ASSOSA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING

PREVALENCE & ASSOCIATED RISK FACTORS OF HYPERTENSION

AMONG PATIENT VISITING OUTPATIENT UNITS OF ASSOSA GENERAL
HOSPITAL & ASSOSA HEALTH CENTER, NORTH -WESTERN ETHIOPIA

June, 2018 G.C

Assosa, Ethiopia

I
 ASSOSA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING

THIS STUDY IS SUBMITTED TO ASSOSA UNIVERSITY COLLEGE OF HEALTH

SCIENCE DEPARTMENT OF NURSING IN PARTIAL FULFILMENT OF THE
REQUIREMENT FOR DEGREE OF BACHELOR SCIENCE IN NURSING ASSOSA

TOWN, BENISHANGUL- GUMUZ REGION, NORTH-WESTERN ETHIOPIA,

2018

By principal investigators:- Ayalnesh Ambissa,

Gelane Biratu &
Lalisa M Gadisa

II
Acknowledgements
Frist and for most, we would like to express our deep & sincere gratitude to creature of us, scholar of
heaven & earth, Almighty God for he helped & stand by us infinitely in all aspects of our study, from
beginning to end. We are also indebted to our academic supervisor, instructor Tesfu Zewdu (BSc, MSc)
and Instructor Desalegn E. (BSc), for their continuous assistance, support & encouragement during
development of this proposal. Indeed, this study has matured through their provision of persistent
comment and evaluation. This study benefited immeasurably from the input we got from Assosa
University, College of health sciences & Department of nursing. It is our great pleasure to thank them
all. We also never undermine our thanks toward professional and non-professional of Assosa general
hospital‘s employee, for they directed us to anywhere we focused & patients, core of our study, who
voluntarily participated in our study through responding to our interview. An encouragement & support
we got from peer friends of our department students who sacrificed their delicious time to our purposive
dissertation are also played unforgettable event which enforces us to thank them all. Great is the exuded
contribution in which they played a community health role through! Lastly but not the least, every
individuals, groups, institutions, departments and others those who are not mentioned here are pillars of
our study through which we succeed in this study which has aimed to improve community health
problem. Hence, we say them all thanks a most!

