Undiagnosed and diagnosed hypertension in a community setting at Hosanna town: Uncovering the burden

Background Hypertension is a leading cause of cardio-vascular diseases and its attributed mortality. No previous study, however, assessed the prevalence and associated factors of hypertension in the study area. Methods We recruited a representative sample of 627 adult individuals from selected kebeles of Hosanna town. A multi-stage sampling technique was employed in the study. A structured questionnaire using the WHO STEPS approach was employed to conduct a face to face interview and physical measurements. For each participant, we measured blood pressure two times after giving 10 minutes breaks between the measurements and we took the average. Hypertension status was defined as “systolic blood pressure ≥140mmhg and/or diastolic blood pressure ≥90mmhg”. Undiagnosed hypertension was defined as participants who had raised blood pressure on measurement, but not aware of it before. We used Multivariable logistic regression model to determine factors associated with hypertension. Results The overall prevalence of hypertension was found to be 17.2% (95% CI 14.5 – 19.9), 19.3% among men and 14.2% among women, of which 10.2% were unaware of it before. Hypertension was significantly associated with old age ≥35 years, excess alcohol intake, consumption of saturated oil/fat), consumption of unspecified different types of oil/fat and overweight/obesity. Conclusion The prevalence of hypertension (both diagnosed and undiagnosed) in the town is unacceptably high. This is also related to modifiable risk factors like excessive alcohol intake, overweight/obesity and consumption of saturated fat/oil. Therefore, designing health information provision systems on the risk factors of hypertension and promotion of good health practices should be considered. Moreover, the health departments should facilitate blood pressure screening programs at community levels to identify and treat undiagnosed hypertension.


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Hypertension is a state of high blood pressure and a leading risk factor of cardio-vascular 42 diseases and attributed mortality, globally (1-4). Non-communicable diseases (NCDs) accounted 43 for 72.3% of global deaths in 2016, of which more than 50% of the deaths were attributed by the 44 cardio-vascular problems (1, 2). There is a declining trend of cardio-vascular diseases (CVDs) in 45 developed world due to effective interventions, but, the burden of cardio-vascular diseases is 46 rising in the developing countries, which put the developing countries in the double burden of 47 disease. Ethiopia is not an exception from this rising trend of CVDs (1, 4-6). 48 In Ethiopia, according to the finding from WHO STEPS survey of 2015, the prevalence of 49 hypertension was found to be 15.8% (7). There are also few studies reported the prevalence of 50 hypertension varying from 8% to 35% (5, 8-16). Moreover, the prevalence of undiagnosed 51 hypertension, those who neither aware of the raised blood pressure nor taking any anti-52 hypertensive medications. Undiagnosed hypertension may pose serious problem, as it is 53 asymptomatic. Reasons reported for high burden of the hypertensive disorder in Ethiopia were 54 due to life style change, effect of urbanization and globalization (6-11, 17). However, the 55 findings reported were controversial and inconsistent with regard to identifying associated 56 factors of hypertension. The prevalence data is important to understand the magnitude and 57 severity of the problem, identifying high risk groups and measuring effects of interventions. 58 However, the data related to the prevalence of hypertension in the study area is limited and some 59 are hospital (facility based). Therefore, this study describes the prevalence of hypertension and 60 identifies associated factors from the local context, using a community based study design and 61 WHO STEPS approach for surveillance of chronic non-communicable diseases (18). was employed to recruit samples to be included in the study. In the first step, samples were 74 allocated to the four sub-cities based on proportion to population size. Then 3 kebeles (lowest 75 administrative units in Ethiopia) from each sub-city were selected randomly. Then by consulting 76 the health extension workers and using family folder of the kebele's population, the final 77 households in the kebeles to be included in the study were identified using simple random 78 sampling. All the eligible individuals in the household were included in the study. 80 Before beginning the data collection, ethical clearance was obtained from Wachemo University 81 ethical review committee and verbal consent of the participants was ensured during the data 82 collection. Face to face interview was conducted by trained nurses by using standardized semi-83 structured questionnaire which is adapted from WHO STEPS approach instrument. Information 84 on tobacco use, alcohol consumption, fruit and vegetable consumption, physical activity, 85 physical measurement, raised blood pressure, chronic disease history and family health was 6 86 collected. Formats adapted from WHO STEPS guidelines were also used to measure blood 87 pressure (BP), pulse rate, weight, height, waist and hip circumference.

