultsinAksumtown,NorthEthiopia
“...Generally,IbelievethatitischanceorGod’s willwhichexposespeopletohypertensionnot
anyotherfactor. Butsometimes,eatingtoomuchfood,especiallytoosweetfoodsuchashoney,
consuminglocalcrop,red‘teff’andredrootincreasedtheriskofgettinghypertension....”
Somediscussantsthathadbetterawarenessregardingtheriskfactorsofhypertensionwere
abletomentionfat,saltandcoffeeasriskfactors.However,stilltheyfailedtomentiontypesof
foodwithhighfatcontent.Forinstance,a30yearsoldwomanclaimed:
“....Highsaltintakeexposespeoplewithhypertension.Inaddition,highfatintakeincreases
theriskofgettinghypertension..................Highfatcontaining foodsareoilofanytype
andanysweetfoodssuchashoney”.
Knowledgeonpreventionmethodsofhypertension
Similartothatofriskfactorsforhypertension,thefocusgroupdiscussionidentifiedlackof
knowledgeonpreventivemeasuresofhypertension.Mostofthediscussantsrevealedthat
hypertensionispreventable.Whentheyareaskedtomentionthepreventivemeasures,most
ofthemdeclaredthatitcanbepreventedbyreducingsaltandcoffee.However,allofthem
reportedthattheyarenotpracticingit.Inaddition,avoidinghighfatintakewasstatedby
mostofthediscussants.However,theyfailedtonameclearlytherecommendeddietaryprac-
ticeorwhattoavoidandwhattoconsume.Forinstance,amanof37yearsoldrevealed:“...I
believethathypertensionispreventablebyimprovingdietarypractice,particularlybyavoiding
highfatintakejustbyavoidingconsumingoilandsweetfoods.Inaddition,itisimportantto
havemedicalcheckup......”Ontheotherhand,mostofthediscussantsfailedtomention
exercise,reducingstress,avoidingalcohol,avoidingsmokingandcontrollingbodyweightas
preventivemeasuresofhypertension.
Prevalence,awareness,treatment,andcontrolofhypertension
Theoverallprevalenceofhypertensionwas16.5%[95%CI:13.4,20.0].Amongallhypertensive
individualsidentified,morethanhalf(57%)werenotawareoftheirhypertensionstatus.More
thantwothird,59(68.6%)oftherespondentshavehadtheirbloodpressuremeasuredatleast
oncebeforebyadoctororotherhealthprofessional,butonly37(43%)havebeentoldbefore
thattheyarehypertensive.Moreover,only11(12.8%)weretakingdrugs(medication)for
hypertensionandtheoverallcontrolrateofhypertensionwasonly2(18.2%)(Table4).
Factorsassociatedwithhypertension
Thisstudyexaminedanumberofindependentvariableswiththeoutcomevariable(hyperten-
sion)inbothbivariableandmultivariableanalyseslevels.Socio-demographiccharacteristics
Table4. Prevalence,awareness,treatment,andcontrolofhypertensionamongadultsinAksum
town,Tigray,northernEthiopia,2015(n=521).
Characteristics Frequency %
Currentlyhypertensive(n=521) 86 16.5
Evermeasuredbloodpressure(n=86) 59 68.6
Everbeentoldbyadoctororotherhealthprofessionalthattheyhavehypertension 37 43.0
(n=86)
Havetakenanti-hypertensivemedication(n=86) 11 12.8
Hypertensioncontrolled(n=11) 2 18.2
https://doi.org/10.1371/journal.pone.0176904.t004
PLOSONE|https://doi.org/10.1371/journal.pone.0176904 May10,2017 9/16
Awareness,treatment,andcontrolofhypertensionislowamongadultsinAksumtown,NorthEthiopia
(sex,agegroup,educationalstatus,ethnicity,religion,maritalstatus,occupationalstatusand
monthlyfamilyincome);behavioral,dietaryandbio-medicalrelatedcharacteristics(smoking,
alcoholuseinlifeandfrequencyperweek,consumingfruitandconsumptionperweek,con-
sumingvegetableandconsumptionperweek,typeoffat/oilmostoftenused,physicalactivity,
BodyMassIndex(kg/m2),familyhistoryofhypertensionandmemberwithhypertension)and
knowledgeonriskfactorsandpreventionmethodsofhypertension(everheardabouthyper-
tension,knowledgeonriskfactorsandpreventionmethodsofhypertension,knowsthat
hypertensionispreventableandcompositeknowledgescore)wereanalyzedtoidentifycandi-
datevariablesforthefinalmodel.Amongtheseexaminedindependentvariables:agegroup,
lowlevelofeducation,physicalinactivity,notconsumingfruitandvegetable,familyhistory
ofhypertension,overweight/obesityandnotknowingphysicalinactivityasariskfactorfor
hypertensionweresignificantlyassociatedwithhypertensioninthebivariableregression
analysis.
