Prevalence of Undiagnosed Hypertension and Associated Factors among Adults in Mizan Aman Town, Bench Sheko Zone, Southwest Ethiopia: A Community-based Cross-sectional Study

Abstract

Background: Undiagnosed hypertension is the leading risk factor for death and disability globally. Its prevalence is increasing worldwide, especially in low and middle-income countries. It is considered a silent killer because it can exist without specific signs and symptoms for many years while once happening with serious complications. Hence, this study aimed to assess the prevalence of undiagnosed hypertension and associated factors among 18 years and above in Mizan Aman town of Bench Sheko Zone in Southwest Ethiopia.

Methods: A community-based cross-sectional study design was carried out among people aged 18 years old and above from April 1 to 30,2021, in Mizan Aman town. Seven hundred fifty-nine subjects were selected by multistage sampling technique. A structured pretested WHO STEPS-wise questionnaire was used to interview the participants. Data entry and analysis were done using EPI data 3.1 and SPSS version 25 statistical software respectively. Descriptive analysis was undertaken and the results were presented using frequency tables, graphs, and statistical summaries. The dependent variable has dichotomized response of yes and no and hence binary logistic regression was used to predict a dependent variable based on independent variables and predictors having P ≤ 0.25 on the bivariable analysis were considered as candidates for the multivariable analysis. Odds ratios with their 95% confidence intervals were calculated to measure the strength of association and finally a p-value < 0.05 was considered statistically significant.

Result: The prevalence of undiagnosed hypertension was 14.8% with 95% CI [12.3-15.6]. Older age (AOR =3.1, 95% CI [1.5-6.5]), male (AOR=2.2, 95%CI [1.3-3.9] low physical activity (AOR=3.9, 95% CI. [1.8-8.3]), less serving fruit and vegetable (AOR=4.5, 95%CI. [2.4-8.8]), and higher BMI (AOR=2.7, 95% CI. [1.6-4.6) were significantly associated with undiagnosed hypertension.

Conclusion: The current study outlined that the prevalence of undiagnosed hypertension was high in the study area. In addition, most of the risk factors identified were modifiable, and hence community-based preventive approaches like lifestyle modification, increasing awareness, and strengthening routine screening at primary health service facilities resulted in a substantial change in tackling the burden effectively.

Background

Worldwide levels of undiagnosed hypertension (HTN) represent the global public health crisis. Globally, it affects around 22% of people aged 18 years and over and is responsible for an estimated 9.4 million deaths per year (1,2).

Undiagnosed HTN potentially increases the chance of developing target organ damage and other life-threatening conditions. While, early diagnosis, treatment along lifestyle modification is essential for the management of HTN. However, in developing countries, the prevention and control measures are grossly inadequate, though the prevalence of the disease is very high (3,4).

Around 75% of people with HTN reside in low- and middle-income countries. People in such settings often have low awareness associated with HTN, its treatments, and control measures and this has led to low healthcare-seeking, which in casual consequences in a high occurrence of undiagnosed HTN in these populations (5). In Sub-Saharan Africa (SSA) non-communicable diseases (NCDs) are continuously increasing and are caused by demographic and epidemiologic transitions; however, low priority with little experience exists in implementing sustainable and successful programs to control HTN (6).

Signs and symptoms of HTN are often undetectable during the early stages and hence many people with the disease are left undiagnosed (7). Undiagnosed HTN increases the chance of headaches including renal failure, myocardial infarction, heart failure, stroke, and premature loss of life (8). The preventable and modifiable factors for high blood pressure include behavioral risk factors; such as weight problems, excessive nutritional salt intake, low nutritional consumption of calcium and potassium, alcohol consumption, psychosocial stress, low tiers of physical activity, and the non-behavioral risk factors like family history of high blood pressure, age, sex. These risk factors result in various long-term disease processes, ending in high mortality rates attributable to stroke, heart attack, tobacco- and nutrition-induced cancers, obstructive lung diseases, and many others (9–12). The weak modern health-seeking behavior of individuals for some hypertensive symptoms was significantly associated with undiagnosed HTN in the study conducted in the Sidama Region of Ethiopia (13).

