Cardiovascular diseases risk perception and communication among urban and rural residents in Ethiopia: A qualitative study

doi:10.21203/rs.3.rs-1395952/v1

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Cardiovascular diseases risk perception and communication among urban and rural residents in Ethiopia: A qualitative study

https://doi.org/10.21203/rs.3.rs-1395952/v1

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Background: The rise in non-communicable diseases (NCDs) burden, particularly, cardiovascular diseases (CVDs) in Ethiopia is driven by rapid urbanization, globalization, urban poverty, a shift in diet and physical inactivity. To tackle this, adoption of appropriate lifestyle and behaviour modifications are required. Such behavioural adoption in turn demands appropriate knowledge about the risk factors, and a reasonably perception of threat of CVDs.

Objective: To explore CVDs risk perception, communication, and health seeking intentions of residents of rural and urban communities in Ethiopia.

Methods: We conducted four focus group discussions (FGDs) and semi-structured risk communication interviews with residents of two communities (urban and rural) in Ethiopia. Two FGDs were conducted in each of the rural and urban communities with separate groups for men and women. The FGD participants were purposively selected with the help of local health extension workers. The FGDs were facilitated by a trained public health researcher, using a FGD guide, and risk communication cue cards. The textual data was analyzed using thematic analysis approach.

Results: In general, awareness of CVDs and conceptualization of disease risk in both setting were low, and risk scores concepts were based on cultural beliefs and setting-specific knowledge, especially in the rural areas. Many participants had not perceived any threat, and indicated limited susceptibility to CVDs, despite their belief that the risk factors are common. Participants that indicated having a prior CVDs diagnosis, did not readily accept their diagnosis, or disclose their status to others, or seek medical care. Some urban participants thought that CVDs are untreatable owing to inaccessibility of care and the common belief that this ‘is the will of God’. Consequently, participants had often opted for traditional or ‘miraculous’ religious healing practices, and, therefore, did not rely on chronic disease management advice.

Interviews using communication cue cards revealed that how and by whom a risk message was communicated was an important consideration for a message to be accepted, and to elicit subsequent health-seeking intention, and possible action(s).

Conclusion: Supporting community-level collaborative learning about CVDs, and their risk factors can support optimal evaluation of personal risk and perception of the threat of CVDs.

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risk perception

risk communication

In low- and middle-income countries (LMICs), cardiovascular diseases (CVDs) death rates have been rising over the past three decades (1, 2), whereas deaths from CVDs in high-income countries have steadily declined over the same period due to treatment for severe CVDs events, introduction of population-wide prevention policies, and early screening and treatment (3). The rise in CVDs deaths in LMIC unfortunately occurs alongside the limited access to population-wide interventions and increasing prevalence of CVDs risk factors in these settings (4). In Sub-Saharan Africa (SSA), the increase in CVDs risk factors is driven by rapid urbanization, globalization, and urban poverty (2), and are related to a shift in diet and lifestyle, whereby conventional diets are replaced by processed and refined foods and physical inactivity is increasing (5).

Ethiopia is experiencing epidemiologic and economic transitions (6) with resultant prevalence of lifestyle related diseases in its population. According to World Health Organization (WHO), around nine percent of all deaths in Ethiopia in 2012 were caused by CVDs (7) while local studies also confirmed the rising burden of CVDs and their risk factors, especially in urban settings (8, 9).

Risk perception is the subjective evaluation of vulnerability or personal damage (10). Research findings show that awareness of CVDs risk factors has a substantial effect on risk perceptions (11). However, in SSA there is limited evidence regarding knowledge of CVDs and their risk factors(2). Another study had reported that obese persons indicated strong perceptions of risk of cardiovascular disease, only when they had experienced chronic disease conditions (12).

The effectiveness of any health programme depends on contextual information unique to the knowledge and perception of the target population. Since risk perception plays an important role in behavioural changes, it can be used to improve the understanding and knowledge of CVDs among populations.

The Ethiopian health service is organized as a three-tier system (13). The Primary Health Care Unit (PHCU) is close to both urban and rural residents and represents the bottom tier of the health system while specialized hospitals are placed at the top of the tier and are located in the bigger towns and cities hence are generally far from most rural residents. In line with this, the health policy of Ethiopia has been geared towards the control of infectious diseases, the reduction of malnutrition and the improvement of maternal and child health(14). The health policy had given very little attention to the care and prevention of non-communicable diseases (NCDs), despite the burden of NCDs in the country is increasing. In 2015, in Ethiopia, the age adjusted death rate from CVDs, one group of NCDs, was reported to be 350 per 100,000 people (15) which is considerably higher than to the rate of 122 per 100,000 people for HIV and tuberculosis combined.

