Study setting, design, and period
A hospital-based cross-sectional study was conducted among diagnosed adult hypertensive patients in public hospitals South region of Ethiopia from June 1/2023 to July 30/2023. Region newly emerged regional in Ethiopia on ward 19 August 2023 after a successful referendum (22). Wolaita sodo capital city of region located 420 km south of Addis Ababa, the capital city of Ethiopia. Region has 12 zones with estimated total population of 7.6 million. During the year of this study, there were 30 hospitals (compressive specialized, referral, general and primary) in the region (23, 24).
Population
All known hypertensive patients who attended the hospital southern regional state of Ethiopia for medical treatment follow-up were recruited, and the study population was randomly selected from among diagnosed hypertensive patients with respective hospital who underwent follow-up during the study period. Hypertensive patients aged ≥ 18 years who attended medical treatment follow-up 6 months before the inception of the study were included, while patients who were unable to communicate properly were excluded from the study.
Sample size determination and sampling procedure
The sample size was calculated by using Epi-data 3.1 by considering the extent of the lifestyle modification practice study conducted in Durame and Nigist Eleni hospitals (27.3%) (15). The sample size was determined for exposure status by using variable cases among exposed individuals (54.95%) and cases among unexposed individuals (40%) for good knowledge about the disease, with an AOR of 1.83, and a ratio of exposed to unexposed individuals of 1 was assumed. The sample size was determined by 95% CI, 80% power, and exposure. Therefore, the total sample size of the study was 412, and after adding a nonresponse rate (10%=41), the final sample size was 443. The same method was used by similar studies (15, 25). The study was conducted at seven selected public hospitals. During start, work up of a sampling frame using the patient’s medical registration number from each hospital hypertension registration book was prepared. After that, the calculated sample size was proportionally distributed to each hospital. The study participants were then picked from each of the selected hospital using a computer-generated specific random sampling method.
Study Variables
The outcome variable of the study was lifestyle modification practices. The independent variables of the study included socioeconomic and demographic factors, such as age, sex, place of residence, religion, ethnicity, marital status, level of education, occupational status, and socioeconomic status; behavioral factors, such as unhealthy diet, physical activity, salt consumption, cigarette smoking, alcohol consumption, weight management, KAP of patients toward LSM behaviors, household food insecurity status, and nutritional diversity; and biomedical factors and individual health profiles, such as family history of hypertension, comorbidity, total cholesterol level, triglyceride, HDL cholesterol, LDL cholesterol, blood pressure, and fasting blood sugar level.
Data collection procedures
The quantitative primary data were collected using structured pretest questionnaires via face-to-face interviews in areas where the privacy of the clients was maintained. The questionnaires included questions about socio-demographic and economic factors, behavioral factors, biomedical/clinical factors, and anthropometric measurements.
Anthropometric measurements of weight and height were taken to calculate BMI. Weight and weight were measured based on standards. Height was measured to the nearest 0.1 cm, and weight was measured to the nearest 0.1 kg. Two nurses and one assistant performed all the measurements, and the average was taken. A third measurement was taken if it differed by 0.5 kg in weight and 0.5 cm in height. Body mass index (BMI) was calculated by using weight and height (kg/m2).
Blood pressure (BP) measurements were taken using a digital sphygmomanometer. Before taking the measurements, the respondent was advised to sit quietly and rest for 5 min with the legs uncrossed and the right arm free of clothing. Then, the right arm was placed on the table with the palm facing upward. The appropriate cuff size was selected. Three measurements were recorded at five-minute intervals. The average of the three readings was considered the actual blood pressure.
Lifestyle modification practices were measured using questionnaires adapted from hypertension self-care activity level effects, which are recommended by the Joint National Committee on Detection, Prevention, Evaluation, and Treatment of Hypertension (JNC7), works in the literature, and the WHO stepwise approach for non-communicable disease surveillance by considering the national situations of the study subjects (26). This tool was initially written in English and then translated into the Amharic version. The Amharic version was again translated back to English to check for consistency of meaning by another person. One senior experienced BSC nurse as a supervisor, two experienced senior nurses who were data collectors and two senior laboratory technologists collected 5 ml venous blood samples from each participant who fasted 9–12 hours overnight to check the lipid status of patients by using a BS-200 Chemistry Analyzer machine made in SHENZHEN MINDRAY to analyze blood chemistry results. Lipid profiles include high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, and fasting blood sugar (27).
