Self-care practice and associated factors among hypertensive follow-up patients at East Gojam zone public hospitals, North West Ethiopia, 2021

Uncontrolled hypertension leads to cardiovascular complications and organ damage. Self-care practice is crucial for the prevention and management of hypertension by improving quality of life, preventing complications and decreasing health care expenditure. The study aimed to assess self-care practice and its associated factors among hypertensive follow up patients at East Gojjam Zone public hospitals; in Northwest Ethiopia. Quantitative cross-sectional study design and qualitative phenomenological approach were applied. The quantitative result was supported by in-depth interview. Out of 480 patients included in the study, 49% have good self-care practices. Out of the total participants 44.6% have poor in antihypertensive medication adherence, 92.5% have low in diet management, 82.8% were poorly practiced physical activity and 62.5% poor practice to weight management. Participants who cannot read and write (AOR = 3.1, 95% CI: 1.6–5.9), and have no comorbidity (AOR = 0.4, 95% CI: 0.2–0.6), uncontrolled blood pressure status (AOR = 2.1, 95% CI: 1.2–3.6), poor social support status (AOR = 2.5, 95% CI: 1.5–4.3) and unfavorable attitude (AOR = 3.1, 95% CI: 1.9–5.2) are the factors for poor self-care practice. During interview; family meal preparation habits, inadequate information about self-care practice during follow-up time, inconvenient working environment, pressure during social events to share food, negligence, and poor self-efficacy were highly described as challenges for practicing and sustaining self- care. The level of hypertension self-care practices was found to be low. Therefore, hypertension self-care practices should be strengthened throughout their follow-up time, and creating awareness in the community is highly encouraged.


INTRODUCTION
Hypertension (HTN), also known as high or elevated blood pressure, is a condition in which the pressure in the blood vessels is persistently elevated. About 22% of adults in the world are estimated to have HTN. Globally, its prevalence continues to grow and is expected to reach 1.56 billion by 2025 with an estimated prevalence of 46%, out of this the African region has taken the highest prevalence (46%) [1]. In Ethiopia, HTN is the most prevalent non-communicable disease with an overall prevalence of 19.6% [2]. If HTN is uncontrolled, it can lead to a heart attack and eventually heart failure and stroke, kidney failure, blindness, rupture of blood vessels, and cognitive dysfunction. It has been estimated that HTN complications cause about 9.4 million deaths per year, which accounts for 17 percent of the world's total deaths. The leading cause of poorly controlled HTN is non-adherence to HTN self-care practice [3]. Self-care practice is backbone and costeffective measure to prevent and control HTN complications. Hypertension self-care requires adherence to medicine, eating a low-fat diet, daily physical exercise, limiting alcohol intake, not smoking, weight loss, blood pressure (BP) self-monitoring, regular health care appointments, and reducing stress [4]. The lifestyle changes can reduce systolic BP by approximately 4 to 11 mm Hg for patients with HTN, with the biggest changes occur by diet and exercise. Also, estimated that for every 1 kg body weight reduction, there is a 1 mm Hg BP reduction [5].
Although HTN is preventable and treatable disease, knowledge of HTN management in developing countries is very poor. In lowincome and middle-income countries, more than 80% HTN burden is attributed to the lack of knowledge and inadequate self-care practices [6]. Previous studies conducted in Ethiopia found that the prevalence of poor self-care practice was between 77% [7] and 72.7% [8], which was high compared to the WHO recommendation that the prevalence of poor HTN self-care should be less than 20%.
Several factors have been associated with adherence to selfcare activities, including socioeconomic status, age, gender, educational status, place of residence, co-morbidity, access to health care, level of health literacy, length of therapy, culture, social support, self-efficacy, source of information on self-care & knowledge of disease & treatment [9][10][11][12]. Even though adherence to self-care practices of HTN is an integral part of patient care to achieve the desired therapy goal, the practice of self-care activities in the African population has remained weak [8]. Measuring the level of HTN self-care activity with its determinants has clinical importance for the creation of successful HTN control strategies. However, factors that contribute to poor self-care practice were not well explored, particularly in North West Ethiopia. Therefore, the first objective of this study was to assess the level of HTN selfcare practices. The second objective was to assess associated factors among HTN patients and supported through qualitative study design after exploring barriers of sustaining self-care practices among hypertensive follow-up patients through.

Study setting
The study was conducted at East Gojjam zone public hospitals. The zone has 21 Districts, one referral hospital, one general hospital, 8 primary hospitals, 102 health centers, and 406 health posts with a history of offering HTN services.

