THE NATIONAL BURDEN OF HYPERTENSION IN ETHIOPIA

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CHAPTER TWO LITERATURE REVIEW

 INTRODUCTION

The preceding chapter presented the overall orientation of the study. This current chapter present literature review of the study. Literature review lays out the foundation of a particular study and informs the researcher about the existing scientific knowledge gaps regarding the study (Boswell & Cannon 2011:118). The global burden of hypertension, the burden of hypertension in Ethiopia, factors associated with hypertension, hypertension prevention and the HBM are areas covered in the literature review.
A meticulous literature review was conducted after searching for literatures using a key word search like hypertension, factors associated with hypertension, hypertension prevention and health belief model on different databases such as Google Scholar, PubMed and University of South Africa (Unisa) Library. Relevant journals, research reports, WHO reports and books were also consulted to suit the need of literature of the study.

 THE WORLDWIDE PROBLEM OF HYPERTENSION

The World Health Organisation (WHO) Statistics 2012 Report showed that one in three adults worldwide have high blood pressure (WHO 2013). A meta-analysis on prevalence of hypertension in Low and Middle-Income Countries (LMIC) also indicated one in three adults in the developing world is hypertensive (32.3%). Moreover, the systematic review showed that highest estimate (39.1%) was reported from Latin America and Caribbean region (Sarki et al. 2015:4).
Cross-sectional studies conducted in India and Malaysia reported that the prevalence of hypertension to be 50.5% and 27.8% respectively (Rampala, Rampal, Azhar & Rahman 2008:14; Manimunda, Sugunan, Benegal, et al. 2011:290). In the western pacific and south-eastern Asia regions, the prevalence of hypertension ranges from 5 to 47% in men and from 7 to 38% in women (Martiniuk, Alexandra, Lee, et al. 2007:75).
National diabetes and metabolic disorders study in China among Chinese adults revealed 26.6% of the adults had hypertension (Gao, Chen, Tian, et al., 2013:4). Prevalence of hypertension in Bareilly District of India was found to be 10.81 % (Mahmood, Srivastava, Shrotriya, Iram & Payal 2011:45).

 THE PROBLEM OF HYPERTENSION IN AFRICA

Cross-sectional household surveys conducted in four rural and urban communities with a primary outcome of measuring the prevalence of hypertension showed the crude prevalence of hypertension. Their findings ranged from 19.0% in Tanzania to 32.0% in Namibia and age adjusted prevalence was 19.3% in Nigeria, 21.4% in rural Kenya, 23.7% in Urban Tanzania and 38.0% in urban Namibia (Hendriks et al. 2012:5).
In African countries like Cameroon and Tunisia, community-based multicentre and national cross-sectional study conducted in major cities presented prevalence of hypertension to be 47.5% and 35.1% respectively (Aounallah et al. 2012:3; Dzudie et al. 2012:3).
A large-scale prevalence study of hypertension in the elderly population of the sub-Saharan Africa reported prevalence of hypertension to be 69.9% of which 62.3 % had not been previously diagnosed (Dewhurst et al. 2013:377). In Africa, 40% of the adult population has hypertension (Steven et al., 2013:16). Overall, prevalence of hypertension is 30.6% in Tunisia, 29.4% in Ghana, 46% in Senegal and 23% in Angola (Agyemang, Bruijnzeels & Owusu-Dabo 2006:70; Pessinaba, Mbaye, Yabeta, et al. 2013:181; Capingana, Magalhães, Silva, et al. 2013:3). A cross-sectional study conducted in public sector workers in Angola informed that the prevalence of hypertension among public-sector workers in Angola was 45.2% (men 46.3% & women 44.2%). Prevalence of hypertension in paid workers in Nigeria was 27.1%, (28.4% in males and 22.9% in females) (Romdhane, Ali, Skhiri, et al. 2012:342; Oghagbon, Okesina & Biliaminu 2008:344).
A cross-sectional study conducted in the rural area of Karimnagar showed the prevalence of hypertension to be 38.5% (Bodhare, Venkatesh, Bele, et al. 2013: 440). A population-based survey in an urban slum in Nairobi showed that age-standardized prevalence of hypertension to be 22.8%, of which 20% of the hypertensive participants were aware of their status (Joshi et al. 2014:4). An analysis of cross-sectional data from Ghana (West Africa) indicated the overall prevalence of hypertension is 29.4 % (Agyemang, et al. 2006: 69).
A community-based study that was conducted in semi-urban community of Nigeria indicated prevalence of hypertension to be 13.3% based on the definition of hypertension at the cut-off point of 160/95. The study concluded that lifestyle changes in the semi-urban community foster the increase in the prevalence of hypertension in the community (Adedoyin, Mbada, Balogun, et al. 2008: 685).
A review from Nigeria indicated the prevalence of hypertension in both men and women ranged from 8% to 46.4%; with regards to gender, the prevalence of hypertension ranged from 7.9% to 50.2% and 3.5% to 6.8.8% in men and women, respectively. The reported prevalence in rural areas ranged from 13.5%-46.4% in both sexes, 14.7%-49.5% in men and 14.3-68.8% in women. Data from urban studies revealed a prevalence range of 8.1%-42.0% in both men and women, 7.9%-46.3% for men and 3.5%-37.7% for women. In general, it is reported that hypertension prevalence was higher in urban than rural areas (Ogah, Okpechi, Chukwuonye, et al., 2012:329).
Studies from sub-Saharan Africa urban and rural adult populations indicate overall prevalence of hypertension to be 16.2% ranging from 10.6% to 26.9% the lowest from Ethiopia and the highest from Ghana and 13.7% in rural area to 20.7% in urban (Twagirumukiza, De Bacquer, Kips, et al. 2011: 1247).
According to the WHO, approximately one billion persons are living with uncontrolled hypertension worldwide. Many studies conducted in different parts of the world show that uncontrolled blood pressure is a common phenomenon among hypertensive patients on treatment. Blood Pressure (BP) control was achieved only in 31.7% of patients in a Turkish study and BP control was more difficult to be achieved in hypertensive patients who are smoker, obese/overweight, and patients with renal disease (WHO 2011:3-18; Seravalle, Koylan, Nalbantgil, et al. 2015: 167).