Primary Health Care Units are generally the entry points to the health system. As such they provide an ideal opportunity to identify high-risk individuals for CVDs who may visit health services for other health problems (16). In general, most people with various NCDs including CVDs may have no symptoms until the disease has advanced dramatically. Screening asymptomatic people for key risk factors could help identify high-risk individuals early and provide the opportunity to avoid disease progression (16). In general, screening of NCDs is relatively inexpensive hence a risk approach is appropriate for implementation at primary health care level (16, 17), especially when considering the huge economic burden NCDs pose at a global level (17, 18).The WHO recommend combination of population-wide and individual based strategies for successful reduction of the burden of NCDs (16).The Ethiopian NCD guideline also promotes early screening, diagnosis and management of NCDs and their risk factors using inexpensive technology, non-pharmacological and pharmacological approaches (19).

However, the success of any preventive intervention such as early screening depends on the availability of context specific information that could improve the knowledge of the target population and their level of perceived vulnerability (2). Therefore, exploring CVDs risk perception, communication, and behavioural change intention among populations is important for understanding and devising strategies for community-driven prevention of CVDs in Africa.

Hence, this formative research was conducted in two selected rural and urban Ethiopian communities and was aimed to investigate people’s awareness, perception, and communication of CVDs risk, and their health seeking intentions.

Study Design: This is qualitative research conducted as a formative study of the CVDs risk assessment and risk score evaluation project undertaken by a research consortium – Collaboration for evidence-based healthcare and public health in Africa (CEBHA+).

We conducted four focus group discussions (FGD) and semi-structured risk communication interviews with residents of project communities. FGD guide and cue cards were used to explore the concept of health risk, particularly, CVDs risk, and risk score among the participants.

Population and Sampling: Two sites were purposively selected for the study, consisting of several kebeles (the lowest administrative structure); viz. Adama town (urban) located about 100 Km Southeast of Addis Ababa, and Adama district communities (rural). Five kebeles were randomly sampled from each of the study communities. Four focus group discussions (FGDs) were conducted with the representatives of adjoining kebeles of the study communities. The FGDs were conducted separately with the men and women in both sites. Each FGD participant was selected with the recommendation of the local health extension workers, as being a head of a model family, who visited each household in each community.

Ethical consideration: Ethics approval for the study was obtained from the Armauer Hansen Research Institute (AHRI)/All Africa Leprosy Rehabilitation and Training Center (ALERT) Ethics Review Committee (AAERC). Oral consents were obtained each participant before the start of the FGDs while strictly complying with national and international ethical guidance during the conduct of FGDs and in data handling.

Focus group facilitation: All FGDs were facilitated by a trained public health researcher with support from a local facilitator, using a semi structured topic guide, and semi-structured risk communication cue cards. FGD guide (Additional File 1) consisted of questions that explored heart-related disease perception, perceived threat, health seeking actions, the concept of risk, and presentation of risk. The focus group discussions were conducted with men and women separately in the respective communities. The FGDs were digitally recorded by permission, and directly translated and transcribed into English. The cue cards options chosen, and the reasons were documented and used to compliment the FGD findings.

Semi-structured risk communication interview: The communication cue cards (Fig. 1) were used to explore how health risk is interpreted and communicated. Communication cue cards had pictures of conventional bar graphs, colours, risk scoring and thermometer-like depictions that are often used to represent health risks were used to explore risk communication choices (20, 21). Five communication options were presented in the cue cards, printed in A3 -sized paper and administered to each focus group participants immediately after the FGD sessions.

In addition, participants were also required to describe or make a sketch (on the cue card) of any risk presentation(s)that could make more sense to them about a likelihood of someone being sick or dying of a heart related sickness. The topic guide and cue cards were developed in Amharic and Afan Oromo languages for the urban and rural participants respectively, and pilot-tested prior to use in the FGDs. Each participant was asked to choose the pre-set options or give their own illustrations that could be used to communicating health risk for better understanding.

Analysis: Data analysis was carried out using a thematic analysis method to explore peoples’ understanding of CVDs. The research team transcribed and analyzed the data jointly following the Braun and Clarke (2006) six-step approach.