Study design and period
Facility-based cross-sectional study design and case study with a phenomenological approach were conducted. It was conducted from May 01 to May 30/ 2021.

Source and study population
The source population were all hypertensive patients on follow-up and hypertensive patients on follow-up in the selected hospitals during the study period were study populations.

Inclusion and exclusion criteria
All hypertensive patients on follow-up greater than 6 months were included in the study, but seriously ill during data collection were excluded from the study.

Sample size determination and sampling procedure
The sample size was determined by using the single population proportion formula for the first objective and the double population formula using Epi-info version 7 for the second objective using the assumptions of 95% confidence interval (CI), 80% power, 5% level of significance, 5% margin of error and 10% non-response rate. Finally, the largest 482 samples were taken as the final sample size from educational status (secondary education) as a significantly associated factor. The qualitative in-depth interviews approach was applied on 14 subjects until data saturation achieved. For the quantitative study, 40% of hospitals were selected randomly. The sample size was allocated to those hospitals proportionally based on the number of hypertensive patients with follow-ups they had during the data collection period. For the qualitative study, the purposive sampling technique was used based on their follow-up for at least twelve months to get their detailed experience of self-care practice.

Outcome measures
Self-efficacy. The exposure of self-efficacy to manage HTN is derived from a five-item scale.
Response options range from 1 (not confident at all) to 5 (totally confident). Respondents who score 4 or above were classified as having good self-efficacy [13].
Social support. Having friends and other people including family to turn to in times of need or crisis gives you a broader focus and positive selfimage [14,15]. The multidimensional scale of perceived social support was used to measure subjectively assessed social support. The multidimensional scale of perceived social support is a 12-item measure of the perceived adequacy of social support on a 7-point Likert-type scale ranging from 1 = very strongly disagree to 7 = very strongly agree. The total score ranges from 12 to 84 with a higher score (≥64) indicating better perceived social support.
Good self-care practice. When patients respond to the mean or above out of the hypertension self-care activity level effects question which contains six categories of self-care behaviors recommended by the joint national committee-8 including medication adherence, low salt diet intake, physical activities, smoking cessation, weight management, and alcohol abstinence.
Medication adherence. There were three questions to measure medication adherence, each contained a minimum of 0 and a maximum of 7 points, therefore totally there was minimum of 0 and maximum of 21 points. Participants who score a 21 were considered as adherent.
Diet quality. Diet quality was assessed based on dietary approaches to stop hypertension containing 11 questions. Each question contains minimum 0 to maximum 7 points. Totally for all 11 questions there were a minimum of 0 and a maximum of 77 points. Participants who score 32 and below were considered having low diet quality; participants who score between 33 and 51 were considered having medium diet quality and participants who score 52 or greater were considered adherent to diet management.
Physical activity. Two questions were used to asses' physical activity. Each questions contain minimum 0 and maximum 7 points. Totally there was minimum of 0 and maximum of 14 points.
Participants who score 8 or above were considered as adherent to physical activity.
Smoking adherence. Two questions were used to asses' smoking adherence. Each questions contain minimum 0 and maximum 7 points. Totally there was minimum of 0 and maximum of 14 points. Participants who score zero was considered as adherent.
Weight management. There was 10 questions to assess weight management. Each question contains a minimum of 1 and a maximum of 5 points. Totally, there was a minimum of 10 and a maximum of 50 points. Participants who scores greater than or equal to 40 points were considered as adherent to good weight management.
Alcohol adherence. Alcohol intake was assessed using 3 questions. Participants who report not drinking any alcohol in the last 7 days or who indicate that they usually did not drink at all were considered abstainers.
Knowledgeable. When participants answer median or above out of the knowledge questions.
Favorable attitude. When patients respond to the median or above out of the attitude questions.
Optimally controlled BP. An average systolic BP < 130 and diastolic BP < 80 mmHg for at least three consecutive follow-up appointments in patients younger than 60 years old [16].

Data collection tool and methods
Data were collected by the interviewer-administered questionnaire which was adapted from previous literature and modified to the context of this study. The questioner has eight parts; Part I: Socio-demographic information (9Q), Part II: Health profile of patient questions (8Q), Part III: questions related to the source of information about nonpharmacological self-care practices (5Q), Part IV: Knowledge questions (12Q), Part V: Attitude questions (10Q), Part VI: Selfefficacy measure questions (5Q), Part VII: Social support questions (12Q), Part VIII: Hypertension self-care activity level effects questions (31Q). The questionnaire was pretested among HTN patients who had to follow up from hospitals other than the study area but had the same characteristics. Five trained clinical nurses and two Bachelor degree nurse supervisors collected data through a face-to-face interview.
For the qualitative part, responses were collected through individual face-to-face in-depth semi-structured probing question interviews by using interview guide questions that contain five items. The interviews were recorded on an audio recorder and hand-written notes were taken to assist with the analysis of the transcribed data.

