Socio demographic characteristics of participant
The study was conducted at west Gojjam zone public hospitals with the response rate of 97.9% (570). Among the participants, more than half (59.65%) were female. Based on their residence 55% of the participant were a rural area. The mean age of the participant was also 54.67 years with a SD ±9.62 (Table2)
Table 2Socio demographic characteristics of individuals with hypertension who had follow up at west Gojjam public hospitals, 2023, (N=570)
Variable
|
Category
|
Frequency
|
Percent (%)
|
Sex
|
Male
|
230
|
40.35
|
Female
|
340
|
59.65
|
Age in years
|
≤64
|
461
|
80.88
|
≥65
|
109
|
19.12
|
Resident
|
Urban
|
255
|
44.74
|
Rural
|
315
|
55.26
|
Marital status
|
Married
|
454
|
79.65
|
Divorced
|
25
|
4.39
|
Widowed
|
91
|
15.96
|
Educational status
|
Unable to read and write
|
316
|
55.44
|
Able to read and write only
|
170
|
29.82
|
Primary level
|
38
|
6.66
|
Secondary level and above
|
46
|
8.07
|
Occupational level
|
Gov’tal employer
|
36
|
6.31
|
Farmer
|
229
|
40.18
|
Merchant
|
125
|
21.93
|
House wife
|
148
|
25.96
|
Others
|
32
|
5.6
|
Family size
|
≤ 3
|
113
|
19.82
|
4-6
|
426
|
74.74
|
≥7
|
31
|
5.44
|
Wealth index
|
Low
|
198
|
34.74
|
Middle
|
189
|
33.16
|
Rich
|
183
|
32.10
|
Others* (daily labour, workless individual, Retirement), Gov’tal= governmental
Health profiles and nutritional status
From the total participants 86.49% had a normal body mass index where as 11.58% were overweight or obese. Based on the family history of hypertension, 8.07% of the participant had a family history Based on knowledge assessment about hypertension, 51.58% of the participant had poor knowledge (Table3).
Table 3 A health profile and patient related status of individuals with hypertension that have a follow up at West Gojjam Zone Public Hospitals at 2023, (N=570)
Variable
|
Category
|
Frequency
|
Percent (100%)
|
Duration of diagnosis of hypertension
|
< 2 years
|
85
|
14.9
|
2-4 years
|
254
|
44.56
|
5-10 years
|
197
|
34.56
|
>10 years
|
34
|
5.96
|
BMI
|
Under weight
|
13
|
2.28
|
Normal weight
|
491
|
86.14
|
Over weight/ obese
|
66
|
11.58
|
Family history towards hypertension
|
Yes
|
46
|
8.07
|
No
|
524
|
91.93
|
Co-morbidity of hypertension
|
Yes
|
53
|
9.3
|
No
|
517
|
90.7
|
Knowledge towards hypertension
|
Good
|
276
|
48.42
|
Poor
|
294
|
51.58
|
Nutritional Education about hypertension
|
Yes
|
520
|
91.2
|
No
|
50
|
8.77
|
Information about the DASH diet
|
Yes
|
539
|
94.56
|
No
|
31
|
5.43
|
Source of information
About the DASH diet
|
Health worker
|
527
|
97.77
|
Family
|
8
|
1.48
|
Friend
|
4
|
0.74
|
Family and social support level
Among the participants 10.88% of the participant had strong social support status where as 24.56% had low social support (Figure 2).
Life style of the participant
From the total respondents, 372(65.56%) of the participant were physically active. Among the activities 49.95%, were doing Vigorous activity at least once per week.
From a total of 570 participants, 160 (28.07%) participants were drank alcohol. Out of 160 participants 94% of them never had a history of drink 8 for men and 6 for women alcohol in one occasion, 2.5% of participant were failed to do because of drinking and 5% of respondents confirmed that a relative/friend/health care providers were concerned about their drinking and advised them to cut down on their drinking on one occasion or more than one occasion. Generally among 160 participants 10 (6.25%) participants were drank alcohol in a no-moderate level (Table4).
Table 4. Physical activity and alcohol consumption status of individuals with hypertension at west Gojjam zone public hospitals, 2023(N=570).