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The research investigators were responsible for the overall management of the project; for 89 development of the final questionnaire, for making the initial contact with and securing 90 participation of the kebeles included, for identifying survey administrators and to train and assign 91 them to the selected kebeles. The Data collectors were ten trained nurses who were supervised by 92 two recruited Bsc. Public health professionals who were working in the study area at the time of 93 data collection.

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Face to face interview was conducted at home level after the interviewers explained the 95 purpose of the study and obtained the participant's informed consent to participate in the study.

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Eligible respondents were declared unavailable if they were not found on three separate 97 visits. After completion of face to face interview, all respondents were given appointment 98 for physical measurements and it was taken in the outreach sites inside the kebele, which is 99 conducive for the community to be involved in the study. All study instruments were reading of the systolic and diastolic blood pressure was recorded. Participants have taken rest for 121 ten minutes between each reading. Hypertensive status of the participants was defined as systolic 122 blood pressure ≥90mmhg and/or diastolic blood pressure ≥140mmhg. Undiagnostic hypertension 123 was defined as participants whose systolic blood pressure ≥90mmhg and/or diastolic blood 124 pressure ≥140mmhg and unaware of it before. Tobacco use was defined as using tobacco between the independent and dependent variables was measured using odds ratios (OR) and 95% 142 confidence interval (CI) and P values below 0.05 was considered statistically significance. 58.5% were males and 41.5% were females and majority of them were in the age category of 25-148 34 years (32.4%). The mean and median age of participants was 36 and 34 years respectively.

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Majority of the respondents are married (65.6%) and self-employed (31.6%). Of all the 150 respondents approached, 95% indicated that they had formal education and able to read and 151 write, but the remaining 5% of the respondents can't read and write (  Fig 1).

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Behavioral and dietary risk factors of hypertension 168 Overall, 29 (4.6%) of the survey population indicated they are current smoker of tobacco products. In the bivariate analysis, variables which were significantly associated with hypertension were: 210 age ≥35 years, current smoker, who are currently drinking more than 5 bottles of alcohol in the 211 week, the type of oil used, spending more than 8 hours per day in a sitting position and abnormal 212 BMI. However, being male sex and not consuming vegetables and/or fruit in the last week didn't 213 shown significant association with hypertension, but they were included in the multi-variable 214 analysis, since they had P-value below 0.25.

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In multi-variable analysis considering those variables having P-value < 0.25 in bivariate analysis, 216 hypertension was significantly associated with age ≥35 years, which are currently drinking more  has been mentioned by other reviewed studies that an increment in age has the effect on the 249 blood pressure, which might be due to changes that happen in the walls of blood vessels as age 250 increases (5, 10, 11). Similarly, consumption of excessive saturated fat/oil is also a risk factor for 251 hypertension. This is because; the body will convert saturated fats into cholesterol, which in turn 252 will narrow the arteries and raises resistance in the blood vessels, resulting in high blood pressure 253 [(23)]. Studies also identified that abnormal BMI (obesity) is associated with hypertension (5, 10, 254 23).

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The present study has employed a community based design, which allows generalization to the 256 population of the town. Moreover, the study included participants' interview and physical 257 measurements using standard procedures, which allowed us to triangulate the study findings 258 from different sources. However, this study has limitations since it has employed cross sectional 259 study design and some of the variables were taken for a study period only. For instance, nutrition We would like to thank Wachemo University for the funding of this study. We would also like to 272 express the study participants and data collectors for their contributions for the success of this 273 study.

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Funding of this study was obtained from Wachemo University.