Data processing and analysis
For the quantitative study, the collected data were coded and entered into Epi data version 3.1 and cleaned and transferred to SPSS version 25.0 statistical software for further analysis.
Factors associated with self-care practices were identified using bivariate and multivariable logistic regression analysis.
Covariates and logistic regression assumptions were checked using a Hosmer-Lemeshow test and goodness of fit by variance inflation factor test. Associations were described using an odds ratio (OR) and the 95% confidence interval (CI). The statistical test considered significant at a P value of less than 0.05.
For the qualitative study, all the interviews were transcribed verbatim immediately and data were analyzed using thematic content analysis methods manually.

Ethical consideration
Before collecting the data, an ethical clearance letter was obtained from Debre-Markos University College of Health Science's research ethical review committee. Permission letter was obtained to collect the data from participants in each studied hospital. The goal of the research was explained to the participants, and informed consent had been taken. The respondents' freedom to decline or withdraw from the interview was assured, and all information provided by each respondent was kept absolutely secret.

Socio-demographic characteristics
Out of the total 482 respondents, 480 participated in the study, yielding a response rate of 99.6%. The mean age of the respondents was 55.4 (standard deviation ±11.2) years. More than half (55.6%) of the respondents were male and 394 (82.1%) of the respondents were married. About 396(82.5%) of respondents were followers of the Orthodox religion. Nearly all (99%) of the respondents were Amhara in ethnicity. About 293 (61%) of respondents had no formal education and 314 (65.4%) of the respondents resided in urban regions (Table 1).

Health profile of respondents
Of the total respondents, 228 (47.5%) participants had a family history of HTN, and more than half of the participants 258 (53.7%) were overweight and obese. About 216 respondents (45%) have uncontrolled HTN. About 231 (48.1%) respondents have comorbidity in addition to HTN.
Nearly one-third of 160 (33.3%) respondents have a treatment duration of 5 years and above.
About 130 (27.1%) of respondents miss their follow-up visits to health institutions ( Table 2).

Source of information about HTN self-care practice
More than half of the respondents 295 (61.5%) heard about the non-medical management of HTN. Of these 253 (85.8%) respondents' get the information from health workers. During their follow-up time, 198 (41.3%) of the study participants did not get any information about the non-medical management of HTN (Table 3).

Individual related findings
About 282 (58.8%) of the participants have good knowledge about HTN self-care practice and 243 (50.6%) of the participants had a favorable attitude toward HTN self-care practice.

Level of hypertension self-care practices
The median score for self-care practice was 72 with interquartile range (IQR) (36, 108) and a maximum score of 133. Out of the total respondents, 245 (51.0%) patients had poor self-care practice with 95% CI (46.56%, 55.51%).
The median score for medication adherence was 21 with an IQR (11, 23) and a maximum score of 24. About 214 (44.6%) of respondents practiced a poor adherence to antihypertensive medications. The median score for good practice to diet was 10 with a maximum score of 57 (IQR 4, 32). Most of the participants 444 (92.5%) practiced low diet quality, 32(6.7%) practiced medium diet quality and 4 (0.8%) practiced good diet quality. The median score for physical activity was 4 with an IQR (2, 7) and a maximum score of 14. About 398 (82.8%) respondents' poor practice of physical activity. The median score of weight management practice of the participants was 38 with an IQR (24, 49) and a maximum score of 50. More than half of the respondents 300 (62.5%) had poor weight management practices.
Factors associated with self-care practice Of all 26 variables, 4 variables (treatment duration, source of information, information per follow-up visit, information clearness in follow-up visit) were not included in regression analysis due to system missing and Multicollinearity problems. The final multivariable logistic regression analysis revealed that educational level, comorbidity, blood pressure control status, attitude and social support were independent factors in the self-care practices of HTN patients.
Patients who cannot read and write were 3.1 times more likely to practice poor self-care (AOR 3.1, 95% CI: 1.674-5.939) as compared to those patients having grade12 and above educational level. Individuals with an uncontrolled BP state were 2.1 times more likely to practice poor self-care (AOR = 2.1, 95% CI:  (Table 5).

