Undiagnosed Hypertension and Associated Factors among Adult Dwellers in Hawela Tula Sub City, Hawassa, Southern Ethiopia: A Community Based Cross-sectional Study

Introduction Hypertension is a common public health problem and often goes unnoticed and can lead to a stroke or heart attack. It contributes to the high burden of cardiovascular disease, premature mortality, reduced quality of life and high costs to the health care system, especially in low and middle-income countries. Therefore, this study aimed to assess the prevalence of undiagnosed hypertension and influencing factors with health-seeking behaviour.Method A community-based cross-sectional study was conducted on 390 randomly selected adults in Hawela Tulla Sub-city, Hawassa, southern Ethiopia from February to June, 2019. Data was collected by pre-tested questionnaires and physical measurements of weight, height and blood pressure were collected through standardized procedures adapted from WHO STEPS survey tools. Data entry and analyzed for descriptive and logistic regression models by SPSS v.23. The result declared as statistically significant at p < 0.05.Result The prevalence of the undiagnosed hypertension among the respondents was 12.3%. The male [AOR= 3.70, 95% CI:1.64-8.32] than female contributing. Family history of hypertension had [AOR 3.69, 95% CI: 1.31-10.34], being physical inactive [AOR 3.21, 95% CI: 1.50- 6.84], salty food consumer [AOR 3.67, 95% CI:1.26-10.64], BMI 25 Kg/m2 and above [AOR 3.06, 95% CI:1.41-6.65] and not seek health care for some early hypertensive symptoms without serious illness [AOR 4.58, 95% CI: 1.85-11.32] when compared to their counterparts, were found to be determinant factors for undiagnosed hypertension.Conclusions and Recommendation The prevalence of undiagnosed hypertension found to be prevalent and calls for intervention. Health officials need to consider integrating the prevention and control of hypertension at the community level. The clinicians need to intervene on unhealthy lifestyles, by promoting healthy practices and health-seeking behavior to prevent undiagnosed hypertension.


Background
Hypertension already affects one billion people worldwide, leading to heart attacks and strokes [1]. It rarely manifests symptoms in the early stages and many people remain undiagnosed and invisible killer that rarely causes symptoms that may be late to successfully control their illness over the long term [2].
Elevated BP is the leading contributor to premature death, accounting for almost 10 million deaths in 2015, 4.9 million due to ischaemic heart disease and 3.5 million due to stroke [3]. The prevalence of hypertension in Africa 46% among WHO regions [4], 25% is the percentage of deaths under 60 that are attributable to hypertension in Africa [5]. The majority of African countries cannot afford the high costs of treatment with many other competing health priorities and limited resources [6].
Ethiopia as a developing country, there are economic development, industrialization, nutrition transition and globalization that lead to a rapid change in lifestyles that paramount the risk of hypertension [7]. However, WHO is working hard to achieve SDG target 3.4 to reduce by one-third premature mortality from NCDs through prevention and treatment at 2030 [8]. There was a high prevalence of hypertension probably indicating a hidden epidemic in this community [9]. The study reports of Ethiopia NCD STEPS, 2016 indicate that 76.6% of the total population never been measured for blood pressure per year. Some studies indicate there was a high prevalence of undiagnosed hypertension among working-age groups that were major health problem which requires urgent action [7,10]. There is a gap in recording and reporting, no study reports show that undiagnosed hypertension in the study area. This study indicates there are hidden epidemics of undiagnosed hypertension, which associated with a sedentary lifestyle, dietary, and not seeking modern health care. This is important for researchers, clinicians, and health planners.

Methods
The source population was all resident households of 4 urban and 8 rural kebele city (the smallest administrative units in Ethiopia) dwellers in Hawela Tula sub-city. While all randomly selected adults from selected households in urban and rural kebele at Hawela Tula sub-city of Hawassa city administration during the study period was the study population. The study was conducted on 390 calculated by a single population proportion formula and 10% possible non-response rate. A multistage random sampling technique. In the first stage, five out of 12 kebeles were selected by simple random sampling technique.
In the second stage, the sample size was proportionally allocated. In the last stage, only one random selected eligible person was interviewed. The age of 18 years or older adults and had no visit to any health facility in 12 last months for BP check before the study period was included. All adults who, are unable to be interviewed, apparently with the history of any major illness, known hypertensive, who are taking anti-hypertensive treatment, pregnant women were excluded from the study.