THE NATIONAL BURDEN OF HYPERTENSION IN ETHIOPIA

In recognition of the 2014 World Hypertension Day, a cross-sectional survey conducted in Addis Ababa among 2,716 adults indicated that 677 (25%) of the adults have hypertension (Abdissa, Feleke & Awol 2015:24). A systematic meta-analysis on the burden of hypertension in Ethiopia showed the prevalence of hypertension estimated to be 19.6% (Kibret & Mesfin 2015:8). Furthermore, a cross sectional study conducted in 2008 among adults of Addis Ababa City (AAC) showed that age-adjusted prevalence of hypertension or known hypertensive to be 31.5% for males and 28.9% for females (Tesfaye, Byass & Wall 2009:5).
Studies in 2013 at South West Ethiopia and in 2014 at North West Ethiopia revealed that the overall prevalence of hypertension to be 13.2% and 18.1% respectively (Gudina, Michael & Assegid 2013:113; Mengistu 2014:3). The overall prevalence of hypertension was found to be 28.3% in a community-based cross-sectional study conducted among adults in Gondar City, northern part of Ethiopia (Awoke et al., 2012:3).
A community-based study among adults in Durame Town, southern part of Ethiopia showed the prevalence of hypertension to be 22.4%. The same study revealed 40% of those hypertensive patients in the study were detected during study period or found to be screened newly (Helelo, et al. 2014:4). Another cross sectional survey conducted in Sidama Zone of SNNPR of Ethiopia showed the prevalence of hypertension to be 9.9% (Giday & Tadesse 2011:142).
An institutional-based cross-sectional study conducted among federal ministry civil servants revealed prevalence of hypertension to be 27.3 % (Angaw, Dadi & Alene 2015:4). A community-based cross-sectional survey conducted in Bedele Town among adults revealed prevalence of hypertension to be 16.9%. The study showed only 44.8% of the hypertensive participants were aware of their status (Gudina, Bonsa & Hajito 2014:23).