Variable
|
|
Frequency
|
Percent (%)
|
Participants who were doing physical activities in a week
|
Vigorous activity
|
279
|
49.95
|
Moderate activity
|
192
|
33.51
|
Light activity
|
353
|
61.93
|
Physical activity status
|
Physically active
|
372
|
65.26
|
Physically inactive
|
198
|
34.74
|
Alcohol consumption
|
Yes
|
160
|
28.07
|
No
|
410
|
71.93
|
Alcohol intake
|
Moderate
|
150
|
93.75
|
Not moderate
|
10
|
6.25
|
DASH diet adherence
Among the seven DASH diet item adherence, the lowest adherence were low fat diary intake (10%) whereas sweet and beverage intake were the highest (94.74%) (Figure 3).
The mean value of the DASH diet adherence score was 24.05 ± 3.407 SD. The minimum and maximum value of DASH diet adherence score of individuals with hypertension were 16 and 33 respectively. From the total, 40.7% (CI; 36.65 - 44.75) were adherent to the DASH diet (Figure 4).
Factors associated with DASH diet adherence of individuals with hypertension in west Gojjam zone hospitals
In the bivariable logistic regression analysis 13 variables were passed for multivariable analysis. After adjusting potential confounders of other covariates, knowledge towards hypertension, co-morbidity with hypertension, social support, family history towards hypertension, and diagnosis duration of hypertension of the participant were significantly associated with DASH diet adherence of the participant.
Respondents those who had good knowledge (AOR=2.54, CI: [1.66, 3.88]) were 2.5 times DSAH diet adherence than those who had poor knowledge. Participants who had a strong support with families, and nehibours (AOR=3.4, CI: [1.12, 4.4]) were 3.4 times adhered the DASH diet than those who had low social support.
Those who had a family history for hypertension also positively associated with DASH diet adherence of the participant (AOR= 3.35, CI; [1.47, 7.6]) as compared to those who had no family history for hypertension. Presence of co-morbidity also positively associated with the dietary adherence of individuals with hypertension (AOR=2.28, CI; [1.12, 4.65]).
Diagnosis duration of the participant also positively associated with their dietary adherence. Those who had a diagnosis duration of 5-10 years and more than 10 years were 2.3 times (AOR= 2.4, CI; [1.25, 4.66]) and 3.3 times (AOR=3.3, CI; [1.6, 11.7]) adhered than those who had a diagnosis duration of less than two years respectively (Table 5).
Table 5. Bivariable and multivariable logistic regression analysis model in west Gojjam zone public hospitals, northwest Ethiopia 2023 (N=570)
Variable
|
Category
|
DASH diet adherence
|
COR
|
P-value
|
AOR
|
95%CI
|
P-value
|
Good
|
Poor
|
|
|
|
|
|
|
|
|
|
Age
|
≤64
|
205(35.96%)
|
256(44.9%)
|
2.43
|
0.000
|
1.8
|
[0.97 , 3.35]
|
0.062
|
≥65
|
27(4.73%)
|
82(14.38%)
|
1
|
|
1
|
|
|
Dx. Duration of hypertension
|
<2 years
|