The principal investigator provided training for one day to have enough knowledge of the techniques, ethics of data collection and quality, and completeness of the data collection process. The data collectors and supervisors were assigned to the hospital where the study was conducted, and the data collection process lasted two months.
Indicators
Low-salt diet- Eight items were used to assess practices related to eating a healthy diet, avoiding salt while cooking and eating, and avoiding foods high in salt content. For each item, participants reported how many days of the past 7 days that they followed a healthy diet. For each item, the responses range from 0 to 7, in which 0 days means zero scores and 7 days means 7 scores. The range was from 0 to 7. The mean score was calculated. A score of five or better indicates that patients who followed the low-salt diet are considered to have good low-salt diet practices (28).
Physical activity - Physical activity was assessed by two items. How many of the past 7 days did you perform at least 30 minutes of total physical activity? How many of the past 7 days did you perform a specific exercise activity (such as swimming, walking, or biking) other than what you did around the house or as part of your work? The responses were summed (range 0–14), and patients who scored eight or more points were coded as having good physical activity. All others were coded as poor practices (28).
Smoking - Smoking status was assessed with one item, how many of the past 7 days did you smoke a cigarette? Respondents who reported 0 days were considered nonsmokers (28).
Weight management - Eight items were assessed using activities undertaken to manage weight through dietary practices such as reducing portion size and making food substitutions as well as exercising to lose weight. The items assessed agreement with weight management activities during the past 30 days. The response categories ranged from strongly disagree (recorded as 1) to strongly agree (recorded as 5). The responses were summed, creating a range of scores from 8 to 40. Participants who reported that they agreed or strongly agreed with all eight items (score ≥ 30) were considered to have good weight management practices (28).
Alcohol - Alcohol intake was assessed using 3 items. Participants who reported not drinking any alcohol in the last 7 days or who indicated that they usually did not drink at all were considered abstainers. All others were considered not to practice alcohol consumption well (28).
Data Quality Control
One-day training was provided for the data collectors as well as a supervisor by the principal investigator to increase awareness of the data collection techniques, ethical considerations, and quality of the data. Before the actual data collection, a pretest was conducted on 5% of a similar population at Bele Primary Hospital. Based on the findings of a pretest, modifications and development of the tool were made. The data collectors were informed to check the completeness of each questionnaire, whether every question had been completely answered, and whether the supervisor rechecked the completeness of the questionnaire immediately after submission.
Operational and term definitions
Adherence: the extent to which a person’s behavior corresponds with recommendations from healthcare providers (16). Adherence to lifestyle modifications: respondents who were adherent to diet-, exercise-, smoking-, and alcohol consumption-related recommendations (16). DASH: a diet rich in fruits and vegetables with low sodium, reduced saturation, and total fat. Diet-related adherence: In this study, respondents who reported that they usually or always consumed a diet rich in vegetables, grains, and fruits; rarely or never consumed salt; and rarely or never consumed foods rich in spices and saturated fat were considered adherent (16). Exercise-related adherence: respondents who reported that they exercised for > 30 minutes per day at least three times per week (16). Smoking-related adherence: respondents who reported that they either never smoked or had stopped smoking (16). Alcohol consumption-related adherence: respondents who reported that they either never consumed alcohol or whose overall FAST score was < 3 were considered adherent to the moderation of alcohol consumption (16). Knowledge about hypertension: Respondents with scores above the mean value on the hypertension evaluation of lifestyle and management scale were considered to have good knowledge about hypertension (16, 29). Lifestyle modification is a nonpharmacological therapy that alters long-term habits and typically comprises dietary approaches to stop hypertension (DASH), reducing body weight, reducing salt intake, smoking cessation, physical activity, and abstaining from alcohol