A total of 26 participants were involved in the FGDs and the risk communication with cue cards, with equal numbers of men and women in both study communities. The participants’ ages ranged between 29 to 63 years. All women were housewives, and all the rural men were farmers. Few of the rural men had some primary school education. Most urban participants were from Ethiopian Orthodox Christian faith, and 65% of them had at least a secondary level education.

Although there were some differences in the views of urban and rural participants, five major themes were emerged during the analyses, namely, knowledge and awareness of heart disease, perception of risk or vulnerability to heart-related diseases, risk conception, communicating CVD risk, and health seeking intentions.

Knowledge and awareness regarding heart disease

HIV, malaria, tuberculosis, typhoid, and typhus fever were the main health problems mentioned by FGD participants in both rural and urban communities. Participants acknowledged that cardio-metabolic diseases such as CVDs (hypertension, heart disease), diabetes, kidney disease, and unintentional injuries were common in their communities. Participants agreed that most people in their communities lacked knowledge about these diseases and stated that the community was unaware of CVDs symptoms, and how to prevent or treat them. Participants from the rural communities indicated a general lack of knowledge about the heart, and possible heart-related disease.

This point was further reiterated by a participant from the urban community as follows:

“Many people [even in the urban community] do not even know where the heart is located let alone about heart diseases”. [male, urban].

They were also unsure whether treatment for CVDs is available at health facilities in their communities. Participants also agreed that, compared to HIV or other infectious diseases, little has been done by the government to raise community awareness about NCDs, particularly, heart-related disease and its possible effect in the communities.

Perception about the heart and risk of CVDs. Despite the low awareness of CVDs, participants in both study communities perceived the heart as an important organ of the body. Hence, the condition of the heart will certainly have serious either negative or positive consequences, depending on the situation, on the general health of an individual. A participant described this as follows:

“Our heart [health] is our [general] health, our kidney’s health. If our heart is healthy then our kidney will also be okay and the reverse is also true”. [female, rural]

She continued to note the connectedness of heart with other vital organs:

“Heart and kidney are not the same, but they are connected”. [female, rural]

Similarly, another participant expressed this assertion as follows:

“When the heart is diseased, as it is inside the body [stomach], it is harmful”. [female, rural]

Perceived risk, and vulnerability to heart-related diseases

Participants were asked ‘what they think might cause harm or danger to their hearts, in particular’. Several factors including actions and behaviours were mentioned by urban participants as the risk factors that could lead to CVDs. These included high intake of alcohol, tobacco smoking, chewing khat (Catha Edulis – a local stimulant plant found commonly in Ethiopia, Somalia, and East Africa), use of various illicit drugs, excess coffee intake, consumption of fatty food, and use of ‘unsafe’ cooking oil. Though most of the above CVDs risk factors were also mentioned in the rural FGDs, polluted air, contaminated water, and behaviours such as chewing of khat, alcohol abuse, and tobacco use were emphasized as the main CVDs risk factors.

The participants in the urban community also mentioned stress, anger, and disturbing noises as potential causes of CVDs. According to this participant, hearing unexpected and bad news about once relatives could also lead to the development of CVDs.

“I may develop heart diseases if I heard a shocking or bad news regarding my family or neighbours” [female, urban]

Interestingly, both urban and rural participants believed that intensive physical work and lifting heavy objects could also cause CVDs.

Perceived vulnerability to heart-related disease: many of the FGD participants did not think they could develop any heart-related disease at any possible time, and were therefore not worried about the risk of the disease. One participant in the rural community said:

…What kind of person ‘is he/she’ who looks forward to become ill in the future?” [female, rural]

She also emphasized caring for her heart only when she is diagnosed by a doctor of heart-related disease. She said,

“I will start caring for my heart when a doctor [in the future] tells me that I have a heart problem.” [female, rural]

Participant had alleged that anticipating a future illness (e.g., or guessing risk in the next five years what your CVDs risk would be) was like calling a bad luck on oneself.

“We don’t know what will happen in the future…..Only GOD knows what will happen to us.” [female, rural]

In addition, it was commonly believed that if this is the will of God (that is to be sick of heart disease) at any time in the future, even knowing and preparing early will not change the circumstance.

As indicated by this quote from a rural participant, people only perceived threat of sickness if they are sick themselves of any CVDs.

