Prevalence and predictors of undiagnosed hypertension among residents of Akesta City, Northeast, Ethiopia, 2023: Community based cross-sectional study

doi:10.21203/rs.3.rs-5237265/v1

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Prevalence and predictors of undiagnosed hypertension among residents of Akesta City, Northeast, Ethiopia, 2023: Community based cross-sectional study

https://doi.org/10.21203/rs.3.rs-5237265/v1

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Background: Hypertension is the world's leading risk factor for death and disability. Occasionally, there is an alarming rise in the prevalence of undetected hypertension; this is especially true in poorer nations due to inadequate screening protocols. However, there are few studies on the prevalence of undiagnosed hypertension in Ethiopia. Thus, the purpose of this study was to identify the prevalence of undiagnosed hypertension and associated factors among Akesta Town residents.

Methods: A community-based cross-sectional study design was conducted among 428 adult residents of Akesta town from April to May 2023. A systematic sampling technique was used to select the study participants. A structured, pretested WHO STEPS-wise tool was used to collect data. Data was entered using Epidata version 3.1, then exported to SPSS version 25 for further analysis. Binary logistic regression, adjusted odds ratio, along with 95% CI, was used to identify significant variables. From multivariable analysis, variables having a p-value <0.05 were considered statistically significant. The results were expressed in texts and tables. Model fitness was assessed using the Hosmer-Lemshow Test.

Results: The prevalence of undiagnosed hypertension was 15.9% (995% CI: 11.2, 21.5). Cigarette smoking (AOR = 11.04, 95% CI: 3.43, 35.57), alcohol drinking (AOR = 5.5, 95% CI: 1.64, 18.78), physical exercise (AOR = 4.78, 95% CI: 1.53, 15.06), and family history of hypertension (AOR = 6.8, 95% CI: 1.83, 25.19) were predictors of undiagnosed hypertension.

Conclusion: According to this study, adult residents of Akesta Town had a significant prevalence of untreated hypertension. Undiagnosed hypertension was predicted by physical exercise, alcohol consumption, cigarette smoking, and family history of hypertension. The government and other pertinent parties will be alarmed by this, prompting them to create public health initiatives, including community-based screening and education campaigns.

Nursing

Factors

prevalence

undiagnosed hypertension

Nowadays, developing countries are affected by non-communicable diseases (NCDs) and infectious diseases(1). One aspect of non-communicable diseases (NCDs) is undiagnosed hypertension (UHTN), which is defined as those with hypertension who did not disclose their condition to a medical provider(2). If hypertension remains undiagnosed and untreated, serious health consequences might occur (3, 4). The risk of consequences are renal failure, myocardial infarction, heart failure, stroke, and early death(5).

UHTN has a detrimental impact on public health worldwide. It is thought to cause 9.4 million deaths annually and impact about 22% of those over the age of 18(6). People with hypertension in low- and middle-income nations make up about 31.5% of the population. Individuals in these environments frequently know very little about hypertension, how to treat it, and how to regulate it.(7). This could result in a low level of healthcare-seeking behavior, which would raise the likelihood of undetected hypertension in these populations.

Thirty percent of people in sub-Saharan Africa had undetected hypertension. Of the people with hypertension, only 18% received therapy, and only 7% had a regulated blood pressure reading. Before the surveys, 27% of the participants knew they had hypertension, and roughly 73% were not aware of it (8).

Research revealed that the illness has grown to be a serious public health issue in Ethiopia. Study percentage in Addis Ababa, Ethiopia was 13.25%(9), and Hawassa, Ethiopia, and in rural areas of central Ethiopia, indicating that the prevalence of undiagnosed hypertension was 12.3% and 21.32%, respectively(10, 11). According to a study done in the Ethiopian city of Debre Markos, the frequency was 12.7% (12). According to a study that was conducted in Dano district, central Ethiopia, the prevalence of undiagnosed hypertension was 21.32%(11). A study conducted in Mizan Aman Town, Bench Sheko Zone, Southwest Ethiopia, indicates that, among people with hypertension, 14.8% did not know that they had hypertension (13). It was found that age, triglyceride levels, alcohol consumption, being overweight, and the existence of undiagnosed diabetes mellitus were substantially linked factors with undiagnosed hypertension in Woliata Sodo town, southern Ethiopia (14).

