Magnitude and determinants of Poor Self-Care Practices and associated factors among Hypertensive Patients attending at Debre Berhan Referral Hospital, Amhara Regional State, Ethiopia

Background: Hypertension is one of a non-communicable diseases that become public health concern and cause early mortality around the globe. Poor management of hypertension is a very important cause for various cardiovascular problems. Reducing the outcome of the disease through compliance to self-care practices is crucial. However, comprehensive assessment on domains of self-care was not well studied. Objective: To assess self-care practices and associated factors among hypertensive patient attending in Debre Berhan Referral Hospital. Method: A hospital based cross-sectional study was conducted. Initially the data were checked manually and entered in to Epi-Data version 3.1. P-value of <0.05 was used as a cut of point to arm statistical signicance. Finally, results were presented in text, tables and graphs. Result: The prevalence of poor self-care practice was had poor self-care practices with 95% CI (71.7, 80.3%). Multivariate analysis indicated that patients without comorbidities 1.5 (1.3-1.9), being aged 60 and above years 4.2 (1.7-10.3) and unavailability of blood pressure apparatus at home were more likely to have poor self-care practice as compared with their counter parts. Conclusion: - The level of self-care practice was found to be low and attention is needed for self-care practices.


Introduction Background
According to the American Heart Association, hypertension (HTN) is a condition in which systolic blood pressure ≥ 140 mmHg and diastolic pressure ≥ 90 mmHg with two or more subsequent readings on different separate occasions. Hypertension is a non-communicable disease (NCD) that has become a public health concern and causes early mortality around the globe. It has an insidious effect and has become the problem in the world, ranking third in causing disability (1).
Globally, raised blood pressure is estimated to cause 7.5 million or 12.8% of all causes of deaths per year.
Hypertension doubles the risk of cardiovascular diseases such as coronary heart diseases (CHD), congestive heart failure (CHF), stroke, renal failure, and peripheral arterial diseases.
The magnitude of hypertension escalated by a number of risk factors. Aging, drinking alcohol, physical inactivity and overweight are the major factors that prone individual to have hypertension. Poor control of hypertension is a very important cause of various cardiovascular complications. In addition, it raises the occurrence of different diseases in our body. As a result, it has a paramount advantage of monitoring hypertension to reduce the outcome of the disease through adhering to self-care practices. (2).
According to the World Health Organization (WHO), one way to better control hypertension is to involve patients in their own self-care practice (3). Self-care is a conscious, active choice and capability of people, families, and communities to engage in health promotion and protection, disease prevention, and dealing with illness and disability either with or without the support of a health care provider (4). It is also described as a process in which individuals and their families maintain health through health-promoting behaviors and managing illness. Evidence shows that self-care practices help patients improve patient satisfaction and quality of life and decrease primary, outpatient and emergency department visits.
Adhering to self-care practices is a crucial part of high blood pressure management. The major areas of self-care for high blood pressure care and management include medication taking and a number of lifestyle factors, such as nonsmoking, weight management, low-sodium and low-fat diet, physical activity, moderation in alcohol consumption, self-monitoring of BP, regular doctor visits, and stress reduction (5).
The Joint National Committee on the prevention, detection, evaluation, and treatment of high blood pressure provides six self-care behavior recommendations considered to be essential to control high blood pressure. These are compliance with medication regimens, involvement in physical activities, and healthy diets low in fat and salt, i.e. follow a dietary approach to stop hypertension (DASH), maintain a healthy weight, reduce alcohol consumption and avoid tobacco. Despite the advantage of these practices to minimize the unwanted effect of hypertension, many patients are not ready to practice it.
The pooled prevalence of hypertension among the Ethiopian population was 19.6%. Subgroup analyses showed that the prevalence of hypertension in the urban population was 23.5% and that of both rural and urban populations was 14.7%. This study also revealed that the prevalence of hypertension among males was 20.6% and females was 19.2% [6]. So, continual increase of hypertension prevalence and complication may due to unclear evidence about self-care practices of hypertension. There is no evidence so far that show the level of self-care practice of hypertensive patients in Ethiopia. As a result, this study aimed to assess self-care practices and its predictors.