“People worry about their disease only when they get sick.” [female, rural]

This assertion was emphasized further this way. “When one is sick you look for help. But when one is not sick, you do not need to worry, as what God allows will come to you, anyway”.

This indicates that, the risk of getting sick of CVDs is not in our hands but is divine arrangement.

Considering the findings from both communities, a disease such as CVDs were considered to be harmful if it affects daily routine activity, make one bed-ridden, takes long time to recover, is incurable, and if it has the potential to result in death.

Risk Conception

With inherent cultural and religious beliefs related to disease occurrence and death, and low health literacy, conceptualizing CVDs risk and risk scores was not feasible, especially in rural areas. In one of the rural groups, the red colour was considered as depicting good health, referring to its resemblance with the colour of blood. On the other hand, one participant disagreed with using colour codes to depict CVD risk levels (or scores), as shown by this quote:

“I don’t need to understand anything including risk of disease. I have to admit my health status and live with the disease”. [female, rural]

Communicating CVD risk

The findings from the health risk communication semi-structured interview indicated that there were mixed views on the use of communication cue card options such as bar graphs, thermometers, and colours for communicating CVD risk. Most participants in both the rural and urban communities considered the red colour, including inside a thermometer, to signify a very high risk, a danger sign, or a life-threatening condition, while few participants suggested using black, yellow or white colors to represent high risk. According to some participants, a yellow color indicates a serious condition, or jaundice, or liver disease, while a white colour was considered as ‘no blood’ signifying an anemic condition. Similarly, most participants selected the colour green to represent lower risk, while a few preferred yellow and white colors.

Most of the participants, especially in the urban site preferred the use of graphs and colours in CVD risk communication (with visual aids), but their responses differed when a risk was communicated in the form of a bar graph, thermometer, or coloured thermometer. Most participants in the urban setting (compared to the rural ones) had correctly reported that a higher count (score) in the bar chart (and thermometer) meant a higher risk. However, a few considered a higher score in the bar graph to represent a lower risk or better health.

The addition of textual explanation to the graphic presentation of risk, bar chart or gauged and colored thermometers was found to increase the comprehension of the risk scoring. This was particularly important as most of the female participants were illiterate. According to these participants, the explanation would make it easier to ask assistance from literate family members. How and by whom the risk was communicated was also found to be an important factor for the message acceptance and its subsequent preventive action in this group of participants. An urban participant showed how he questioned the experience of healthcare providers and rejected the advice by saying:

“I was told that I have heart disease. But I was not convinced of my case, so I was afraid to take the drugs prescribed for me”. [male, urban]

Another participant stated that:

“If a healthcare provider told me that my condition is hopeless and it is too late for me, there is no point for me to act on it”. [male, urban]

In the rural community, the use of testimony from people who suffered and recovered from CVDs was a preferred health education strategy rather than dictating to people the expected behaviours on issues related to a healthy lifestyle, such as eating right, avoiding alcohol and tobacco, exercising regularly, and complying with treatment. In general, urban participants recommended that community health education and promotion of CVDs risk reduction using practical demonstrations and examples, including graphs, colors, percentages, and time frames (e.g., five-year risk). Other useful approaches mentioned by participants included mass media campaigns and the use of trained peer educators who can teach the community in normal social gatherings like coffee ceremonies and “idir” (burial associations) meetings. As a trusted source of health information, engaging community health workers and health care professionals in such meetings was also mentioned to enhance the desired behaviour change.

“…as to me, health education messages will be more acceptable when it comes from an experienced healthcare professional. They are more trusted in the community and can discuss the problem in more friendly way and at personal level” [male, urban]

Health seeking behaviour and treatment intentions

In the rural communities, mainly, participants had indicated that people often seek the services of traditional or religious healers for various health problems, and not specifically for heart-related health problems. Some urban male participants had indicated that they or others have visited traditional or religious healers to address anomalies including heart-related problems. According to these participants, people opt to religious healing looking for a radical ‘miraculous ‘cure not just disease management with a lifelong treatment. It is also related to the participants’ belief that heart diseases are incurable. Some urban male participants went ahead to also mention a specific traditional healing practice undertaken to address suspected heart-related health problems called ‘Birchiko Neteka’.