III
Acronyms

ACE Angiotensin Converting Enzyme

AGH Assosa Health Center

AHA American Heart Association

AOR Adjusted Odds Ratio

ASU Assosa University

BMI Body Mass Index

BP Blood Pressure

CDC Centers for Disease Control and Prevention

CHD Coronary Heart Disease

CVA Cerebrovascular Accident

CVD Cardiovascular Disease

DBP Diastolic Blood Pressure

HCT Hydrochlorothiazide

HIV Human Immuno-Deficiency Virus

HR Heart Rate

HTN Hypertension

JNC Joint National Committee

IV
JUSH Jimma University specialized Hospital

LMI Low middle income countries

mmHg Millimeter of Mercury

MRFIT Multiple Risk Factor Intervention Trial

NCD Non-communicable diseases

NHANES National Health and Nutritional Examination Survey

NSAP National strategic action plan

OPD Out Patient Department

SBP Systolic Blood Pressure

SSA Sub-Saharan Africa

STEP STEPwise Approach to surveillance

TB Tuberculosis

USA United States of America

W.H.O World Health Organization

V
Table of Contents
Acknowledgements ...................................................................................................................................................III
Acronyms .................................................................................................................................................................. IV
List of Tables and figures ........................................................................................................................................ VIII
Executive summary .................................................................................................................................................. IX
1. INTRODUCTION ................................................................................................................................................. - 1 -
1.1. Statement of the problem............................................................................................................................ - 2 -
2. Literature Review .............................................................................................................................................. - 5 -
3. OBJECTIVES ........................................................................................................................................................ - 9 -
3.1. General objective ....................................................................................................................................... - 9 -
3.2. Specific objective ........................................................................................................................................ - 9 -
3.3. Significance of the study............................................................................................................................. - 9 -
4. METHODS & MATERIALS ................................................................................................................................. - 10 -
4.1. Study Area ................................................................................................................................................ - 10 -
4.2. Study design & period .............................................................................................................................. - 10 -
4.3. Population ................................................................................................................................................. - 10 -
4.3.1. Source population ............................................................................................................................. - 10 -
4.3.2. Study population ............................................................................................................................... - 11 -
4.4. Inclusion & exclusion criteria.................................................................................................................... - 11 -
4.4.1. Inclusion criteria ................................................................................................................................ - 11 -
4.4.2. Exclusion criteria................................................................................................................................ - 11 -
4.5. Variables ................................................................................................................................................... - 11 -
4.5.1. Dependent variable ........................................................................................................................... - 11 -
4.5.2. Independent variable ........................................................................................................................ - 11 -
4.6. Operational definitions............................................................................................................................. - 12 -
4.7. Sample size determination ....................................................................................................................... - 12 -
4.8. Sampling technique & sampling procedure ............................................................................................. - 13 -
4.9. Data collection procedure ........................................................................................................................ - 13 -

VI
 4.9.1. Data collection instrument ............................................................................................................... - 13 -
4.9..2. Data quality control ......................................................................................................................... - 14 -
4.9.3. Data processing and analysis ............................................................................................................. - 14 -
5. Ethical considerations.................................................................................................................................. - 15 -
6. Result ............................................................................................................................................................... - 16 -
6.1) Identified result ........................................................................................................................................ - 16 -
6.1.1 Socio demographic characteristics ........................................................................................................ - 16 -
6.2) Risk factors for hypertension ................................................................................................................... - 25 -
6.3) Strength and limitations ............................................................................................................................... - 27 -
6.3.1) Strength ................................................................................................................................................. - 27 -
6.3.2) Limitation .............................................................................................................................................. - 27 -
7) Discussion ........................................................................................................................................................ - 28 -
8) Conclusion ....................................................................................................................................................... - 29 -
9) Recommendation ............................................................................................................................................ - 30 -
10) References ..................................................................................................................................................... - 31 -
10) Assurance of principal investigator ............................................................................................................... - 34 -
Annex 1: English version informed consent form ........................................................................................... - 35 -
Annex 2: English version Questionnaire ......................................................................................................... - 36 -

VII
List of Tables and figures

Figure 1:conceptual framework ........................................................................................................9

Figure 1: Proportional allocation…………………………………………………………………...15

Table 1: Classification of BP………………………………………………………………………17

Table 2:Socio-demographic characteristics…………………………………………………………20

Table 3: Daily duration of time spent by sitting……………………………………………………22

Table 4: Frequency of daily eating both fruit and vegetable……………………………………….23

Table 5: Prevalence of HTN & DM with the complication of the HTN in the fgamily…………....25

Table 6: Frequency and percentage of disease complication of HTN……………………………..26

Table 7: Multivariate associations between socio-demography & family history of HTN with
hypertension…………………………………………………………………………………………27

VIII
Executive summary
Background:- Hypertension, the leading global risk factor for mortality and the third leading risk
factor for disease burden, is an increasing public health problem in sub-Saharan Africa. This study aims
to evaluate the prevalence & associated risk factors of hypertension among outpatients of Assosa general
hospital & Assosa health center.

Objective:- To assess the prevalence and associated risk factors among patients visiting outpatient
units of Assosa general hospital & Assosa health center, Benishangul Gumuz region, Assosa zone,
Assosa town, Western Ethiopia

Methods & materials:- Institutional based cross sectional study design with quota non-probability
sampling technique was conducted among patients visited OPD units of AGH and AHC from March to
June 2018. All outpatients was included. Pretested structured self-administered questionnaire was used
to collect socio-demography, genetic & family related factors, life style and comorbidity data. Data was
collected by face to face interviews using pre-tested structured questionnaire. SPSS version -20 software
was used to enter & analyze data. Descriptive statistics like frequency table, chi-square test of
independence & logistic regression was used to characterize disease and associated factors