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 FACTORS ASSOCIATED WITH HYPERTENSION

A study form China presented one between two (56.5%) elderly people aged 65 years is hypertensive, which shows the strong association of hypertension increasing with age. In the same study, it was reported that prevalence of hypertension was higher among rural residents compared to urban residents in economically developed regions of China (Gao et al. 2013:5).
In India, a study showed that having consumed alcohol in the last 30 days was significantly associated with hypertension (Manimunda et al. 2011:290). NCD risk factors such as age, gender and overweight or obesity were reported as predictors of hypertension in Nigeria (Okpechi et al. 2013:5).
A cross-sectional study conducted at Gilgel Gibe Field Research Centre reported prevalences of determents factors of hypertension to be 9.3% for smoking, 7.3% for alcohol consumption, 27% for fruits and vegetables consumption below adequate level ,16.9% for low physical activity, and 38.6% for chat chewing (Alemseged, Haileamlak, Tegegn, Tessema, et al. 2012:22).
Being over 30 years, having a family history of hypertension, BMI ≥25 kg/m2, and excess meat consumption were found to be significantly associated with hypertension whereas tea drinking was found as a protective factor for hypertension from a study in Sidama Zone (Giday & Tadesse 2011:142).
A meta-analysis in Low and Middle-Income Countries (LMIC) showed that there was no significant difference in the burden of the disease between male and female. Rather older age (>65 years), not having formal education, overweight/obese and urban residence were factors strongly associated with hypertension (Sarki et al 2015:9). Moreover, obesity or higher BMI and increase in age are strongly associated with hypertension (Hendriks et al., 2012:5).
A study from Ethiopia reported age and BMI were significantly associated with mean systolic blood pressure and diastolic blood pressure in males and females, while educational level was inversely associated with both blood pressures in males. Current daily smoking was strongly associated with hypertension while the level of total physical activity was inversely associated with Systolic Blood Pressure (SBP) in males (Tesfaye, et al. 2009:5).
Studies showed that having hypertension increased with in males and with decreasing levels of education in Malaysia, Nigeria and India (Rampala et al. 2008:14; Manimunda et al. 2011:290; Okpechi et al. 2013:5). However, in Tunisia, the prevalence of hypertension was higher among women than men and it was more prevalent among the illiterate group in comparison with the lower and intermediate or higher education level groups. In the same study, hypertension was found to be more prevalent among widowed/divorced subjects (Romdhane et al. 2012: 342).
A cross-sectional study has shown association between hypertension with overweight/obesity in India, in Nigeria and in north-west Ethiopia (Manimunda et al. 2011:290; Okpechi et al. 2013:5; Mengistu 2014:4). In line with this, a survey in Senegal reported that hypertension was associated significantly with obesity and diabetes (Pessinaba et al. 2013:182).
Prevalence of hypertension was significantly higher among individuals aged 40 years and above, with high BMI (Mahmood et al. 2011: 46). Increased age, cigarette smoking, family history of hypertension, self-reported Diabetes Mellitus (DM), and BMI > 25 kg/m2 were found to be significantly associated with hypertension (Angaw et al. 2015:4). A population- based study in Eastern Uganda identifying peri-urban residence, increasing age and being over-weight were factors associated with being hypertensive (Mayega, Makumbi, Rutebemberwa, et al. 2012:5).
Being unmarried among women is identified to be factors associated with hypertension in a population-based survey in rural Uganda (Maher, Waswa, Baisley, Karabarinde & Unwin 2011:1066).
In study from Ethiopia, it was found that participants who had self-reported diabetes were about four times more likely to be hypertensive. Those who did not walk at least for 10 minutes continuously on daily basis were about three times more likely to be hypertensive. Compared to those having normal BMI, obesity were significantly associated with hypertension (Awoke et al. 2012:3). A case control study in north Ethiopia reported the association between work involving vigorous intensity physical activity that cause large increases in breathing or heart rate was protective from hypertension (Bayray & Berhe 2012: 4209).
In Ethiopia, the association of hypertension for those who have used tobacco in their lifetime is higher than those who never used tobacco and also there is significant association between alcohol consumption and hypertension (Getahun et al. 2010). Cigarette smoking, alcohol consumption and chat chewing were associated with increased mean Diastolic Blood Pressure (DBP) in Addis Ababa (Prevett 2012:1). Similar study conducted in Butajera, southern Ethiopia indicated chat chewing is high risk of developing hypertension. However, another cross sectional study revealed that there was no significant association between smoking and hypertension in south-west Ethiopia (Getahun & Tesfaye 2010; Gudina, et al. 2013:114).