21(3.68%)
|
64(11.23%)
|
1
|
|
1
|
|
|
2-4 years
|
87(15.26%)
|
167(29.3%)
|
1.58
|
0.104
|
1.6
|
[0.9, 3.16]
|
0.102
|
5-10 years
|
104(18.24%)
|
93(16.31%)
|
3.4
|
0.000
|
2.4
|
[1.25, 4.66]
|
0.009
|
>10 years
|
20(3.5%)
|
14(2.45%)
|
4.3
|
0.001
|
3.3
|
[1.6, 11.7]
|
0.004
|
Co-morbidity
|
Yes
|
33(5.8%)
|
20(3.5%)
|
2.63
|
0.001
|
2.28
|
[1.12 , 4.65]
|
0.023
|
No
|
199(34.9%)
|
318(55.8%)
|
1
|
|
|
|
|
Family History of hypertension
|
Yes
|
34(5.96%)
|
12(2.1%)
|
4.66
|
0.000
|
3.35
|
[1.47, 7.6]
|
0.004
|
No
|
198(34.73%)
|
326(57.19%)
|
1
|
|
1
|
|
|
Family size
|
≤3
|
27(4.73%)
|
86(15.08%)
|
1
|
|
1
|
|
|
4-6
|
194(34.03%)
|
232(40.7%)
|
2.66
|
0.000
|
1.59
|
[0.88, 2.89]
|
0.12
|
≥7
|
11(1.93%)
|
20(3.5%)
|
1.75
|
0.19
|
1.57
|
[0..59, 4.2]
|
0.36
|
Job
|
Governmental employer
|
26(4.56%)
|
10(1.75%)
|
6.28
|
0.000
|
2.4
|
[0.82, 7.2]
|
0.105
|
Farmer
|
67(11.75%)
|
162(28.42%)
|
1
|
|
1
|
|
|
Merchant
|
73(12.8%)
|
52(9.12%)
|
3.39
|
0.000
|
1.14
|
[0.57, 2.3]
|
0.69
|
Housewife
|
58(10.17%)
|
90(15.79%)
|
1.55
|
0.032
|
1.13
|
[0.54, 2.37]
|
0.73
|
Others
|
8(1.4%)
|
24(4.21%)
|
0.8
|
0.246
|
0.53
|
[0.15, 1.86]
|
0.32
|
Resident
|
Urban
|
141(24.73%)
|
114(20%)
|
3.04
|
0.000
|
1.56
|
[0.87 - 2.79]
|
0.129
|
Rural
|
91(15.96%)
|
224(39.3%)
|
1
|
|
1
|
|
|
Sex
|
Male
|
81(14.21%)
|
149(26.14%)
|
1
|
|
1
|
|
|
Female
|
151(26.49%)
|
189(33.16%)
|
1.46
|
0.029
|
1.05
|
[0.546, 2.02]
|
0.88
|
BMI
|
Under Wt.
|
5(0.87%)
|
8(1.4%)
|
0.97
|
0.96
|
1.6
|
[0.418, 6.19]
|
0.49
|
Normal Wt.
|
192(33.68%)
|
299(52.45%)
|
1
|
|
1
|
|
|
Over weight
|
35(6.14%)
|
31(5.44%)
|
1.75
|
0.032
|
0.95
|
[0.51, 1.76]
|
0.87
|
Knowledge towards hypertension
|
Good
|
156(27.37%)
|
120(21.05%)
|
3.72
|
0.000
|
2.54
|
[1.66, 3.88]
|
0.000
|
Poor
|
76(13.33%)
|
218(38.24%)
|
1
|
|
1
|
|
|
Social support
|
Low
|
36(6.31%)
|
104(18.24%)
|
1
|
|
1
|
|
|
Moderate
|
151(26.49%)
|
217(38.07%)
|
2.01
|
0.002
|
1.5
|
[0.39, 1.07]
|
0.093
|
High
|
45(7.89%)
|
17(2.98%)
|
7.64
|
0.000
|
3.4
|
[1.12, 4.4]
|
0.022
|
Wealth Index
|
Low
|
72(12.63%)
|
126(22.10%)
|
1
|
|
1
|
|
|
Middle
|
76(13.33%)
|
113(19.82%)
|
1.18
|
0.414
|
0.82
|
[0.511, 1.34]
|
0.445
|
Rich
|
88(15.44%)
|
95(16.66%)
|
1.62
|
0.026
|
0.84
|
[0.499, 1.43]
|
0.53
|
Educational status
|
Unable to read and write
|
100(17.54%)
|
216(37.89%)
|
1
|
|
1
|
|
|
Able to read and write
|
79(13.86%)
|
91(15.96%)
|
1.87
|
0.001
|
0.70
|
[0.42, 1.176]
|
0.18
|
Primary
|
22(3.86%)
|
16(2.8%)
|
2.97
|
0.002
|
0.54
|
[0.169, 1.75]
|
0.311
|
Secondary and above
|
31(5.44%)
|
15(2.63%)
|
4.46
|
0.000
|
1.03
|
[0.28, 3.81]
|
0.95
|
Qualitative result
Socio-demographic characteristics
A total of eight in-depth interview were conducted with hypertension patients. All participants have had hypertension for at least three years. Among the participant two of them were male (Table 6).