Qualitative section
A total of fourteen in-depth interviews were conducted until the data saturation was attained. All participants have had HTN for at least two years. Nine of the participants were female. All respondents were between the age of 30 and 80 years, and seven of them were married. About their educational background, one has attended college, three had secondary education, one could write and read-only and nine of them were not read and write. Among the participants, 13 were orthodox religion and one was Muslim religion followers. After all in-depth interviews were completed, we categorized in into 3 thematic areas. The first theme explores barriers to participating in self-care practice activities. The second theme explores the challenges of sustaining self-care management activities. The third theme describes the effect of HTN on lifestyle.
Theme 1: Barriers to participating in the self-care practice activities Family meal preparation habits were identified as a barrier to selfcare practice as expressed by the respondents: "it is so challenging to prepare food separately for me out of my family. Even my family feels unhappy when they prepare without salt…" 34-year-old male respondent Inadequate information on HTN and its self-care practice by the doctor at follow up visits were recognized as barriers; as stated by a respondent: "I've stopped taking medication for 1 year. I don't do anything special right now. I drink coffee, I use salt, and I don't know what blood pressure control is…." 55-year-old female respondent" "…after I take pills for blood pressure, my blood pressure became normal and after that no need of taking drugs…" 65-yearold man.
The inconvenience working environment was also mentioned as a barrier which was well explored by the respondents "…. Even if I was committed to regular exercise, it is not convenient. There is no place to exercise" 60-year-old man.  It was difficult to prepare individual meals for one person in a family. Ethiopian culture does not allow men to engage in the preparation of food. As mentioned by a respondent, a man with HTN must eat whatever is served to the family stated as follow participant "…I eat what my wife and children eat. It is difficult to prepare a separate meal just for myself; you know it just is not convenient" 76-year-old male participant.
The patients recognized that negligence and poor self-efficacy to practice self-care activity were also challenging; as stated by a respondent: "Poor controlling of my blood pressure is the problem of me that I am not giving attention to lifestyles" a 60-year-old male participant.
"I don't exercise regularly. I walk sometimes on the street when I have the time but scheduled sport is not practiced." 34-yearold woman.
"Exercise at my age?! I cannot think of it. It is difficult…" 77-yearold woman.

Theme 3: Effect of HTN on lifestyle
The patients believed that the diagnosis of HTN had a profound effect on their lifestyle; a change of lifestyle after a diagnosis of HTN requires discipline and motivation "…. I can't eat as much as I want. I have a lot of family workload to prepare food…." 51-year-old female participant.
"It is challenging to cope the life style change, difficult to work hard due to pain and selective way of diet consumption for HTN management " 36-year-old female participant.