CHAPTER ONE  ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION ABOUT THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 RESEARCH PURPOSE
1.5 RESEARCH OBJECTIVES
1.6 RESEARCH QUESTIONS
1.7 THEORETICAL FRAMEWORK
1.8 SIGNIFICANCE OF THE STUDY
1.9 DEFINITIONS OF TERMS
1.10 RESEARCH METHODOLOGY
1.11 ETHICAL CLEARANCE
1.12 ETHICAL CONSIDERATIONS
1.13 SCOPE AND LIMITATIONS OF THE STUDY
1.14 STRUCTURE OF THE THESIS
1.15 CONCLUSION
CHAPTER TWO  LITERATURE REVIEW
2.1 INTRODUCTION
2.2 THE WORLDWIDE PROBLEM OF HYPERTENSION
2.3 THE PROBLEM OF HYPERTENSION IN AFRICA
2.4 THE NATIONAL BURDEN OF HYPERTENSION IN ETHIOPIA
2.5 FACTORS ASSOCIATED WITH HYPERTENSION
2.6 LEVELS OF HYPERTENSION PREVENTION
2.7 THE HEALTH BELIEF MODEL
2.8 CONCLUSION
CHAPTER THREE  RESEARCH METHODOLOGY
3.1 INTRODUCTION
3.2 RESEARCH PURPOSE AND OBJECTIVES
3.3 RESEARCH APPROACH
3.4 PHILOSOPHY
3.5 RESEARCH DESIGN
3.6 RESEARCH METHOD
3.7 ETHICAL CLEARANCE
3.8 ETHICAL CONSIDERATIONS
3.9 CONCLUSION
CHAPTER FOUR  DATA ANALYSIS AND PRESENTATION OF RESULTS
4.1 INTRODUCTION
4.2 FINDINGS OF THE QUANTITATIVE PHASE
4.3 FINDINGS OF THE QUALITATIVE PHASE
4.4 CONCLUSION
CHAPTER FIVE  DISCUSSION OF RESEARCH FINDINGS
5.1 INTRODUCTION
SECTION A
5.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS
5.3 KNOWLEDGE OF RESPONDENTS ON HYPERTENSION RISKY BEHAVIOUR AND PREVENTION
5.4 ATTITUDES OF PARTICIPANT ON HYPERTENSION RISKY BEHAVIOUR AND PREVENTION IN TERMS OF THE HEALTH BELIEF MODEL (HBM)
5.5 BEHAVIOURAL MEASUREMENTS
5.6 PREVALENCE OF HYPERTENSION
5.7 FACTORS ASSOCIATED WITH HYPERTENSION
SECTION B
THEME 1 CONCERNS OF HYPERTENSION
THEME 2: VIEW OF HEALTH CARE PROVIDERS ABOUT HYPERTENSION PREVENTION ACTIVITY
THEME 3 HEALTH SYSTEMS FACTORS AND POLICY
THEME 4: CONCERNS OF PARTNERSHIP
5.8 CONCLUSION
CHAPTER SIX  GUIDELINES FOR HYPERTENSION PREVENTION AMONG ADULTS IN ETHIOPIA
6.1 INTRODUCTION
6.2 BACKGROUND AND PRINCIPLES OF GUIDELINE DEVELOPMENT
6.3 PURPOSE AND OBJECTIVES OF DEVELOPING THE GUIDELINES
6.4 SCOPEING OF THE GUIDELINE
6.5 THE PROCESS OF DEVELOPING THE GUIDELINES
6.6 APPLYING THE ‘SURVEY LISTS’ TO THE GUIDELINE DEVELOPMENT
6.7 GUIDELINE DEVELOPED FOR THE PREVENTION OF HYPERTENSION AMONG ADULTS IN ETHIOPIA
6.8 CONCLUSION
CHAPTER SEVEN  CONCLUSION, RECOMMENDATIONS AND LIMITATIONS
7.1 INTRODUCTION
7.2 CONCLUSION OF THE STUDY
7.3 LIMITATIONS OF THE STUDY
7.4 RECOMMENDATIONS
7.5 CONCLUDING REMARKS
REFERENCES
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