Study area and Design- Community based cross-sectional study design was conducted from May 23 -July 5, 2020, in Dano district, West Shewa, Oromia, Ethiopia. Dano district is located 225 Kilometer to the west of Addis Ababa, the capital city of Ethiopia and Seyo is its major town. The 2017 Ethiopian census projection reported a total population of Dano district is 122,618 of whom and 60,706 and 61,912 were Men and women respectively. Dano District has 27 Gandas (The small administrative unit),five urban administration and 23 rural Gandas(11).
Population and sample size - Those Adults aged 19 to 65 years living in the rural areas Dano district were included in the study whereas, those Adults who were previously diagnosed with hypertension, those screened for hypertension in the last year, pregnant mothers and mothers in post-partum periods were excluded from the study. A multi-stage sampling technique was used to select the study participants. Stage one; selecting representative Gandas; seven rural Gandas were randomly selected by the lottery method from 23 rural Gandas of Dano district. Stage two, selecting eligible individuals; those eligible individuals were enumerated and registered to get a complete frame of the study population among randomly selected Gandas. In order to get those eligible individuals during data collection easily, the corresponding individual household was coded and registered in lining with their name. Stage three, the total sample size was allocated by probability proportional to size to each Ganda based on the number of eligible individuals they have. Then finally, 605 adults were selected using computer generated Lottery method based on the determined proportion of each Ganda’s.
Data collection tools and procedure - Participants information on Socio-demographic variables behavioral and life style, physical measurement and biochemical measurement( blood glucose level) was collected using standardized WHO STEPS wise approach V.3.2(12) tool that designed for surveillance of non-communicable disease. Participants health seeking behaviour was assessed using questionnaire adopted from health belief model(13, 14) and participants knowledge was assessed using a questionnaire which was adapted from Hypertension Knowledge-Level Scale (HK-LS) after reliability assessed for reliability (15).
The questionnaire that was developed in the English language was translated to Afan Oromo and return back to the English language to see for the consistency of both the English and Afan Oromo version of the questionnaire.
At first glance, eligible adults were enumerated; their corresponding households were coded and registered in lining with the individuals’ name by health extension workers. Secondly, Data were collected by healthcare professionals holding at least BSC degree in nursing and public health officer after intensive training was given on the objectives of the study, STEPS survey procedures, and tools. A pre-test of the structured questionnaire was conducted before the actual data collection on in adjacent Ganda, that was not included in the study to check for the validity of the instruments and then necessary corrections were made. Blood pressure was measured using, Riester ri-champion®N, automated and clinically validated (to the British Society for hematology standard). The participants were asked to rest (relax) with setting on the chair; legs uncrossed, feet on the floor, back supported and insured empty bladder, no smoking, exercise coffee/tea 30 minutes before measurement. Device integrity was checked and disinfected using 70% Isopropyl Alcohol to protect them from COVID-19. Then, the participants were positioned in such a way that the arm was supported on the desk to keep the upper arm at the same level as the heart. The upper arm was uncovered 2 inches above the elbow crease. Cuff placed on the upper arm on the brachial artery. Three blood pressure measurements were taken 3minutes apart in a sitting position. Finally, the mean of the three readings was taken to determine the BP status of the respondents.
Anthropometric measurement was carried out using standard procedures and the calibrated instruments. The participant's weight was measured by PRESTiEGE a portable adult digital weight scale. Weight of the participants was recorded to the nearest 0.1kg. The participant’s height was measured using PRESTiEGE a portable Stadiometer. Then the participants were asked to stand on the footplate with back against the Stadiometer, bring the legs together legs are straight, arms are at the sides, and shoulders are relaxed, back of the participants was touch the stadiometer at heels, buttocks, upper back and head. Then, the headpiece lowered until it touches the crown of the head firmly and compressing the hair. It was recorded to the nearest 0.1cm.
Participant’s random and/or fasting blood glucose was measured using Gmate™ voice blood glucose monitoring system with GmateTM glucose test strip. A single used sharp lancet was used to prick the participant’s side of non- dominant ring finger after they washed their hands thoroughly. Then sufficient amount of blood was applied to the reagent area (about 0.5µl) (16).Used lancet was disposed to safety box to prevent cross-contamination. The respondent was declared unavailable if not found on two separate visits.
Data processing and analysis
Completed questionnaires were coded and entered into Epi Data version 3.1 computer program and SPSS version 23.0 was used for analysis. Data were cleaned and edited by simple frequencies and cross-tabulation before analysis. The cleaned final data was then analyzed with SPSS version 23.0.
Regarding the analysis of the outcome variable, Intra-class Correlation Coefficient (ICC) if the item deleted was tested to see intra-observation reliability for both Systolic and Diastolic blood pressure. Then after, the mean score of three blood pressure readings was used to classify the participants’ blood pressure. Accordingly, the mean score of systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90mmHg was coded as 1 and mean systolic blood pressure < 140 mmHg and/diastolic blood pressure < 90 mmHg was coded 0.
Participant’s health-seeking behavior to Hypertension was analyzed from the data collected using a health-seeking behavior questionnaire by calculating the total health-seeking score from 10 items of the health-seeking question with 3 points Likert scale (Yes = 2, I am not sure = 1 and No = 0) was used to calculate health-seeking behavior of adults. Those Adults with the score 11.318 or more were coded 0 and those with lower than 11.318 were coded 1. BMI of the participant was calculated from the height and weight of the individual.
Participant’s knowledge about hypertension was analyzed from data collected using a knowledge questionnaire by calculating the total knowledge score from 20 questions proposed to measure the participant’s knowledge about, causes, risk factors, and prevention method of hypertension. Those adults with the score 23.3 or more were coded Zero and those with lower than 23.3 were coded one. The participant’s history of chronic illness coded 1 if the response is “Yes” 0 if the response is “No”.
Bi-variable logistic regression analyses were done to see the association between each independent variable and the outcome variable. Even though variables with p-value < 0.20 in the bi-variable logistic regression analysis were a candidate for multivariable logistic regression analysis, ranking was done based on their p-value to consider them in multivariable logistic regression analysis since there were more variables than expected to be included in multivariable logistic regression. The logistic regression model fitness was checked using Hosmer-Lemeshow and statistics, not significant was declared as a model fitted. Multicollinearity was checked (VIF < 10) indicating the non-existence of multicollinearity among the variables in this study. Both crude and adjusted odds ratio along with 95% CI was estimated to measure the strength of association. The level of statistical significance was declared at a p-value of less than 0.05. Tables and figures were used to display the results.
Ethical and Legal consideration- The study was approved by the Ambo University, Medicine, and Health Sciences College Health Research Ethics Review Committee (CHRERC). The permission and support letter was obtained from the Dano district health department. Voluntary informed, written, and signed consent was obtained from all subjects after describing the nature and purpose of the study by the language they can understand. Each enumerators and data collector were given a face Mask and sanitizer during enumeration and data collection period respectively. Each participant washes his or her hand before physical, biochemical measurement and Blood pressure measuring devices were disinfected using 70% Isopropyl Alcohol to protect them from COVID-19.Those participants, who identified with hypertension, and diabetic mellitus were given advice and linked to the nearby health institution for further investigation and treatment. Health education was given for pre-hypertensive participants.