Undiagnosed hypertension was found to be significantly predicted by overweight, sedentary lifestyle, cigarette smoking, health-seeking behavior, dietary pattern, and monthly income, according to a study (15). According to a study conducted in urban communities of south-west Ethiopia, factors significantly associated with undiagnosed HTN in the study area were age, BMI with overweight, triglyceride, and waist-to-hip ratio (16).

In other finding, age of participant, occupation, marital status, and dietary practices were significantly associated with UHTN (17). Age, occupation, marital status, information source, and history of vegetable consumption were found to be linked with UHTN in another study conducted in Addis Ababa (9). In the other study, UHTN was substantially correlated with age, sex, chat-chewing, smoking, marital status, alcohol consumption, and diabetes mellitus(14). In the other study, UHTN was substantially correlated with age, sex, knowledge of hypertension, and regular physical activity (2).

Based on the aforementioned research, we draw the conclusion that the prevalence and contributing variables for UHTN differed between studies and environments. Because of this, figuring out the prevalence and contributing variables to undiagnosed HTN will be useful in developing preventative and management plans for UHTN. There isn't a research in Akesta, Ethiopia, despite UHTN's major influence on the population. Determining the prevalence of UHTNin in Akesta town, Ethiopia in 2023 is the goal of this study.

Study period and setting

The study was conducted in Akesta town from April to May 2023. Akesta town is 100 km far from Dessie, the capital city of South Wollo Zone, and 501 km from Addis Ababa, the capital city of Ethiopia. Based on the report from the city administration, the total population of Akesta town is estimated to be 30, 023; of the total 12,672 of them are male, and the rest, 17,351, are female. Among the total 30,023 people residing in the town, about 60% are estimated to be above 18 years old.

Study design

A community-based, cross-sectional study design was conducted.

Population

All adult residents of Akesta town were the source population, while residents in Akesta town in selected households were the study population.

Eligible criteria

Residents with the age ≥18 years and those residents living in Akesta town >6 months were included, and known hypertension patients and pregnant mothers were excluded from the study.

Sample Size and Sampling Technique

The sample size was calculated using the single population proportion formula by considering the following assumptions: prevalence of undiagnosed hypertension in Mizan Aman Town 14.8%(18), 95% CI and 5% of margin of error.

Whereas n=sample size; P=prevalence of undiagnosed hypertension; d=margin of error; Zα/2= 1.96 (CI).By adding 10% non-response rate, the final sample size was 214. Sample size was also calculated using the second objective (factors affecting undiagnosed hypertension), which was 428. Thus, the sample size calculated using the first objective is less than from the second objective.

The number of blocks was determined using the thumb rule. There are 32 blocks in Akesta town; 10 blocks are selected using simple random sampling technique (lottery method). Then households were selected using systematic sampling techniques. In selected households, participants were interviewed using the prepared WHO-step-wise tool. The sampling frame was prepared using the list of households from the family folder available at health posts. Finally, one adult whose age was 18 years and above was selected from each household using a simple random sampling technique (lottery method).

Study Variables

Dependent variable

Undiagnosed Hypertension (Yes, No)

Independent variables

Socio-demographic characteristics (sex, age, and occupation, personal and family history of morbidities, knowledge and practice of the study participants towards hypertension, cigarette smoking, alcohol consumption, and performing physical activity) were considered independent variables.