Methods And Materials Study Area and Period
Debre Berhan is the capital city of North Shoa, one of the 13 zones of Amhara regional state, which is located 130 kilometers away from Addis Ababa. The town has a latitude and longitude of 9°41′N 39°32′E Coordinates: 9°41′N39°32′E and an elevation of 2,840 meters. It is bounded by Chacha on the South, Mendida on the west, Keyit on the north, and Ankober on the East [7].
The study was conducted in Debre Berhan Referral Hospital. In Debre Berhan Referral Hospital, there were 860 hypertensive patients who had regular follow-up, which was the minimum number of patient ows within the three month report. The study was conducted from February 1-30, 2018.

Study Design
A hospital-based cross-sectional study was conducted.

Source population
All adult hypertensive patients who have follow up at Debre Berhan Referral Hospital.

Study Population
All hypertensive patients who have follow up at Debre Berhan referral Hospital during the study period.

Inclusion criteria
Hypertensive patients aged ≥ 18 years who were in follow up for at least three months were included in the study. Since it is di cult to get consent from under 15, we took those patients whose age was greater than 18 years.

Exclusion criteria
Individuals who were not able to hear and speak and those who weren't volunteer to participate were excluded from the study.

Sample Size Determination
For the rst objective The required sample size for the rst objective of this study was calculated by using a single population proportion formula through the assumption of 95% con dence internal (CI), 5% margin of error, and prevalence of exercise compliance (43.7%) from a previous study performed in Addis Ababa (15)

For second objectives
We have computed sample size calculation by double population proportion formula. However, the sample size we got was smaller than the rst objective calculation. So, we selected sample size with the highest number i.e with the rst objective calculation.

Sampling procedure
In Debre Berhan Referral Hospital, there were 860 hypertensive patients who had regular follow up. To select the study participants, systematic random sampling was used. First, the list of patients (sampling frame) was prepared from the follow-up unit registration book, and the sampling interval was computed.
The sampling interval (k) was calculated by dividing the total number of patients who were enrolled in follow-up by the sample size, i.e., 860/416=2. Therefore, the sampling interval or k value was 2. The rst sample was selected randomly which was 2. Therefore, every K th value (K=2) was selected until reaching the nal sample size of 416 from the sampling frame.

Data Collection Methods
Adapted standardized questionnaires were developed by reviewing different studies. The levels of selfcare practice assessment tools were adopted from Warren Findlow's Self-care Activity Tools [15] and a study performed on the lifestyle modi cation of hypertensive patients and related literature [14]. Data were collected by using an interviewer-administered questionnaire to collect information about patient health status, hypertension-related knowledge and self-care practice as well as social support. The questionnaire was translated into local language (Amharic language) and returned to English language by consulting experts to ensure consistency. Eight diploma nurses who were uent speakers in local language collected the data when the patients came to the hospital for chronic follow-up, and two BSc Nurse Supervisors supervised the data collection.

Dependent variable
Self-care practices of hypertensive patients.

Independent variables
Socio-demographic factors: Age, sex, marital status, educational status, place of residence, employment status, religion, family history of HTN and income.
Health pro les of the patient: -Sources of Medical wage/cost, Chat chewing habit, Obesity, Proper health education in the health setting and presence of comorbidity (Diabetes, Stroke, and heart attack), Body mass index, Knowledge of hypertension and social support and stress management.
Health care-related and socio-cultural factors: Social support from family or partner, patient-provider relationship, self/home BP monitor, knowledge of HTN, unhealthy diet, physical inactivity, tobacco use, harmful use of alcohol, duration since diagnosis of disease and availability of BP apparatus