As a developing country, Ethiopia, there are economic development, industrialization, nutrient transition, and globalization that lead to a rapid exchange in existence that paramount the risk of HTN (14). According to the Ethiopian NCD STEPS survey of 2016,76.6% of the entire population has never been measured for blood pressure in a year and among these, the working-age groups have the highest share (6,7).

HTN and raised blood sugar are increasing partly because of an increase in risk factors including smoking, obesity, harmful use of alcohol, and lack of exercise (15). Despite evidence HTN burden in the community, the unknown status of the population their health status, low community awareness, and the priority given to its prevention and control by the communities and government are very low in Ethiopia (16).

The lifestyle of the Ethiopian population is changing due to economic development, urbanization, and demographic transition. These rapid changes have led to the necessity of conducting a study on undiagnosed HTN and its associated factors. Much research on the area has been done at the facility level and again they were mainly focusing on the overall prevalence of HTN in Ethiopia and elsewhere but those which were conducted at the community level as well as those which were focused on the associated factors were limited. Therefore, this study is aimed to assess the prevalence of undiagnosed HTN and associated factors among adults in Mizan Aman town in the Southwestern regions of Ethiopia.

Methods And Materials

Study setting, design, and period

A community-based cross-sectional study was conducted from April 1 to 30, 2021, in Mizan Aman town, the capital and administrative center of Bench Sheko Zone in the Southwestern Nations Nationalities Peoples Region (SWNNPR). Based on the report from the sub-city administration office, the total population of Mizan Aman town is estimated to be 54, 951, of the total 26,925 of them are male and the rest 28,026 are female. Among the total 54, 951 population residing in the town, about 60.3% are estimated to be above 18 years old.

 Sampling techniques and sample size 

A multistage sampling method was employed to recruit study participants. First, three kebles (the smallest administration localities), (Addis Ketema, Edget, and Kometa Keble) were selected using simple random sampling out of the five kebles in the town. Secondly, the sample size determined, the households, was allocated proportionally to each of the selected keble and the households were selected within each keble using the computer-generated random sampling technique (Figure1). 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 if there were two or more eligible adults living in the same household.

Inclusion: All adults aged 18 years and above who reside in the study area during the study period.

Exclusion: Medically confirmed cases of HTN, pregnant women, and women at ministration period have been excluded from the study.

The sample size was calculated to get the maximum representative sample size and to determine each specific objective separately.

For the first specific objective, the sample size was calculated using single population proportion formula based on the following assumptions. The prevalence of undiagnosed HTN (p=12.3%) was taken from a previous similar study (7), 95% level of confidence, 3% margining of error (d), a design effect of 1.5 and 10% for a possible non-response rate was taken and the formula applied as shown below.

For the second specific objective, the sample size was calculated by using EPI INFO stat calc for population proportions to estimate a sufficient sample. Factors associated with HTN and respective parameters are obtained from a study conducted in different parts of Ethiopia. Finally, the prevalence of gender (being male ) to be 16.13% with an AOR of 2.5 at (1.2,5.2)of CI was taken from a study conducted in Hawela Tula Sub-City, Hawassa, Southern Ethiopia (7), and taking 95% confidence interval, 80% power, 1.5 a design effect and, 10% of non-response rate were used to calculate sample size for each associated factors.

Among the given two computed alternatives, the first computed alternative yielded the maximum number than the one produced by the double population proportion formula and hence, the final sample size for this study was found to be 759 subjects.

Data Collection

A structured, and pretested questionnaire adapted from the WHO STEPS wise approach for surveillance of NCDs in developing countries was used to interview the participants (17).

Data collection was done sequentially in a two-step process:

Step 1: Interview-based 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, body mass, and waist and hip circumference.

Anthropometric measurements were taken based on the WHO guidelines, as specified in the Food and Nutrition Technical Assistance (FANTA) anthropometry manual (18). Blood pressure was measured in a sitting position with a supported back, and digital automatic blood pressure (BP) device was used to measure the BP of the participants. The participants were taking rest for at least 5 min before measurement. Three measurements of BP on a single visit were taken at least one minute apart, and this survey considered the last two measures of BP levels and used their mean to detect HTN. At least two visits were made for those study participants whose BP was elevated at the first contact. According to the WHO guideline, a participant with systolic blood pressure (SBP) ≥140mmHg or diastolic blood pressure (DBP) ≥90mmHg will be diagnosed as a HTN case (19).