Operational definition

Undiagnosed hypertension: adults (aged 18 years and above) were considered undiagnosed for HTN if, at the time of the survey, he or she was diagnosed as hypertensive (SBP ≥140mmHg or DBP ≥90mmHg) but never took any prescribed antihypertensive medicine to lower or control blood pressure and was never told by a health professional that they have HTN before this study.

(18).

Khta chewing: regular chewing of Khat (a psychoactive substance) for at least 1 year before we conducted the survey. Khat has a physiological effect that may make a person who uses it not notice the early symptoms of HTN(10).

Alcohol intake: individuals who were taken more than three units of alcoholic beverage per day.

(19).

Smoking: individuals who had a history of smoking or are current smokers(19)

BMI: was calculated as the weight of an individual in kilograms per height in meters squared. Obesity or overweight was considered when the BMI was above 25 kg/m2(10).

Sedentary lifestyle: referred to a type of lifestyle involving little or no physical activity, such as reading, watching television, or using a mobile phone for a long time during the day(10).

A family history of HTN: were considered if a person’s first-degree relative (apparent, a grandparent, or a sibling) had been diagnosed with HTN and/or were receiving drug therapy for HTN(20).

Physical exercise: Performing physical activity three days/week for 20–30 min duration(21).

knowledge: Good knowledge is if the participants total knowledge score is above
the mean score of the total knowledge question, while poor knowledge is if the participant’s total knowledge score is below the mean score of the total knowledge question(11).

Data collection and procedure

The participants were interviewed using a standardized questionnaire that was modified from the World Health Organization's STEPS-wise method for NCD surveillance in developing nations (22).

Data collection was done sequentially in a two-step process. Step 1: Interviewer-administered questionnaire on selected major health risk behaviors, including smoking, alcohol consumption, poor fruit and vegetable consumption, and physical inactivity. Step 2: Physical measures of health risks such as height, weight, blood pressure, and body mass index. Blood pressure was measured in a sitting position from the left arm with a supported back, and an android blood pressure cuff was used to measure the BP of the participants. The participants were taking rest for at least 15 minutes before measurement. Two measurements of BP on a single visit were taken at least twenty minutes apart, and this survey considered the last two measures of BP levels, and the average of two separate BP measurements was taken in the final analysis to detect hypertension. At least two visits were made for those study participants whose BP was elevated at the first contact. Blood pressure had a systolic blood pressure (SBP) ≥130 mmHg or diastolic blood pressure (DPB) ≥80 mmHg on at least two occasions (23). Height and weight were measured to calculate body mass index. Using a tape meter, the height of the study participant was measured to the nearest 0.1 cm. with the Frankfurt plan position and the four points (heel, calf, buttock, and shoulder) touching the vertical stand and their shoes taken off with a checked tape meter. Weight was measured with light clothes and shoes by using a checked digital weight scale to the nearest 0.1 kg. BMI was calculated by dividing weight in kilograms of adult height in meters squared formula. BMI < 18.5 kg/m2 was considered underweight, 18.5–24.9 kg/m2 was normal, 25–29.9 kg/m2 was overweight, and ≥30 kg/m2 was obese(24). Hypertension knowledge was assessed by questionnaires adapted from the previous studies. The behavior of participants and clinically related variables were assessed by using WHO STEPS-wise approach guidelines on the chronic risk factor surveillance questionnaire, which was developed in 2005(22).

Data quality management

Data was collected by three nurses and one supervisor. Training was given for data collectors and supervisors for one day. The questioner was prepared in English, then translated into Amharic and then retranslated back to English to maintain consistency. In addition, this pre-test was conducted in Gimba town with 21 participants.

Data processing and analysis

Data entry was done by using EPI data version 3.1 and exported to SPSS version 25 for analysis, and the descriptive analysis was undertaken, and the result was presented using frequency tables, graphs, and descriptive statistical summaries. The undiagnosed HTN status had been dichotomized as yes or no, and then binary logistic regression was applied to identify predictors of undiagnosed hypertension. From bivariable analysis, variables with a p-value <0.25 were candidates for multivariable logistic regressions. Odds ratios (OR) with 95% confidence intervals were calculated to measure the strength of association, and the p-value < 0.05 was considered statistically significant. Multicollinearity was checked using VIF (variance inflation factor). The model of fitness was checked using the Hosmer-Lemshow test.