Result:- The study was conducted among 194 participants (152 from AGH and 42 from AHC) with
102 males and 92 females. Prevalence of hypertension among patients visited outpatient units of Assosa
General Hospital and Assosa Health Center was 17.5%, and was slightly highest in male than female.
Independent risk factors for hypertension among patients visited OPD units of AGH & AHC was family
history of hypertension (CI=95% and COR=4.497(1.133-17.844) and being private employee (CI=95%
and COR=0.0017(0.001-0.407)

Conclusion & recommendation:- Prevalence of HTN was low and influenced by some risk
factors like work status and previous family history of hypertension. Even if usual usage of salt and
using vegetable oil was not associated factor, being non-government employee was independent factor
of HTN. Further study is needed to investigate it. To increase preventative methods of HTN, health
education supported by mass media and different posters is essential at different government & non
government work sector.

Key words: Prevalence, hypertension and associated risk factors

IX
1. INTRODUCTION
Hypertension means high pressure in the arteries (1). It is commonly known as high blood pressure.
Blood pressure is described by two values, pressure during systole (top value) and pressure during
diastole (bottom value). Normal blood pressure is between 90/60 mmHg and 120/80 mmHg. Blood
pressure between 120/80 mmHg and 139/89 mmHg is called pre-hypertension, and a blood pressure of
140/90 mmHg or above is considered high. An elevation of the systolic and/or diastolic blood pressure
increases the risk of developing heart disease, kidney disease, hardening of the arteries, eye damage, and
a stroke. These complications of hypertension are often referred to as end-organ damage because
damage to these organs is the end result of chronic high blood pressure. Most of the time hypertensive
people show no symptoms in the early stages, symptoms only manifest after end-organ damage. That is
why hypertension is described by some clinicians as a ‗silent killer‘. Symptoms that may occur include
chest pain, confusion, ear buzzing, irregular heartbeat, nosebleed, tiredness, headache and vision
changes. These symptoms are usually a result of end-organ damage and the presentation depends on the
organ that is affected (2).

For this reason, the routine screening of symptomatic individuals is critical in early diagnosis, treatment
and control of high blood pressure. Early diagnosis, treatment and optimum control of hypertension are
keys to reducing morbidity and mortality of hypertension related illnesses. Although the list of causes of
hypertension is endless, in more than 90 % of people with hypertension, the causes are not known and is
defined as ‗essential hypertension‘ (which means the cause of hypertension cannot be identified) (3).

Diagnosis of hypertension is made by the observation of persistently high blood pressure. This needs
accurate measurement of blood pressure on at least two different occasions, in each time the individual
is given enough time to relax. In very high blood pressure levels (SBP≥160 mmHg and/or DBP ≥100
mmHg) with evidence of target-organ damage only one reading is necessary to start on treatment (1,2).
Hypertension is an important public health challenge worldwide because of its high prevalence and
concomitant increase in risk of disease. In 2008, worldwide, approximately 40% of adults aged 25 and
above had been diagnosed with hypertension. According to the 2010 global non-communicable disease
status report, the number of people with the condition rose from 600 million in 1980 to 1 billion in
2008. Compared to the high income countries, Hypertension is more prevalent in low- and middle
income countries (LMIC). Globally nearly 9.4 million peoples dies every year due to high blood
pressure, and it is one of the most important causes of premature death (4). Complications and burden

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from raised blood pressure is also growing worldwide, affecting approximately one billion people, a
figure that is predicted to increases, especially in low, lower middle income countries than high income
countries(5). Across the WHO regions, the prevalence of raised blood pressure was highest in Africa,
where it was 46% for both sexes combined. In all WHO regions, men have slightly higher prevalence of
raised blood pressure than women. This difference was only statistically significant in the Americas and
Europe (6) .