“I never encountered a person who suffered from heart diseases and seek care at health facilities. But most people complain about heart ‘weakness’ and sinking down of the heart. I knew people who visited traditional healers (bone settler or Wegesha) for these complaints- to do Birchiko Neteka.” [female, rural]

According to the participants, the ‘Birchiko Neteka’ practice involves, first, the traditional healer taking small cotton socked in alcohol, burn it with fire over the affected area on the patient’s chest wall. Then the healer will immediately cover the flame by a glass, allowing the flame to be extinguished, but the glass be attached with the chest wall. Finally, the healer pulls the glass from the patient’s chest wall. This is believed that, as the glass is pull off, the heart problem will get out of the body.

Participants also indicated their lack of empowerment to assess their CVDs risk since it is impossible to forecast ones’ future, including their health. This finding could be an important influence of health-seeking intentions in this population.

A follow up study (citizen science mobile survey) was commissioned to ascertain if community members would be willing to attend a local clinic to access care if screened and referred for CVDs care. Findings from this new study will give added information on health seeking and contextual issues around it.

Barriers to care seeking for cardiovascular disease

According to participants involved in these FGDs, the harmfulness of a disease was gauged by its potential to cause disability, paralysis, make a person bed ridden or lead to death. As people could give greater attention to diseases with such serious consequences, CVDs prevention interventions in these communities should include descriptions of their potential complications. Generally, CVDs were considered harmful by the participants of this FGDs. However, in the urban setting, participants reported that many people affected by CVDs often find it difficult to accept their diagnosis, disclose their status to others as well as seek appropriate medical care. They fear and are ashamed by the labeling effect of being diagnosed with a lifelong disease, as shown in the following quote:

“Diagnosis with these diseases will make the person incomplete”. [male, urban]

To these participants, a person with chronic disease like CVDs and being on lifelong medication is not as healthy as a person without the disease, irrespective of the presence or absence of symptoms. According to them, a person with such chronic disease cannot be considered full healthy as he/she needs to take medication continuously to remain healthy or restore to a healthy state. Accepting diagnose of heart disease was therefore consider as a stigma in the communities.

In addition, people often do not know the common symptoms of CVDs and are hence unable to seek medical care. Even for those who may recognize the common symptoms of CVDs, care was thought to be both physically and financially inaccessible. Therefore, these participants often looked for an alternative source of care, such as religious, or traditional healing.

This qualitative study has given an insight regarding people’s awareness of CVDs, its risk factors as well as their perceived risk and views on risk communication. According to the findings of this study both rural and urban Ethiopian participants’ understanding of CVDs, its risk factors, risk scoring, and CVDs preventive and therapeutic approaches was poor, in keeping with other studies in the sub-Saharan Africa (2, 22, 23).

The diagnosis of a chronic condition such as CVDs (or any NCDs) was considered to be ‘disabling’, and many of the participants had found it difficult to accept such a condition(s). This perception had, therefore, made the participants to often refrain from seeking health care and or deny their vulnerability to CVDs (or any NCDs). This might be linked to cultural and deep religious beliefs, and perceptions which defines some behaviours of the participants (who were majorly from Ethiopian Orthodox faith). This finding of our study, is akin to the studies undertaken among Korean immigrants (24) and African American women in North Carolina (25), in which the majority of participants did not believe that they were at risk of developing CVDs.

On the other hand, many of the participants expressed a fatalistic attitude towards CVDs, as heart-related diseases are often presumed to be predetermined and therefore inevitable. In which case, participants believed that, nothing can be done to change the course of the disease or the consequences of their risk factors. The participants tried to justify this by mentioning some people with the risk factors didn’t develop CVDs while other develop it even though they protect themselves from those risk factors. Importantly, the low perceived behavioural control to affect ones’ future could be seen from the perspective of lack of self-efficacy in adopting preventive behaviours. Therefore, community health education programme should target not only the knowledge dimension but also include strategies that improve self-efficacy of individuals. These findings were also important in enabling us (i.e., CEBHA + research team) to plan and undertake community level education before we conduct a community-based CVDs risk screening and referral study.

According to this study, CVDs risk communication options that re-enforced the depictions or graphs with added messages is more likely to enhance understanding and assessment of risk especially in rural settings. Therefore, adding textual explanation to the graphic presentation of risks with visual aids was also found to potentially increase the uptake of health education messages. While trustworthiness of the healthcare provider facilitates the acceptance of the message by the patient, upholding hope also encourages preventive action by the patient. Other studies also confirmed that risk communication has the ability to affect patients' commitment in making healthier lifestyle changes to reduce possible CVDs risk (25, 26).