Socio-demographic characteristics of participants

A total of 428 participants participated, which yielded a 100% response rate. The majority of respondents, 274 (64%) were females. Forty-seven point two percent of the respondents were in the age group of 36–50 years. The study revealed that 84.1% of them were married. Among the respondents, 45.3% were educated at a diploma or higher level (Table 1).

Table 1

Socio-demographic characteristics of adults in Akesta town, North East Ethiopia, 2023(n = 428)
Variables	Variable categories	Frequency	Percent (%)
Age	15–25	20	4.7
	26–35	94	22.0
	36–50	202	47.2
	51–65	88	20.6
	> 65	24	5.6
Sex	Female	274	64.0
Sex	Male	154	36.0
Marital status	Single	22	5.1
	Married	360	84.1
	Divorced	40	9.3
	Widowed	6	1.4
Education status	Uneducated	26	6.1
	Primary	66	15.4
	Secondary	142	33.2
	Diploma and above	194	45.3
Religious	Orthodox	24	5.6
	Muslim	394	92.1
	Protestant	10	2.3

Knowledge towards the causation of Hypertension

The majority of respondents (362 (84.6%) knew that eating salt-rich foods causes hypertension. The majority (68.7%) of the respondents knew overweight was the cause of hypertension (Table 2).

Table 2

Knowledge towards the causation of Hypertension among residents in Akesta town, North East Ethiopia, 2023 (n = 428).
Variables	Variable categories	Frequency	Percentage
Salt rich in food	Yes	362	84.6
Salt rich in food	No	66	15.4
Over weight	Yes	294	68.7
Over weight	No	134	31.3
Cigarette smoking	Yes	340	79.4
Cigarette smoking	No	88	20.6
Alcohol drinking	Yes	330	77.1
Alcohol drinking	No	98	22.9
Anxiety	Yes	182	42.5
	No	224	52.3
	Do not know	22	5.1

Behavioral and clinical factors

Behavioral factors including alcohol intake, cigarette smoking, trend of BP checkup, Khat consumption, and BMI status were assessed. Based on this, 66 (15.4%) consumed alcohol daily, 238 (55.6%) had a history of regular BP checkups, 150 (35%) had no regular physical exercise, and 72 (16.8%) were overweight (Table 3).

Table 3

Frequency distributions of behavioral factors among residents in Akesta town, North East Ethiopia, 2023(n = 428).
Variable	Category	Frequency	Percentage %
BMI category	Under weight	32	7.5
	Normal	324	75.7
	Overweight	72	16.8
Drink alcohol	Yes	66	15.4
Drink alcohol	No	362	84.6
BP check up	Yes	238	55.6
BP check up	No	190	44.4
Physical Exercise	Yes	278	65.0
Physical Exercise	No	150	35.0
Smoking cigarette	Yes	62	14.5
Smoking cigarette	No	366	85.5
Khat chewing	Yes	130	30.4
Khat chewing	No	298	69.6
family history of HTN	Yes	24	5.6
family history of HTN	No	404	94.4

Prevalence of undiagnosed hypertension

The prevalence of undiagnosed hypertension among adults was 15.9% [95% CI: 11.2, 21].

Factors of Undiagnosed Hypertension

In the bivariable analysis, cigarette smoking, alcohol drinking, family history of hypertension, physical exercise, BMI, and Khat chewing were associated with undiagnosed hypertension. In multivariable analysis, cigarette smoking, alcohol drinking, family history of hypertension, and physical exercise were found to be significantly associated with undiagnosed hypertension.