Data quality assurance

Data were collected by two senior nurses under one supervisor following the training given on interviewing techniques, anthropometric measurements, and handling of data collection instruments for one day. The Questionnaire was prepared in English, then translates into Amharic, and then retranslated back to English to check its consistency. A pre-test was done on 5% of the sample out of the study area and then appropriate revision on the tool was done. Double-entry of the data to epidata software for data verification was also performed.

Data analysis 

Data analysis was done by SPSS for windows version 25 and the descriptive analysis was undertaken and the result was presented using frequency tables, graphs, and descriptive statistical summaries. The undiagnosed HTN status has dichotomized response of yes and no and hence bivariable analysis was performed using binary logistic regression to identify candidate variables for the multivariable logistic regression model to identify explanatory variables associated with the outcome variable. Then those variables with a p-value <0.25 were included in multivariable logistic regressions for adjustment of confounding factors. 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. The Hosmer-Lemeshow test was used to assess the fitness of the model (chi-square 3.9 with a p-value of 0.9).

Operational definition 

Standard operational definitions were adapted for key variables to maintain consistency and uniformity of the information.

Undiagnosed HTN: adults (aged 18 years and above) will be 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 been told by a health professional that they have HTN before this study (19).

Harmful use of alcohol: alcohol consumption of more than 14 units/week for men and more than 8 units/week for women in the last 12 months before the survey. Its calculation is then: Unit of alcohol = vol (in ml) X % alcohol/ 1000 and for different local alcoholic beverages then was: Tella (4%), Tej (10%) and arake (40-45%) alcohol content, (as Glass 250ml and bottle as 330ml) (20).

Low consumption of fruits and vegetables: Fewer than 5 servings (<400gm) of fruit and, or vegetables per day in that 1 serving is defined as one orange/apple/banana or three tablespoons of cooked vegetables (17).

A current smoker: an adult who has smoked 100 cigarettes in his or her lifetime and who currently smokes cigarettes. A previous smoker: an adult who has smoked at least 100 cigarettes in his or her lifetime but who had quitted smoking at the time of the interview. Never smoker: an adult who has never smoked, or who has smoked less than 100 cigarettes in his or her lifetime (21).

 Physical activity; the subjects' physical activity was classified as high, moderate, and low

High physical activity is defined as a vigorous-intensity activity on at least 3 days achieving a minimum total physical activity of at least 1500 min/week OR 7 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities achieving a minimum total physical activity of at least 3000 min/week. Moderate physical activity is defined as 3 or more days of vigorous-intensity activity of at least 20 min per day OR 5 or more days of moderate-intensity activity and/or walking of at least 30 min per day OR 5 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities achieving a minimum total physical activity of at least 600 min/week. A low physical activity: not fulfilling the criteria for moderate and high physical activity (22).

A family history of HTN is considered if a person’s first-degree relative (a parent, a grandparent, or a sibling) had been diagnosed with HTN and/or was receiving drug therapy for HTN (23).

Results

Socio-demographic characteristics

A total of 759 participants were randomly selected and included to study in Mizan Aman town with 97.2% response and data was collected from 738 study subjects, 482 (65.3%) males and 256 (34.7%) females. The highest percentage (51.9%) of the study participants were in the age categories of 18-34 years 96%, while 13% were in the age of 55 years and above. The mean age of the respondents was 38.85 (14.57SD) years (Table1).

Behavioral characteristics

The number of current smokers was 196 (26.6%) and all the smoked were manufactured tobacco products. The mean age at first started current smoking was 26.4 (6.3 SD). The majority (63.8%) of respondents declared someone smoked at the workplace in their presence within the past seven days. The proportion of current and past drinkers were 30.3% and 30.6%, respectively. Among the current drinkers, 20.1% of them were men but only 5.7% of women drank four or more days in the last week before the survey. About 71.3% of study participants eat saturated oil frequently whereas 32.7% of them use fatty food frequently. Nearly, 84.3% of the participants reported that they add salt to their food frequently and 62.3% of the study participants consumed more than five servings of fruit and vegetable per day for more than three days in a typical week. Among the study participants who respond about their physical activity, 22.1%, 19.1%, and 58.8% had low, moderate, and high levels of physical activity respectively. About 30% of respondents have a sedentary lifestyle, exactly 24.4% of respondents have a history of raised blood glucose and 24.1% were current khat chewers. About 21.5% of study subjects’ body mass index (BMI) was greater than 25kg/m2 and among those women respondents 13.6% had central obesity (WHR > 0.85); whilst 6.6% of men had central obesity (WHR>1.0) (Table 2).