Allidentifiedcandidatevariablessuchasagegroup,lowlevelofeducation,physicalinactiv-
ity,notconsumingfruitandvegetable,familyhistoryofhypertension,overweight/obesityand
notknowingphysicalinactivityasariskfactorforhypertensionwerealsoassessedinthefinal
modelandmultivariablelogisticregressionanalysisrevealedthateducationalstatuswasasso-
ciatedwithhypertension.Thelikelihoodofbeinghypertensivewasaboutfivetimesmore
likelyamongrespondentswhowereunabletoreadandwrite[AOR=4.73,95%CI;1.11,
20.23]comparedtothosewithabovesecondaryeducation.Physicallyinactiverespondents
[AOR=20.11,95%CI;8.75,46.20]wereabout20timesmorelikelytodevelophypertension
thanthosewhowerephysicallyactive.Knowledgeonphysicalinactivityasariskfactorwas
alsoassociatedwithhypertension;respondentswhodidn’tknowphysicalinactivityasarisk
factorofhypertension[AOR=3.57,95%CI;1.69,7.69]weremorelikelytobehypertensive
thantheircounterparts.Moreover,overweight/obese(BMI(cid:21)25kg/m2)respondents
[AOR=9.2,95%CI;4.54,18.67]wereatmorethanninetimesatincreasedriskofbeing
hypertensivecomparedtothosewithnormalBMI.Likewise,respondentswhodidnotcon-
sumefruit[AOR=4.31,95%CI;1.74,10.66]weremorelikelytobehypertensive(Table5).
Discussion
Thiscommunitybasedcross-sectionalstudyconductedinAksumtownassessedthepreva-
lenceandfactorsassociatedwithhypertension.Inthisstudy,theprevalenceofhypertension
was16.5%(95%CI:13.4,20.0).Thisfindingisconsistentwitharecentlyconductedmeta-anal-
ysisstudyontheprevalenceofhypertension(19.6%,95%CI:13.7,25.5)inEthiopia[10].How-
ever,thefindingofthiscurrentstudyishigherthanthefindingofsimilarstudiesinEthiopia;
insouthwestEthiopia(13.2%),innorthwestEthiopia(13.3%),andinsouthernEthiopia
(10.1%)[20–22].Theobserveddiscrepancycouldbeduetodifferenceinstudytime,which
suggeststhattheprevalenceofhypertensionisincreasingovertimeinEthiopia.
Conversely,thefindingofthecurrentstudyislowerthanthefindingsofothersimilarstud-
iesinEthiopia:Gondar(28.3%),Durame(22.4%)andAddisAbaba(30%)[19,23,24].This
couldbeduetothefactthatageispositivelyrelatedwithhypertensionandalloftheseprevious
studiesrecruitedolderparticipants((cid:21)34yearsinGondar,>31inDurameand(cid:21)25yearsin
AddisAbaba)comparedtothecurrentstudywhichrecruited(cid:21)18yearsadults.Inthecurrent
studyasignificantproportion(34%)oftherespondentswerebetween18and29years.Simi-
larly,thefindingofthecurrentstudyislowerthanthefindingsofsimilarstudieselsewhere;a
recentlyconductedsystematicanalysisinAfrica(30.8%)[9],andinEurope(28.0%–44.0%)
[25].Thediscrepancycouldbeduetothedifferenceinlifestyle.
PLOSONE|https://doi.org/10.1371/journal.pone.0176904 May10,2017 10/16