Due to the fact that high priority is given to the investigation of communicable disease; in Ethiopia,
there is scarcity of data on prevalence and associated factors of hypertension in general population and
particularly among vulnerable groups who are predisposed to hypertension and other cardiovascular
disorder than general population. Thus the purpose of this study is to assess the prevalence and
associated risk factors of hypertension among outpatients of Assosa general hospital and Assosa health
center, Assosa town, Ethiopia.

1.1. Statement of the problem

It is estimated that nearly one billion people are affected by hypertension worldwide, and this figure is
predicted to increase to 1.5 billion by the year 2025 (6). Centers for Disease Control and Prevention
(CDC) estimates that 43 million people in the United States have hypertension or are taking
antihypertensive medication, which is almost 24% of the adult population. According to the World
Health Organization, non-communicable diseases constituted by cardiovascular diseases (including
hypertension), diabetes, cancers and chronic respiratory diseases are increasing to epidemic levels but
are not noticed or little attention is paid to them especially in the middle and low income countries (7).
Hypertension is the major risk factor for cardiovascular diseases (CVD) which are the major cause of
death in the developed countries. Multiple Risk Factor Intervention Trial (MRFIT) in the United States
data showed that the relative risk for coronary heart disease mortality varied from 2.3-6.9 times higher
for persons with mild-to-severe hypertension compared to persons with normal blood pressure and the
relative risk for stroke ranged from 3.6-19.2. The population attributable risk percentage for coronary
artery disease varied from 2.3-25.6%, whereas the population-attributable risk for stroke ranged from
6.8-40 (8)

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With urbanization, the problem of hypertension and other non-communicable diseases is growing
rapidly to epidemic levels in the developing countries. This invisible epidemic is an underappreciated
cause of poverty and hinders the economic development of many countries (9). Despite impacting the
poorest people in low-income parts of the world and imposing a heavy burden on socioeconomic
development, non-communicable diseases (NCD) prevention is currently absent from the Millennium
Development Goals. However, in all low and middle income countries and by any measure, non-
communicable diseases account for a large enough share of the disease burden of the poor to merit a
serious policy response (10). Contrary to common perception, non-communicable diseases affect
developing countries more than developed countries, World Health Organization estimates that about
80% of chronic disease deaths occur in low and middle income countries (11). After an assessment of
the evidence concerning hypertension in Sub-Saharan Africa in a systematic review of literature, Juliet
Addo Etal concluded that hypertension was of public health importance in sub-Saharan Africa,
particularly in urban areas and there was evidence of considerable under-diagnosis, treatment, and
control(12).

Prevention strategies such as promotion of physical activity, low salt diet (including regulation of salt
content in processed food), cessation of smoking, moderation of alcohol consumption and monitoring
and control of hypertension can be done at primary health center at reasonable cost compared to the
inpatient management of stroke, myocardial infarction, dialysis in case of renal failure or other
complications of hypertension (1). The increasing prevalence of hypertension is attributed to population
growth, ageing and behavioral risk factors, such as unhealthy diet, harmful use of alcohol, lack of
physical activity, excess weight and exposure to persistent stress(13). It is the most important modifiable
risk factor for cardiovascular, cerebrovascular and renal disease. The comparative Risk Assessment
Collaborating Group has identified hypertension as the leading global risk factor for mortality and as the
third leading risk factor for disease burden. Early diagnosis, treatment and strict control blood pressure
in hypertensive individual is not only cost-effective but also has potential for great impact on the
hypertension related morbidity and mortality. Hypertension share risk factors (unhealthy diet, physical
inactivity, tobacco use and harmful alcohol consumption) with other non-communicable diseases and
these can be monitored together and act as early warning signs for most non communicable disease
epidemic. Up to 80% of heart diseases and strokes can be prevented by eliminating the shared risk
factors (9). In high income countries, numerous studies have been conducted to estimate the prevalence
of hypertension. In some countries national studies have provided estimates of the prevalence of

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hypertension. It is estimated that, in Sub Saharan countries, hypertension causes to 7.5 million deaths,
among about 12.8% of the total annual deaths (14). Previously, there was no study conducted on the
Assosa general hospital (AGH) and Assosa health center (AHC) with the same population and topic.
Hence, this study has purposed to assess prevalence and associated risk factors of hypertension among
outpatients of Assosa general hospital and Assosa health center.