Prevalence of undiagnosed HTN

The mean SBP and DBP of the study participants were 119.97mmHg (17.4SD) and 80.48 mmHg (11.74SD) respectively. The prevalence of undiagnosed HTN was 14.8% [12.3-15.6] 95% CI. The prevalence of undiagnosed HTN among the study participants varied across their age, sex, serving fruit and vegetable, physical activity, and BMI. The prevalence of undiagnosed HTN was higher among older age participants (>/=55 years and above age group) than the younger age group and again the prevalence of undiagnosed HTN was higher among participants with higher BMI (25.2%) than normal BMI (11.9%). It was also higher among participants who had low physical activity (37.4%) compared with high physical activity (7.4%).

Factor Associated with Undiagnosed HTN

Many associated factors of undiagnosed HTN were identified by the current study. The age group of 55 years and above were 3.1 times higher at risk for undiagnosed HTN compare to the 18-34 years of age group (AOR=3.138, 95% CI [1.511-6.516]). The odds of having undiagnosed HTN was 2.2 times higher in male than female (AOR=2.239, 95% CI [1.295-3.870]).

Eating fruit and vegetable was significantly associated with undiagnosed HTN. Those eating fruit and vegetable less than five servings per day for less than three days per week were 4.5 times (AOR = 4.549, 95% CI [2.352-8.800]) increased the risk of undiagnosed HTN as compared to that experienced eating for greater than five servings per day for more than three days per week. Besides, the odds of having undiagnosed HTN were 3.9 times higher among those who did not take part in high physical activity compared to those who took part in high physical activity (AOR=3.878, 95% CI [1.803-8.341]).

In addition, the odds of having undiagnosed HTN was 2.7 times higher among those whose BMI was greater than or equal to 25 Kg/m2 when compared to those whose BMI was less than 25 Kg/m2 (AOR =2.667, 95%CI [1.551-4.588]) (Table 3).

Discussion

This community-based study has attempted to determine the prevalence, which is 14.8%, and identified factors associated with undiagnosed HTN. Characteristics such as age, sex, physical activity, servings of fruit and vegetable, and BMI were predicted undiagnosed HTN.

The finding on the prevalence of undiagnosed HTN was in line with the findings of the study in the Gulele sub-city of Addis Ababa (13.3%), Hawassa (12.3%), in Ethiopia (7,24). This finding was closer to findings outside of Ethiopia, India (15.2%), and Bangladesh (11.1%) (13,25). The current finding was lower than the findings of studies conducted in a rural area of West Bengal (24.1%), Gadarif in eastern Sudan (33.5%), and a study conducted in River Nile State, Sudan (38.2%) (4,26,27). This difference might be due to study setting and sample size in that their studies were conducted in rural communities and used large sample sizes and also attributable to the differences in lifestyle in a different setting. However, it is higher than the findings reported from a study done in the Gilgel Gibe area in Ethiopia (7.5%) (28). These differences might be related to increasing urbanization, lack of awareness, and willingness to participate in regular health check-ups in the absence of health problems, coupled with accessibility barriers to screening services, and differences in study population used in various studies.

This study showed that undiagnosed HTN was significantly increasing as age increased. Those with age groups of 55 years and above were 3.1 times more likely to develop undiagnosed HTN as compared with the age group of 18-34years. This finding sharply contrasted with a study conducted in Nepal, which shows elderly patients (≥65 years of age) had a lower likelihood of being undiagnosed for HTN than patients aged 15–24 years (29). But this finding is in line with the study findings conducted in Addis Ababa, southwest Ethiopia, and Gimbi in Ethiopia (3,30,31). The finding was also supported by studies conducted outside of Ethiopia, Bangladesh, and South India, which revealed the magnitude of HTN increased with the increment of age (32,33,34,35,36). It is mostly related to the biological effect that increased arterial resistance due to age-related changes in the arterial wall that the thickening of the arterial wall or arteriosclerotic structural alterations and calcification in old age.