Another important finding of this study was that CVDs care and treatment in the study settings were considered to be both physically and financially inaccessible. This assertion is similar to a study from Vietnam (27) in which NCDs care which includes CVDs were major causes of catastrophic health expenditure that leads to family impoverishment. Some participants in our study even considered CVDs to be untreatable. This might be due to the high undiagnosed CVDs rates (e.g. hypertension) (28), late presentation of patients and the ultimate poor outcomes of persons with CVDs. Hence, health-seeking behaviour of participants is limited. One study also revealed that in sub-Saharan Africa, primary and secondary preventive health care measures for CVDs are very inadequate (12).

This study has a number of strengths. First and for most, it addresses an important but somehow neglected public health problem in the study area. Secondly, the study has used appropriate study design and involved model family heads as study participants to better understand the target communities CVDs risk perception and risk communication which will improve the successes of future interventions. Thirdly, it has included participants both from urban and rural communities. However, this study has also some limitations. The most important limitation of this study is that it involved only FGDs in only two communities in Ethiopia, and also one FGD per gender in each setting. It could have been more informative if more FGDs were included in each category. In addition, the findings of this study may not be transferable to other sites considering some unique features of these communities.

In this study which was conducted in the rural and urban communities in Ethiopia, CVDs awareness was generally low, and conceptualizing risk and risk scores was based on cultural and religious beliefs, especially in rural areas. Communicating risk of CVDs morbidity and mortality proved challenging, due partly to cultural and religious beliefs. However, adding textual explanations (that are in consonant with the context of the setting) to graphical presentation of risk, improved the comprehension by study participants particularly in the rural setting. This, therefore, indicates that community-prioritized visual aids can help in communicating health risk in the communities. In addition, health promotion messages that uphold hope, and delivered by trusted healthcare providers could enhance the acceptability of the health risk message and support possible adoption of preventive actions and or health seeking behaviour. Lastly, essential CVDs care was perceived to be inaccessible for participants, both physically and financially. Therefore, we recommend, education on NCDs should be mainstreamed for the Ethiopia’s community health extension programme which has been shown to enhanced realization of good health and well-being (sustainable development goal number 3). Engaging religious leaders in the delivery of health messages could also enhance uptake and adoption of the intended behaviour by emphasizing individual’s role in keeping oneself healthy, in addition to ‘God’s will’. Acceleration of the integration of NCDs care into primary health care should also be emphasized to address the problem of accessibility to essential NCDs care.

AHRI - Armauer Hansen Research Institute

ALERT - All Africa Leprosy Rehabilitation and Training Center

AAERC - AHRI/ALERT Ethics Review Committee.

CEBHA+ - Collaboration for evidence-based healthcare and public health in Africa

CVDs - cardiovascular diseases

FGD - Focus group discussions

LMICs – Low-and-Middle-Income Countries

NCDs - Non-communicable diseases

PHCU - Primary Health Care Unit

SSA - Sub-Saharan Africa

WHO - World Health Organization

Ethical approval and consent

Ethical clearance to conduct this study was obtained from AAERC. Because of cultural reasons associated with signing on paper and also most participants especially in the rural areas were illiterate, oral consent was sought which was also approved by the ethics committee (AAERC). In addition, both international and national ethical guidelines were followed in interacting with study participants and handling their data.

Consent for publication

All authors involved in this study have given their consent for publication including preprint publication.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Conflict of interest

All authors have no conflict of interest to declare.

Funding

This study was funded by BMBF (German Ministry of Education and Research) under the Research Networks for Health Innovations in Sub‐Saharan Africa Project (Number: 66.3010.7-002.12). This supported the Collaboration for Evidence-based Health Care and Public Health in Africa (CEBHA+) formative study.

Authors’ contribution

HG, RH, KM, NL and KO have been involved in the conceptualization, project designing, data analysis and write up of this manuscript. KK and WT have involved the data collection, transcription and initial drafting of the manuscript. MZ was engaged in the analysis and initial drafting of the manuscript. EG, ATM and PD have involved in the analysis and write up of the manuscript.

Acknowledgment

We would like to thank all the FGD participants for taking time to share their views with us. We also acknowledge the health extension workers who have facilitated the selection of study participants, and the entire CEBHA+ project team in Ethiopia.

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No competing interests reported.

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Cardiovascular diseases risk perception and communication among urban and rural residents in Ethiopia: A qualitative study

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