Data collection method and instruments
Data were collected by pre-tested structured questionnaires and physical measurements of weight, height and blood pressure were collected through standardized procedures adapted from a modified WHO STEPwise approach to surveillance-Instrument v.3.1 [11].
The questionnaire was pretested on 5% of the study participants found outside of the study area and modifications were made based on the findings. Data collectors were five clinical nurses supervised by investigators. Training and practical demonstrations on interview techniques and measurement procedures were given to data collectors for two consecutive days assessed for competency.
Data entry, cleaning, and analysis were done by SPSS V. 23. All factors with a p-value <0.2 in the bivariate logistic regression analysis were a candidate to the multivariable model to control confounding effects. The Hosmer -Lemeshow goodness-of-fit statistic was used to assess whether the necessary assumptions for the application of multiple logistic regression are fulfilled. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Finally, p-value <0.05 declared a significant association.
Ethical clearance was obtained from Hawassa university college of medicine and health sciences ethical review committee, support letter was also requested from the SNNPR, Hawassa city & Hawela Tulla Sub-city health bureau. All participants informed well about purpose, risk and benefit, and confidentiality. Participation was fully voluntary and written informed consent (verbal consent for who cannot read and write respondent) was obtained from each participant.

Terms and definitions
Undiagnosed hypertension: was defined as SBP 140 mmHg and above, and/or DBP 90 mmHg and above, without previous history or anti-hypertensive treatment during survey diagnosis [12].
Physical inactivity-Who involved in combination of moderate and vigorous activities for less than 10 min/day, or 30 min and above of moderate dynamic exercise on 5-7 days per week [13]. Cigarette smokers: who had used cigarette smokers form of tobacco in the last 30 days [14].

Associated Factors for Undiagnosed Hypertension
In the multivariate analysis sex of respondent, occupation, family history of hypertension, physical inactive, consume high salty food, BMI (Kg/m2) and health seeking behaviour were remains as determinant for prevalence of undiagnosed hypertension. Regarding to the modifiyable risk factors, the study participants who were physical inactive was approximtely 3 times more likely exposed to had undiagnosed hypertension with [AOR The male participants were more likely to had undiagnosed hypertension than female contributing. Which was similar with study conducted in North India [17] and Durame Town [22]. This may due to related with ability to afford fatty food, sugar, cigarette smoking, alcohol and being physical inactivity due to utilization of vehcle. The prevalence of undiagnosed hypertension was high among adults who had family history of hypertension. This result inline with study report from Jigjiga city of eastern Ethiopia [23], and Gondar, Northwest Ethiopia [9]. This may due to variability in blood pressure might explained by genetic factors. Physical inactive study participants were more likely exposed to had undiagnosed hypertension. This was consistent with study findings from Gondar city in Ethiopia [24], Addis Ababa Ethiopia [25] and Kerala, India [26]. This may due to rapid growth of urbanization, in urban areas using taxis, motor cycles to move from place to place may affect the mobilization of dwellers.
The prevalence of undiagnosed hypertension was high among more salty food consumer than their counterpart. This study result inline with North India [17] and in Jigjiga city of eastern Ethiopia [23]. This agreement may due to high salt containing foods increase high absorption of water and increase blood volume that responsible for high blood pressure.
Being over weight/obesity was more likely exposed to develop undiagnosed hypertension when compared to their counterparts. This was agree with study findings from Gondar city Despite to other study findings, there was no another socio demographic and other behaviour al factors had statistically significant association with undiagnosed hypertension on this study. This may be due to the minimum prevalence of these factors in the community studied.
This study result shows there was high prevalence of undetected hypertension among adults in selected house hold at Hawela Tulla Sub-city. Which related to occurred irrespective of the income status and due to low level of health seeking behaviour of the study participants. This study findings suggest for we need more attention on different strategies to address early detection for better prevention, evaluation, and management of high blood pressure in adults.
This study has potential limitations as the study is cross-sectional in design; it neither represents seasonal variation of nutritional outcomes nor establishes causal relationship.
There was no pregnancy test for to female participants and early pregnancy that can not be noticed by participants and data collectors was difficult to differentiate. For harmful alcohol consumption calculation majority reports maily locally prepared alcohol and which was hard to estimate the concentration.

Conclusions
This study result shows there was high prevalence of undiagnosed hypertension when compared with other studies and indicates there is hidden epidemic in this population.
Being male, having family history of hypertension, being physically inactive, high salty food consumption, and over weight/obesity and not seeking modern health care for some hypertensive symptoms without serious illness were associated with undiagnosed hypertension and statistically significant when compared to their counterparts.

Availability of data and materials
There is no remaining data and materials, all information is clearly presented in the main manuscript.

Competing interests
The authors declare that they have no conflict of interests.

Funding
No funding was obtained.

Authors' contributions
DW wrote the proposal, participated in data collection, analyzed the data and drafted the paper. EM and DG approved the proposal with some revisions, participated in data collection, analysis and manuscript writing. authors read and approved the final manuscript.