Cigarette smoking was 11 folds more likely to develop undiagnosed hypertension as compared to non-cigarette smoking persons [AOR = 11.04, 95%CI: 3.43, 35.57, P = 0.000]. Those participants who had drunk alcohol were 5.5 times more likely to develop undiagnosed hypertension as compared to non-alcohol drinkers [AOR = 5.5, 95% CI: 1.64, 18.78, P = 0.00]. Family history of hypertension was about 6.8 folds more likely to develop undiagnosed hypertension as compared to no family history of hypertension persons [AOR = 6.8, 95% CI: 1.83, 25.19, P = 0.004]. Besides, the odds of having undiagnosed hypertension were 4.8 times higher among those who did not participate in physical activity [AOR = 4.779, 95% CI: 1.53, 15.06, P = 0.007](Table 4).

Table 4

Bi-variable and multivariable analysis of factors associated with undiagnosed hypertension among residents in Akesta town, North East Ethiopia, 2023.
Variable	Variable Category	Undiagnosed Hypertension		COR CI (95%)	AO R CI (95%)	P value
Variable	Variable Category	Yes	No	COR CI (95%)	AO R CI (95%)	P value
Smoking cigarette	Yes	40	22	21.95(8.8,54.8)	11.04(3.43, 35.57)	0.000
Smoking cigarette	No	28	338	1	1
khat chewing	Yes	40	88	4.42(2.06,9.47)	1.9(.632, 5.642)	0.255
khat chewing	No	28	272	1	1
Drink alcohol	Yes	40	26	18.4(7.7,44.5)	5.5(1.64, 18.78)	0.006
Drink alcohol	No	28	334	1	1
Physical Exercise	Yes	32	238	1	1
Physical Exercise	No	36	122	2.2(1.05 ,4.60)	4.779(1.53, 15.06)	0.007
family history of HTN	Yes	38	40	10.1(4.46,23.04)	6.8(1.83, 25.19)	0.004
family history of HTN	No	30	320	1	1
BMI	Normal	38	318	1
	Overweight	30	42	5.98(2.64,13.51)	1.20(0.302 ,4.773)	0.794

AOR: Adjusted Odds Ratio, COR: Crud Odds Ratio, 1-referance category

In this study, the prevalence of undiagnosed hypertension among adults was 15.9% [95% CI: 11.2, 21]. This is lower than a study conducted in Dabat district and Gondar Town.(27.9%)(2). The difference might be because of sample size and characteristics of participants. The study included both rural and urban residents, and the sample size was 2200. On the other hand, this is higher than the study conducted by Gilgel Gibe(7.5%) (25). It may be due to the lack of community-based hypertension screening and prevention strategies in our study area so that the burden of hypertension remained remarkable. The prevalence of this study was lower than a study done globally on undiagnosed hypertension, around 22% (6). The prevalence in our study was lower than in low- and middle-income countries (31.5%) (7). The prevalence of this study was lower than the study in Wolayita town, Ethiopia, which revealed that the prevalence of undiagnosed hypertension was 28.8% (95% CI: 24.7–33.2%)(14). This may be due to the socioeconomic and sociocultural differences, which contribute a significant role in hypertension development (7). The prevalence of undiagnosed hypertension in this study was aligned with a study conducted in Bangladesh, which was 15.8%(26), in Hawassa, Southern Ethiopia, 12.3%(10), Gulele Town 13.25%(9), Mizan Aman 14.8% with 95% CI [12.3-15.6] (27).

Significant variables were identified; accordingly, participants with a family history of hypertension had 6.8 times more chance of developing hypertension than their counterparts (AOR = 6.8, 95% CI (1.83, 25.19), p = 0.02). This was the study conducted in Debremarkos, which indicated that it was significantly higher in patients with a family history of hypertension (AOR = 2.21, 95% CI 1.04, 4.46) (28). This may be related to the increased risk of undiagnosed HTN among people with a family history of HTN, which could be related to genetic factors.