Regarding the gender difference, males were 2.2 times more likely to be undiagnosed for HTN compared to females. This finding was similar to a study done in Hawela Tula Sub-City, Hawassa that men were at 2.5 times higher risk of undiagnosed HTN than women (7). Again this study finding was supported by a study conducted in southwest Ethiopia, which shows men were at higher risk for undiagnosed HTN than their counterparts (37). And other studies which were done in southern Ethiopia, Nepal, and, southern Tanzania uncovered that HTN was significantly higher in males than females (29,30,38). However, some studies demonstrate that the odds of having HTN were higher in women (27,36). Thus, the significant difference might be due to the presence of coexisting risk factors and having a lower frequency of health facility visits trained in males and hormonal variation. That is, androgens increase blood pressure via the renin-angiotensin system (RAS) which promotes oxidative stress leading to the production of vasoconstrictor substances and a reduction in nitric oxide availability (39). Other studies suggested that ovarian hormones, especially estrogen, may have the potential to keep blood pressure lower, as well as the cellular, biochemical and molecular mechanisms by which sex hormones may modify the effects of HTN on the cardiovascular system (40).

The current study revealed that there is an association between undiagnosed HTN and fruit and vegetable consumption. Those who consume fruits and/or vegetables less than five servings per day for three or fewer days in a typical week were 4.5 times more likely to develop undiagnosed HTN compared to those who consume fruits and/or vegetables for more than five servings per day for three or more days in a typical week. This finding was supported by a study done in the Gulele sub-city of Addis Ababa, which shows, the prevalence of undiagnosed HTN by people who did not consume fruits and vegetables in a typical week was 3 times more likely than those who consume fruits and vegetables 4-7 times in a typical week (24). Studies conducted in southwest Ethiopia also pointed out that eating fruit and vegetable three or fewer days per week was associated with undiagnosed HTN (37). It is widely accepted that fruit and/ or vegetable are an important component of a healthy diet and that their consumption could help prevent a wide range of CVDs including HTN CDs which the world health organization (WHO) aims to promote this consumption (41).

The odds of having undiagnosed HTN were increased by 3.9 times among those who didn't involve in high physical activity as compared to those who did the high physical activity. This finding was concordant with a study conducted in southwest Ethiopia and Nepal, which conveyed that being involved in vigorous activity were less likely to develop HTN than their counterpart (37,42). Hence, these findings suggest that several cardiometabolic problems may arise soon as a consequence of insufficient physical activity. Rapid urbanization, high population density, increased use of motorized vehicles, and, modern technology might be predisposing factors for low physical activity among this study population.

The other important finding was about the association of BMI and undiagnosed HTN that being overweight or obese increases the risk of undiagnosed HTN. Those who had a BMI greater than or equal to 25 Kg/m2 were about 2.7 times more likely at risk of undiagnosed HTN as compared to those with a BMI of less than 25kg/m2. This finding was similar to a study conducted in, Jigjiga Town of Ethiopia that those who had BMI ≥ 25 were 2 and 2.8 times more likely to be undiagnosed hypertensive when compared to those who had BMI less than 25 respectively (37,43,44). Moreover, the current study agreed with different findings from Gondar city, Durame town, and Hawela Tula sub-city of Hawassa in Ethiopia; India, and Nigeria (7,45,46–48). It could be related to urbanization which changes in dietary habits and reduced physical activity that leads to obesity while this study was quite lower than a study conducted in Hawassa that identified BMI was among the factors associated with HTN BMI 25Kg/m2 were 5 times more at risk for HTN than those with BMI less than 25 Kg/m2 as well as in a hospital-based study in Bahir Dar Felege-Hiwot referral hospital that peoples of BMI >=25 were 4.79 folds more likely to develop undiagnosed HTN than underweight individuals (43). Some of the variability between these reports could be due to the study setting and the difference in lifestyle. There are several mechanisms hypothesized to explain the link between obesity with HTN. It is generally thought that the accumulation of visceral and ectopic fat in several tissues and organs alters the metabolic and hemodynamic pathways, and additionally, insulin resistance and inflammation may promote an altered profile of vascular function and consequently leading to the development of HTN in obese people (49). The reduction of overweight and obesity by improving nutrition and increasing regular physical activity is the best way to avoid or improve HTN (50). It is important to teach people with high BMI to use interventions that could reduce their BMI and check their BP regularly to reduce the risk of undiagnosed HTN and its consequences.