Operational De nition
Adherence is used to describe the congruence between recommended practice and actual behavior (8).
Adherence to physical exercise: -means participants had scored an 8 and better were coded as adhering to physical activity from two exercise-related question questions, each weighing 7 points (9).
Good self-care practice refers to the level of self-care practice when the respondents comply to four and above self-care practices out of six components of self-care practices with necessary of medication adherence.
Poor self-care practice -refers to the level of self-care practices when the respondents comply with less than four domains of self-care practices.
Adherence to a low salt diet: -the state to which the respondent follows the above mean of twelve healthy diet-related practice questions.
Comorbidity refers to other coexisting diseases/conditions among hypertensive patients, such as diabetic mellitus and renal disease.
Dietary approach to stop hypertension (DASH):-is a specialized diet, which is high fruit, vegetables, sh and low fat diet and recommended by international heart association.
Hypertensive patient: an individual with SBP ≥ 140 and DBP ≥ 90 mmHg or reported known antihypertensive drug users.
Blood pressure: -is the force exerted by blood against the wall of arteries as a result of the pumping action of the heart. In this study, blood pressure was measured three times at ve-minute intervals, as recommended by the American Heart Association.
Adherence to self /home BP measurement: -means that respondent who has functional BP apparatus and properly checks their BP in home.
Good weight management practices: -respondents who score above ≥ 40 from total weight management practices questions (9).
Alcohol abstainer: -refers to respondents who don't drink alcohol at all was considered abstainers.
Smoking status: -refers to respondents who report 0 days of cigarette smoking habit in the last seven days.
Medication adherence: -means that participants followed the 3 recommendations of medication adherence on 7 out of 7 days.

Data Processing and Analysis
First, the data were checked manually for completeness and consistency. The coded data were entered into Epi-Data 3.1. The data were exported to SPSS version 22 for further analysis, and simple frequencies, means, media, modes and measures of variability were used to describe the characteristics of the participants. Then, the information was presented using frequencies, summary measures, tables and gures.
Bivariate logistic regression was used to determine the association between predictors and outcome variables. It was checked by crude odds ratio and 95% con dence interval. Independent variables with pvalues ≤ 0.2 were considered for multivariate analysis.
Multicollinearity was checked to see the linear regression among the independent variables by using the variance in ation factor and standard error. Variance in ation factor > 10 and standard error > 2 were dropped from multivariate analysis. Finally, model tness was checked using the Hosmer and Lamshow test.
Adjusted odds ratios with 95% con dence levels were used to determine factors associated with self-care practices. In multivariate analysis, adjusted odds ratios with 95% CIs were computed, and statistically signi cant variables were those with p-values <0.05.

Ethical Consideration
Ethical clearance was obtained from the Haramaya University Institutional Health Research Ethics Review Committee (IHRERC).The o cial letter was written from Haramaya University to the North Shoa Health Bureau. Letter of approval was obtained from north Shoa zone health bureau to collecting data from the facility. Additionally, oral consent was asked from the study participant before dealing with the questionnaires. One hundred twenty-six (31%) of them were adherent to low salt intake habits, whereas 280 (69%) were non-adherent to low salt intake practices ( The factors that were signi cantly associated in the bivariate model with a p-value ≤ 0.2 were taken into the multivariable model. In bivariate logistic regression, poor knowledge status of the patient about hypertension, the types of medication that the patient takes, age group greater than 60 years old, No source of medical wage, duration of HTN in years since the rst diagnosis, the unavailability of BP measurement apparatus in home or nearby, no formal education, occupational status, no social support and poor stress-management status and having comorbidity status were the variables signi cantly associated with self-care practices.

Factors associated with adherence to self-care practices during multivariate logistic regression analysis
In multivariate logistic regression analysis, among the variables that showed a signi cant association in the bivariate analysis, poor knowledge status of the patient about hypertension, age group greater than 60 years old, unavailability of BP measurement apparatus in home or nearby, absence of social support and poor stress-management status and having comorbidity were retained as signi cant predictors of poor self-care practices of hypertensive patients.
Patients who were sixty years old and above were four times (AOR= 4.243; 95% CI: 1.744-10.322) more likely to have poor adherence to self-care practices about hypertension than with the age group 21-39 years old. In addition, patients who had poor knowledge about hypertension were 2.6 times (AOR=2.692; 95% CI; 1.173-6.180) more likely to have poor self-care practices about the disease than those with good knowledge status.
Patients with unavailability of blood pressure measurement apparatuses at home or nearby were 3.4 times (AOR=3.358; 95% CI; 1.673-6.740) more likely to have poor self-care practices than those who did have access to it. Patients who have concurrent illness were 1.5 times (AOR=1.5: 95% CI; (1.276-1.855) more likely to practice poor self-care than patients who hadn't concurrent (comorbidity) diseases. Patients who hadn't social support were 2.4 times (AOR=2.432: 95% CI; 1.350-4.384) more likely to practice poor self-care than those patients who had social support. "See table 1".