DISCUSSION
This research sought to determine the prevalence of self-care in hypertensive patients in terms of adherence to antihypertensive drugs and lifestyle improvements. The overall prevalence level of self-care practice in this study was 51% with 95% CI (46.55, 55.51). This was in line with a study conducted at Jimma hospital which was 55.3% [17] and Nigeria which was 47.4% [18]. However, the result of this study was lower than a study conducted at Mizan Tepi hospital which was 66.7% [19], Durame hospital which was 72.7% [8], and Addis Ababa which was 77% [7]. On the other hand, the finding of this study was higher than a study conducted at Hiwot Fana and Jugola hospital which was 37.9% [20], Nekemite hospital [21] which was 31.1%, Saudi which was 25.6% [22], Ghana which was 28% [23] and Iran which was 27%. This discrepancy might be due to differences in lifestyle, culture, economic status, access to health care facilities, and level of education of the general public. In addition, differences in the level of knowledge about self-care practices among HTN patients across the region and countries; the level of understanding of health care workers on HTN self-care practices may contribute to the variation of HTN self-care practices across the countries. Furthermore, the differences in analysis and measurement tools.
This finding was higher than studies done at Durame 42.5% [8], at Hiwot Fana and Jugola 18.2% [20], at Saudi 20.7% [22], and Uganda 24.4%. [24]. This might be due to the difference in dietary habits awareness of diet management across the region and the country. Also, the difference in measurement tools, and socioeconomic and socio-cultural values can be the source of variations in the finding. This also, supported by the qualitative part of this study revealed a variety of food with fruit and vegetable was not affordable and does not give emphasis.
Also, the qualitative part of this study revealed that poor physical activity was a major challenge. This might be due to limited or lack of structured settings for physical exercise around the workplaces as well as in the general public in the study area. Moreover, the patient's awareness and attitude towards physical activity limited their practice.
The prevalence of smoking in this study was 3.3% with 95% CI (2.05%, 5.38%). This finding was lower than a study done at 37. 5 Poor practice in %   [29] and Iran 15.3% [30]. Also, the prevalence of alcohol consumption in this study was 9.8% CI (7.42%, 12.80%). This was in line with a study conducted at Jimma [12] which was 11.7% and Durame [8] which was 12.1%. However, this finding was much lower than studies conducted in different parts of Nigeria which were 28.7% and 21.7% [27,28], and Kenya which was 13.1% [26]. The variation in the findings might be due to differences in socio-cultural and religious perspectives. In the current study area, smoking and alcohol consumption are highly discouraged within the community.
Patients who cannot read and write were 3.1 times more likely to practice poor self-care as compared to those in grades 12 and above educational level. This was in line with studies at Durame [8] and Ayder hospitals [22]. This is due to patients who cannot read and write miss the information sources like posters, leaflets, and other written material that assist HTN self-care practice.
Patients who had no co-morbidity were 41.8% more likely to practice self-care activities. This finding was consistent with the study done at Addis Ababa [25]. This might be due to comorbidities will exacerbate the patient's symptoms and make them unable to adapt to lifestyle changes [31].
In this study, uncontrolled BP state were 2.1 times more likely to practice poor self-care than those who had a controlled state of BP. This was in line with a study done at Hiwot Fana and Jugola Hospital Harare, Ethiopia [20] this might be because good self-care practice can control blood pressure. The study also showed that hypertensive patients with poor social support were 2.5 times more likely to practice poor self-care practice. This was in line with a study done at Desse town public hospital and health centers, Ethiopia [23], Addis Ababa hospital [25], and Jimma hospital [12]. This might be due to the social support can encompass multiple dimensions that positively influence patients' lifestyle modification through having regular follow-up visits, managing stress, and being psychologically active in self-care-practice.
The study also depicted that; attitude was significantly associated with self-care practice. Patients who had unfavorable attitudes were 3.1 times more likely to practice poor self-care. In addition, the qualitative part of this study revealed that an unfavorable attitude toward self-care practice led to high blood pressure resulting in the development of symptoms and complications of HTN. This might be due to patients having a favorable attitude toward HTN can understand the complications of the disease so that they practice self-care activities effectively to prevent those complications.

Limitation of the study
Hypertensive patients attending follow-up in health centers were not included in the study.
Research methodologies involving self-reported measures depend largely on individuals' memory recall bias and denial of poor practices from the respondents may exist which affects the result of the study.

CONCLUSION
The level of self-care practice was found to be low compared to the WHO standard. Particularly dietary approach to control HTN, physical exercise, and weight management was very low. Patients who were unable to read and write, have uncontrolled state of BP, poor social support and unfavorable attitude, and comorbidity were significantly associated with HTN self-care practice. The pressure during social events, preparing separate meals for one person in a family, negligence, and temptations were recognized challenges for HTN self-care practice. Therefore, designing policies towards improving and modifying education of HTN self-care practices should be made. Special attention should be given to patients with low educational levels, patients with additional comorbidity, uncontrolled state of HTN, poor social support, and those with unfavorable attitudes towards HTN management modalities. In addition, assessing and close monitoring of HTN self-care practice at every follow-up visit should be conducted to address their gaps.

Summary
What is known about the topic?
• Self-care practice is the backbone for the prevention and management of hypertension.
• Self-care practice components are diet, exercise, weight management, stopping smoking and alcohol, and medication adherence.
• If there is a gap in self-care, there will be uncontrolled hypertension • Uncontrolled hypertension leads to cardiovascular complications and organ damage.
What this study adds?
• Hypertension patient has a poor self-care practice in the medication adherence, diet management, poorly practiced physical activity, poor practice of weight management.
• comorbidity, family meal preparation habits, inadequate information about self-care practice during follow-up time, inconvenient working environment, pressure during social events to share food, negligence, and poor self-efficacy were highly described as challenges for practicing and sustaining self-care.

DATA AVAILABILITY
All materials and data are available from the corresponding author without any restriction.
thanks also go to the hospital administrators of the study area. Lastly, we acknowledge our data collectors, supervisors, and friends that support us throughout our work.

AUTHOR CONTRIBUTIONS
BA and HZ performed the analysis and interpretations. TS wrote the first draft, and BA, HZ, MM and NM contributed to the design of the study and substantive revision of the final draft. All authors read and approved the final manuscript.

FUNDING
The work was supported by Debre-Markos University, College of health sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. The funders had no role in the study design, data collection, and analysis, decision to publish, or preparation of the manuscript.