Table 6. Socio demographic characteristics of participants in the qualitative study, west Gojjam zone public hospitals, 2023 (n=8)
Participant code
|
Sex
|
Age
|
Educational status
|
Residence
|
Occupation
|
Dx duration
|
Hos.name
|
P1
|
F
|
46
|
Degree
|
Urban
|
Government employer
|
10
|
Merawi
|
P2
|
F
|
60
|
Unable
to read
|
Rural
|
Housewife
|
4
|
Merawi
|
P3
|
F
|
50
|
Unable to write and red
|
Rural
|
Housewife
|
3
|
F/Selam
|
P4
|
M
|
45
|
Secondary
|
Urban
|
Merchant
|
6
|
F/Selam
|
P5
|
F
|
40
|
Primary
|
Urban
|
House wife
|
5
|
Durbete
|
P6
|
M
|
54
|
Read and write
|
Urban
|
Merchant
|
3
|
Durbete
|
P7
|
F
|
56
|
Read and write
|
Urban
|
Housewife
|
8
|
F/Selam
|
P8
|
F
|
45
|
Unable to read and write
|
Rural
|
House wife
|
7
|
F/Selam
|
Hos.name= Hospital name, Dx duration= Diagnosis duration, F/Selam= Fnote-Selam
The qualitative results of the data are described below. The qualitative data were analyzed through thematic analysis. The report was described in four themes: DASH diet, importance of the DASH diet for controlling hypertension, barriers to adherence to DASH diet, and commitment of the participant to adhere. Barriers to DASH diet adherence were also classified into sub themes.
DASH diets for hypertensive patient
DASH diets are a diet item which are recommended for hypertensive patient to eat or not to eat. Most participants stated that foods like fatty foods, salt and sugar are a restricted food for hypertensive patients. Participants stated their idea as follow;
"Should not eat salty, sugary food. In addition, the three white things like salt, sugar, and fat should be avoided; they are very harmful to health, not only for a person with high blood pressure but also for a healthy person........" (46-year-old female).
All participants also stated that alcohol and coffee are the restricted drinks for hypertensive patients.
“---.a person with high blood pressure should not take alcohol, and coffee. Even If you want to drink coffee, drink one cup of coffee per day without sugar” (56 year’s old, female).
Other participants also stated that alcohol but also raw meat and raw milk were the prohibited food for hypertensive patient.
"We should be eaten without salt. Alcohol, katicala, tella, raw meat, and raw milk should be avoided. Even if they drink milk, it should be boiled and cooled unless avoided" (54-year-old male).
A woman also states that some grains which lead increment of blood pressure should be avoided. She stated as follow
"Grains that lead to increased blood pressure should be avoided. Cereal seeds, "When I drink barley tea, my blood pressure goes up, so I don't drink barley tea"
(46-year-old female).
Vegetables and “enjera ftft” (a staple food in most parts of Ethiopia which is made of a locally grown grain ‘teff) are also a recommended foods for hypertensive patients.
“Nothing is recommended to eat .....the only recommended food is enjera with
Low salt low concentration wott” (in Amharic, “wuha wuha yemil wott”) (60 years old, female).
“A person with high blood pressure should eat a lot of vegetables” (40 year’s old, female)
Important of DASH diet
All participant stated that the recommended diet is important for hypertensive patient for maintaining their health and controlling the blood pressure status.
Most Participants were reasoned ought that adhered recommended diet were important for maintaining their blood pressure level as follow;
"It is very useful; I was on a diet for eight years before I started the medication…….
…..Now, I used the medication and the food properly, and I have normal blood pressure and I don't remember that I am hypertensive patient, I am very healthy now" (46-year-old female).
Other participants also explores his idea as follow;
“Adjusting the diet of a person with high blood pressure is very important because lowering blood pressure by food not less than a medicine. I wasn’t on food much before….. now I strictly follow my feeding habit” (45 year’s old male).
Other participant also described that interrupting her feeding habits lead increment of her blood pressure. Described as follow;
"Yes, it is good to do it properly. Even though salt is not added, medication by itself will burn the heart. A few weeks before, I was grieving because of my sister's death. I was interrupted my dietary habits, due to such a problem, my blood pressure became increased" (60-year-old female).
Some participants also described that adhering recommended diet were important for maintaining their health but interrupting the dietary habit were the cause of their illness, described as follow;
“-------For instance, if I consume salty food at home or at someone else's, the next morning I get sick. In addition to taking low-salt foods, healthy nutrition is lowering my blood pressure, lead well healthy” (56 year’s old, female).
A 40 years woman also stated that;
"……When I eat salty foods, my blood pressure increases instantly. And when I protect myself from such habits, the pressure goes down" (40-year-old female).