Cigarette smoking was significantly associated with hypertension in multivariable analysis. Participants had 11 times more chance of developing hypertension than non-cigarette smokers (AOR = 11.04, 95% CI (3.43, 35.57), p = 0.000). This study was conducted in the southern Ethiopian Gurage Zone and indicated that the prevalence of hypertension was significantly higher in patients with cigarette smoking(29). This might be due to the hemodynamic effects of cigarette smoking being mediated primarily by nicotine, which can increase blood pressure (BP) acutely and temporarily via stimulation of the sympathetic nervous system.

Drinking alcohol is a predictor for UHTN. Participants who had drunk alcohol were 5.5 folds more likely to develop hypertension than non-drinking alcohols (AOR = 5.5,95% CI (1.64, 18.78), p = 0.002). This study conducted in South Africa, 6.42, indicated significantly higher hypertension in patients with drinking alcohol(29). The finding might have occurred because of similarities or differences in the amount and concentration of alcohol that might be consumed in the two areas, and it is also possible that alcohol ingestion raises the blood pressure by decreasing the vasodilators.

Physical exercise was a significant factor for UHTN. Participants who had not been involved in physical activity were 4.8 times more likely to develop hypertension as compared to their counterparts (AOR=4.779,95% CI (1.53, 15.06), p=0.007). This finding was consistent with a study conducted in Mizanaman town, bench Sheko zone, south-west Ethiopia, which was 3.9 times among those who didn't involve in physical exercise(13). Hence, these findings suggest that several cardiometabolic problems may arise soon as a consequence of insufficient physical exercise.

Limitation of the study

The limitation of this study was that all possible factors responsible for hypertension were not collected and assessed due to time and resource limitations.

According to this study, adult residents of Akesta Town had a significant prevalence of untreated hypertension. Undiagnosed hypertension was predicted by physical exercise, alcohol consumption, cigarette smoking, and family history of hypertension. The government and other pertinent parties will be alarmed by this, prompting them to create public health initiatives, including community-based screening and education campaigns

AOR

Adjusted Odds Ratio

COR

Crude Odds Ratio

HTN

Hypertension

NCD

Non-communicable Disease

SRS

Simple random sampling

UHTN

Undiagnosed Hypertension

WHO

World Health Organization.

Ethical statement

An ethical letter was obtained from Tropical college of Medicine ethical review committee (reference number: TCOM/RCS/6235/16). A letter of permission was obtained from the chief executive officers of the study hospitals. Informed consent was obtained from the study participants prior to the study commencement. The objective of the study was clearly explained to the study participants. Data was collected anonymously to ensure confidentiality, and all data collection was conducted in compliance with the Declaration of Helsinki.

Consent for Publication
Not applicable.

Data sharing Statement
the data used for the study are available from the corresponding author at any time.

Funding

Not applicable

Disclosure

The authors declare that they have no competing interests.

Author’s contribution

Each author contributed significantly to this study. The conception, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing (original draft), writing (review), and editing were all heavily influenced by the contributions of each author. Finally, all authors agree to be accountable for all parts of the work, approve the final version of the article to be published, and choose the journal to which the piece has been submitted.

Acknowledgement

We would like to thank data collectors, supervisors and the study participants for their valuable contribution to the study.

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The authors declare no competing interests.

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Prevalence and predictors of undiagnosed hypertension among residents of Akesta City, Northeast, Ethiopia, 2023: Community based cross-sectional study

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Abstract

Introduction

Materials and Methods

Dependent variable

Independent variables

Operational definition

Data quality management

Results

Socio-demographic characteristics of participants

Knowledge towards the causation of Hypertension

Behavioral and clinical factors

Prevalence of undiagnosed hypertension

Factors of Undiagnosed Hypertension

AOR: Adjusted Odds Ratio, COR: Crud Odds Ratio, 1-referance category

Discussion

Conclusion and recommendation

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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