consumption for months or years (29). Good lifestyle modification Practice: Participants responded with a mean score of the recommended lifestyle practice questions or above(29). Poor lifestyle modification practices: Participants who responded with a score below the mean score on recommended lifestyle practice questions (29). Dietary Approach to Stop Hypertension: a diet rich in fruits, vegetables, whole grains, low sodium, reduced saturated fat, and total cholesterol (29). Hypertension was defined as systolic BP ≥ 140 mmHg and diastolic BP ≥ 90 mmHg, and stage 1 hypertension was defined as SBP 140–159 mmHg and/or DBP 90–99 mmHg. Stage 2 hypertension, SBP > 160 or DBP > 100 mmHg. Severe hypertension, SBP > 180 or DBP > 110 mmHg. Prehypertension patients had a systolic blood pressure (SBP) of 120–139 mmHg or diastolic blood pressure (DBP) of 80–89 mmHg (30). Current alcohol drinkers are those who consumed a standard alcoholic drink within the past 30 days. Standard alcohol: an alcoholic drink that contains approximately 10 g of ethanol, which is 285 ml of regular beer, 30 ml of spirits (brake/arake or katakala), 120 ml of wine, 200 ml of tella, 150 ml of taiji or 60 ml of an aperitif (16). Current smokers are those who smoke tobacco products daily (31). Lipid profile: Total cholesterol > 200 mg/dl, triglyceride > 150 mg/dl, HDL-cholesterol (< 40 mg/dl for men, < 50 mg/dl for women), LDL-C > 100 mg/dl, and FBG ≥ 126 mg/dl (27). Physical activity was measured based on questions related to the number of days and time spent on vigorous and/or moderate activities at work, travel to and from places, and recreational activities. Then, the responses were changed to MET-minutes/week (27). Vigorous-intensity activities are activities that generate large increases in breathing or heart rate for at least 10 minutes continuously (27). Moderate-intensity activities are activities that produce small increases in breathing or heart rate for at least 10 minutes continuously, whereas low-intensity physical activity occurs when the study subject performs vigorous or moderate physical activity less than 600 MET (multiples of the resting metabolic rate)-minutes/week (27). High servings of fruits and vegetables: more than five servings of fruits and vegetables per day, whereas low servings of fruits and vegetables: less than five servings of fruits and vegetables per day (31). Favorable self-care practices included taking medication regularly, monitoring BP ≥ 2 times/month, engaging in physical activity ≥ 4 days a week, trying to keep one’s weight down, and not smoking (32).
Data analysis procedure
The data were checked for completeness, coded, and entered into Epi-data version 4.6.0.2. Data cleaning and analysis were performed with STATA version 14, and descriptive statistics, such as frequencies, proportions, means, standard deviations, and tables, were used to present the results of the study. Bivariate and multivariable binary logistic regression analyses were used to determine the associations between different variables, and odds ratios with 95% confidence intervals (CIs) were calculated for the degree of association between dependent and independent variables to identify important determinants of lifestyle modification practices.
Multivariate analysis was performed for variables with p values less than or equal to 0.25 in the bivariate analysis to assess possible confounders. Both crude and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. During the analysis, Hosmer and Lemeshow’s test was performed to check model fitness. A p value < 0.05 was considered to indicate statistical significance.
Ethical statement
This study was approved and waived by the institutional review board (IRB) of the ethical review committee of the College of Health Sciences and Medicine of Wolaita Sodo University. The study was conducted following the relevant guidelines, regulation, and principles of the Helsinki Declaration. Also permission letter to conduct the study was obtained from Wolaita Sodo Comprehensive Specialized Hospital. Additionally, written informed consent was obtained from the study participants before data collection. The confidentiality of the information was maintained by avoiding any personal identifiers, such as the patient’s name, on the questionnaires during the data collection. The information obtained from the participants who were used only for the study was kept confidential and did not harm them. Finally, the recorded data were kept safe by locking them in the locker, and the key of the lock was accessed only by the principal investigator.
Patient and public involvement
No patients or the public were involved in the design, analysis, or interpretation of this study, and they were not involved in the dissemination of the results.