Discussion
Self-care practice is a crucial part of high blood pressure management (5). It also provides additional insight for clinicians working with a hypertensive patient population. Health care providers can be more effective lifestyle counselors when they understand speci c areas that can help patients achieve optimal BP control. Poor self-care practice has a signi cant impact on patient and cause different problems. It may increase primary, outpatient and emergency department visits for patients. The prevalence of poor self-care practices was very high. Poor Self-care practices were signi cantly associated with age above 60+, poor knowledge status, absence of BP apparatus at home or nearby, presence of concurrent illness and poor or no social support.
This study nding revealed that 75.6% of the patients had poor self-care practices. This nding is much higher than that of a study performed in Saudi Arabia, which was only 4.2% (10). This discrepancy could be explained by methodology differences, and the latter included a small sample of only male participants and used all domains to study.
The level of medication adherence (63.5%) in this hospital was closer to the study conducted in Jimma (60.5%, medication adherence) (13) and Adama (59.5%) (12). This might be due to similarity in socioeconomic characteristics and lifestyle of the participants. This nding was also comparable to the nding in North Carolina (58.6%). This nding was much higher than the nding done in Pakistan (49.5%) (14) and southern India (36.1%) (15).The presence of this difference may be explained by differences in socio-demographic characteristics.
The practice of consuming a low salt diet and following the DASH approach in this study was 31%, which was higher than a study performed in northern Carolina (22%) (16) and southern India (12%) (17). The possible justi cation for this increment could be that most of the participants in this study were enrolled from urban and semi-urban residents; as a result, the participants would have better awareness and information about the importance of consuming a low salt diet. In addition, the study conducted in North Carolina had a much smaller sample size (n=186) than this study (n=416). The difference could also be explained by the participant age cut off point for inclusion. In North Carolina, participants who were ≥ 21 years old were included, but in this study, the participants were included if they were 18 years old or older.
The level of low salt intake was much lower than the two local studies done in Jimma (55.9%) (13) and Addis Ababa (69.5%) (11).
In this study, exercise-related adherence was 27.6%. The nding of this study was lower than that of the study carried out in North Carolina (52.2%). The possible explanation could be differences in culture and the absence of organized setup to perform physical activities. The ndings of this study were comparable to those of a study performed in Addis Ababa and South India, where exercise-related adherence was 31.4% and 24.5%, respectively (11,17). A local study in Jimma found that 55.2% of the participants were physically inactive, which showed that the sedentary life style is increasing in low-and middle-income countries such as Ethiopia, causing an increase in the prevalence of chronic diseases such as HTN (18). Smoking is an important risk factor for CVDs, including HTN.
In this study, 71.9% of the respon dents moderated their alcohol intake. This study was comparable with the ndings in Addis Ababa (74.8%) (11) and North Carolina (65.1%) (16) but lower than the study carried out in Nepal (84%) (19). This discrepancy could be due to cultural and religious factors as well as environmental factors.
Findings related to weight management practices of hypertensive patients showed that the level of good weight management practice was 23.4%. This result was much lower than the study carried out in Nepal (78%) (20). A possible explanation could be the lack of accessibility of facilities to maintain good weight practices in developing countries such as Ethiopia.
Patients who were sixty years old and above were four times more likely to have poor self-care practices about hypertension than patients in the age group 21-39 years old. This was in line with a study done in South India (15), Indianapolis(21) and Gondar (22). This can be explained by the fact that elderly patients mightn't have support from family and can't perform those self-care activities independently.
Patients who had poor knowledge about hypertension were 2.6 times more likely to have poor self-care practices about the disease than those whose knowledge was good. This nding is in line with a study carried out in Uzbekistan (23). The possible reason could be explained by patients who have poor knowledge mightn't have enough understanding about the disease process and the importance of compliance with self-care practices.
Patients who hadn't available blood pressure measurement apparatuses at home or nearby were 3.4 times more likely to have poor self-care practices than patients who have available blood pressure measurement apparatuses at home or nearby. Patients who have concurrent illness were 1.5 times more likely not to practice self-care activity than patients who hadn't concurrent (comorbidity) diseases. This was comparable with a study carried out in Northwest Ethiopia (24) and Adama (25).
The possible reason could be that if there is comorbidity, they would have an extra burden of taking more medication, which would result in discomfort and may cause gastrointestinal upset. Additionally, when patients have additional health problems, their attention might be focused on the newly developed disease. Patients who have no social support were 2.4 times more common to practice self-care than those patients who have support from family members or friends. The possible reason could be that patients who have no support from family or friends wouldn't have a good relationship with them, which would create a negative attitude towards performing self-care practices. Additionally, patients wouldn't have trust in the health care services and health care providers to do what they recommend to do.