In the current analysis, alcohol was not found to be significantly associated with undiagnosed HTN. while, a study conducted in Addis Ababa (51), Dire Dawa (52) Gurage zone (53), and Nepal (68) reported the association between alcohol consumption and HTN. However, some studies found protective effects of alcohol on HTN (54,55). These differences in findings might have occurred because of differences in the amount and concentration of alcohol that might be consumed in different areas.

The current study does not find a significant association between undiagnosed HTN and a family history of HTN contrary to the positive association between family history and HTN in the study of Hawela Tula of Hawassa (7), Durame (45), western India (25), and Pelotas (56). The increased risk of undiagnosed HTN among people with a family history of HTN could be related to genetic factors. The lack of association in this study might be attributable to participants’ ignorance of the HTN status of their parents and families.

Limitations of This Study

The WHO STEP-wise protocol employed in this study involved gathering self-reported information on the participants' socio-demographic characteristics and information on participants' behavioral variables. Another limitation of the study was the lack of some important measurements such as biochemical measurements and hence unable to determine the level of blood glucose or cholesterol in the study.

Conclusion

AOR                          Adjusted Odds Ratio 

BMI                            Body Mass Index

CI                               Confidence Interval 

DBP                           Diastolic Blood Pressure

HTN                           Hypertension

IRB                            Institutional Review Bored

MMHG                      Millimeter of Mercury

NCD                           Non-Communicable Disease

OR                              Odds Ratio

SBP                             Systolic Blood Pressure

SD                               Standard Division 

SNNPR                        South Nation Nationalities and Peoples Region

SPSS                            Statistical Package for Social Science 

WC                               Waist Circumference

WHO                            World Health Organization

WHR                            Waist to Hip Ratio

Declarations

Ethical Approval

This study was conducted in line with the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Ethical Review Committee of Institute of Health of Jimma University, Permission was also obtained from the Mizan Aman town administration office. Brief explanations about the purpose and benefit of the study were described to all the study participants. For their full cooperation, verbal and written consent was obtained from each study participant. Names and other personal information that can violate the confidentiality of the respondents were not used. Confidentiality and privacy were ensured for collecting information from the study participants and the right of the respondents to withdraw or not to participate was respected. Participants' feedback form was prepared and provided an overview of results from the physical measurements, and also, counseling service was provided to those with high BP, on lifestyle modification, and to have regular check-ups. Finally linking to the nearest health facility was also done.

Competing interests

The authors declare that they have no competing interests.

Author’s contribution

Sebsibe Elias formulated and designed of the research topic, collected the and supervised the data collection, analyzed the data, interpreted the results, and drafted the manuscript. Teshome Kabeta contributed to designing of the study, performed data analysis, and critically reviewed the drafted manuscript. Both authors had full access to all the data and take responsibility for the integrity of the data and the accuracy of the analysis and both authors read and approved the final manuscript.

Funding

This research received no fund from anyone.

Availability of data and materials

All data used during this study are available upon request from the corresponding author.

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Tables

Table 1: Socio-demographic characteristics of the study participants in Mizan-Aman town, Bench-Sheko zone, southwest Ethiopia, 2021.

Table 2: Behavioral characteristics of the study participants in Mizan-Aman town residents, Bench-Sheko zone, southwest Ethiopia 2021.

Table 3: Bivariable and Multivariable Logistic Regression model showing independently associated factors with undiagnosed HTN among the study participants in Mizan-Aman town, Bench Sheko zone, southwest Ethiopia, 2021.

Key   * = candidate variables in Bivariable logistic regression at p-value <0.25 **statistically significant variables in final model of logistic regression at p-value <0.05

 N.B: Hosmer Lemeshow’s goodness-of-fit test produces a chi-square of 3.853 with a p-value of   0.870.