Barriers for adherence of DASH diet
In this study barriers for DASH diet adherence were classified in to three sub themes. Under each sub theme (economic and accessibility barrier, Individual barrier, socio-cultural barrier) the quoted idea of participant were cited as bellow;
Economy/ accessibility
Financial problems like inadequate money to buy vegetables and/or fruits, and inaccessibility of fruits and vegetables were the barriers for DASH diet adherence of individuals with hypertension. Participants were explore their ideas as follow.
"First is economy; if there is economy, it is possible to take the so-called thing. For a person who does not have an economy, his feeding habit is inappropriate. So economy is the challenge for getting the recommended diet" (46 year’s old, female).
Another participant also stated that the cost of fruit and vegetables were also a barrier for his dietary adherence.
"Even if eating fruits and vegetables is good, it is so costy. To buy one kilo of banana, seventy birr should be needed. In this situation, "not every day, even once a week, is difficult to get it" (40 years-old female).
Since most participants live in rural settings, they complained that getting the fruits and vegetables they want is impossible. Inaccessibility matters for the participant's dietary adherence.
“As you just said, fruits and vegetables are not available in rural areas.
Sometimes may be if we goes to market, we bought, unless we did not get it”
(50 Years old, female).
Individual barrier
Individual barriers like discomfort with the DASH diet and the working condition of the participant were affecting the participant's dietary adherence.
"I don't like low-salt foods like "alcha shiro wott" and herbaceous foods, which do not feel comfortable to me. I don't feel happy if I don't eat "mereq wott," (which is prepared with meat). I try to reduce the salt as much as possible, and it is easier to eat even if it is made with a little salt" (56 years old, female).
The work condition of the participant was also a challenge for DASH diet adherence. A participant was explored the barrier of his work condition on his dietary adherence as follow;
"It's hard when you are taking the pill and going to work. The work conditions may be exposed to the sun. After working, I came to home, and eating foods that are non-testy and salt less food is the challenge for me. Because of my tiredness, I need special foods. Even if I eat “shiro-wott”, or boiled beans with a little contact with salt, my blood pressure will increase" (54 years old, male).
Socio-cultural barrier
Social barriers like social interaction with community through social ceremonies and in Amharic (“tezkar, edir”), lack of family support and cultural habit of the community were the barrier for their DASH diet adherence.
A participant which came from rural explored that cultural habit were a barrier for her dietary adherence.
"Eating alone, apart from children and husband, while managing a family is not acceptable in the community. Because of such an issue, I am preparing foods once as a whole family, including me, and eating with them in a common plate…...” (45 years old female).
Another obstacle to the participant's adherence to a diet was their social life. The individual were listed their barrier as showed below:
“Social life also one challenge for hypertensive patients. You may be invited to ceremony from someone's house and it is a difficulty if you say i don't want to drink
“Tella” (it is a locally prepared alcoholic beverage) or eat foods. But now I don't go to any ceremony because my involvement on ceremony bother others for me and it makes me discomfort” (54 years, male,).
Lack of Family support by work, idea or any else were also a barrier for adherence of the DASH diet.
“The challenging situation is a family concern. I don't have a daughter who can assist me in the kitchen, the only responsible to cook is me. Because of work load, I can't do prepare foods separately for family members and for me alone. Because of such issue on certain days, I eat enjera with pepper otherwise I eat with family” (50 year’s old female).
Commitment for DASH diet adherence
Commitment to DASH diet adherence is a promise of participants to eat a recommended diet or on the way of doctors/ health workers advice for the adherence of DASH diet.
The majority of participants were dedicated to adhering the DASH diet. They express their ideas as follow;
“It is my obligation to do. In order to live, it is important to continue to follow the
advice of experts. The reason is that I want to take care of myself, because I have children who are not able to support themselves, so family, especially mother is important, not only for me but also for my children. So I have the responsibility to take care of myself properly”
(46 year’s old, female).
Some participants were also committed to adhere the DASH diet because of fear of age related hypertensive complications.
“----. But for the future because of my age, I might eventually be unable to manage my blood pressure, therefore I'll make an effort to control my diet as much as possible” (56 years old, female).
Other participant also stated that, he is committed to take the DASH food for hypertensive as well as diabetic patients, because of the risk association of diabetes and hypertension. Describe as follow;
"In addition to having high blood pressure, I have also diabetes ...I pay great attention to what I eat, since if my blood sugar levels increase, it will have also an impact on my blood pressure. I'll keep following the recommended diet for both cases” (45 year’s old male).