Conclusion
The levels of poor self-care practices were found to be high among adult hypertensive patients. Thus, patients are at higher risk of complications, especially target organ damage, such as heart, kidney, and brain.
The predictors of poor self-care practices among adult hypertensive patients in the study area were poor knowledge status, presence of comorbidity, no social support, and unavailability of BP apparatus and age of the patient more than 60 years. Prevention of comorbidities, medical services accessibility at home or nearby, such as the BP apparatus, health education about hypertension and having good social support from family or friends, have paramount importance for good self-care adherence.

Recommendations
Based on the ndings of this study, the following recommendations were made: For Debre Berhan Referral Hospital They should provide training about self-care practice compliance for health care providers speci cally working in the chronic outpatient department as well as a means of accurately monitoring and evaluating self-care practices.
For health care providers They should:-1. Providing information on the prevention of comorbidities (concurrent illness) for clients and important others.
2. Offering health education (information) for hypertensive patients (mass health education) at the time of follow-up day can increase patients' knowledge and attitudes to adhere to their self-care practices. By doing so, cardiovascular mortality and further complications must be prevented.

For further researchers
Research is needed to identify more variables that may determine the level of self-care practices of adult hypertensive patients in the study, especially with a qualitative type of study design.

Strength and limitation of the study
Strength of the study The strength of this study is the use of standardized tools to assess self-care practices. The study participants were adequately informed about the relevance of this study and the importance of telling the truth. Additionally, the data collectors employed were working out of the chronic illness unit.

Limitation of the study
Due to the nature of the cross-sectional study design, it is di cult to know the cause-effect relationship.
Recall bias may be present because it may have forgotten the activities they performed. Since the data were collected using the interviewer-administered technique, this study may have social desirability bias.

Declarations
Ethics approval and consent to participate Ethical clearance was obtained from the research review committee of Haramaya University. Letters were secured from the North Shoa zone health bureau. Verbal informed consent was obtained from the study participants. All the information obtained from the study participants was kept con dential throughout the process of study, and the name of the participant was replaced by code. Withdrawal from the study at any point if they wished was assured.

Consent to publish
Not applicable Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to some privacy reasons, but part of the row dataset will be available in the recommended publicly available data repository of BMC or from the corresponding author on reasonable request.  Notes: *AOR is statistically signi cant at P<0.05, ** AOR is statistically signi cant at P<0.001.
Abbreviations: AOR, adjusted odds ratio; CI, con dence interval. Figure 1 A pie chart that depicts the knowledge status of hypertensive patients attending in Debre Berhan Referral

Figure 2
A Bar graph that depicts the components of self-care practices of patients attending in Debre Berhan Referral Hospital North Shoa, Amhara regional state, Ethiopia 2018 (n=406).