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2. Literature Review
The global prevalence of hypertension is estimated to be 30% of adult population, varying between
economically developed and developing countries and between rural and urban areas of the same
population. It is the third cause of disability adjusted life-years worldwide accounting for 13% of all
deaths globally (15). According to a systemic review of global burden of hypertension, the lowest
prevalence of hypertension was 3.4% in rural India and the highest was 72.5% in Polish women.
Developed countries had prevalence ranging between 20% and 50% while developing countries had
significantly lower rates, except for Zimbabwe (urban) which had rates comparable to the developed
countries (16)

A series of studies and surveys conducted by National Health and Nutrition Examination Survey
(NHANES) between 1976 and 2004 to assess the trends in hypertension prevalence, blood pressure
distributions and mean levels, and hypertension awareness, treatment, and control among US adults,
aged more than 18 years, showed that there was an increasing pattern of awareness, control and
treatment of hypertension, and that prevalence of hypertension was increasing reaching 28.9% as of
2004, with the largest increases among non-Hispanic women (17). The prevalence, awareness, treatment
and control of hypertension in the Jackson Heart Study in the United States were 62.9%, 87.3%, 83.2%
and 66.4% respectively (18).The results suggested that public health interventions were relatively
effective in increasing awareness and treatment among the study population, the African Americans. In
the U.S.As, essential hypertension has been associated with Family history of hypertension, an advanced
age, African-American race, obesity, inactivity, cigarette smoking, excessive salt intake and excessive
alcohol intake.

In a general population study in Turkey, 44% were found to be to be hypertensive with higher rates in
women (46.1%) than men (41.6%) (19). More than half of the hypertensive participants (54.5%) were
being treated for hypertension but only 24.3% of these had adequate control of the blood pressure (20).
This means that more than 85% of hypertensive participants were still at high risk of developing
hypertensive related morbidity and mortality. The prevalence of hypertension was found to be strongly
linked to age, with 16.9% and 84.4% of the age groups 20- 29 years and 60-69 years respectively being
hypertensive. Similar pattern was seen in Egypt in which the youngest age group (25 to 34 years)
hypertension was present in 7.8% of the population, where as the prevalence rate was 59.4% in the 65-
74 age group. However the overall prevalence of 26.3% was much lower than that in Turkey (44%). In

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Egypt, awareness, treatment and control of hypertension were at 37.5%, 23.9% and 8.0% respectively..
These figures are too low to have an impact on the morbidity and mortality of hypertension related
illness which is increasing in the developing countries. Hence public health interventions are needed to
increase awareness, treatment and control of hypertension (21).

In a study of the sex difference in the awareness and treatment of hypertension in France, women were
found to have a better awareness of hypertension than do men (69.8% and 51.8%) and their hypertension
was treated and controlled better (51.2% and 25.3% compared to 30.0% and 9.2% for treatment and
control in females and males respectively) (22).

Age, male gender, obesity (measured by BMI), low education level, non-smoking, family history of
hypertension, medical conditions, occupation and parity (in women) were found to be significant risk
factors for hypertension in Turkey (20). Optimum control of hypertension is the goal of pharmacological
and non-pharmacological interventions. In the United States, factors that were associated with good
control of hypertension were being married, having a health insurance, visiting the same health facility,
being seen by the same health care provider, having blood pressure checked in the preceding six months
and preceding 6-11 months and reported using lifestyle modifications (23). In the inter-ASIA study in
China, participants who were former smokers, overweight/obese, had higher income or their blood
pressure measured in the previous five years preceding the study were likely to be aware of their
hypertension. Current smokers, those who consumed alcohol or the less active participants were less
likely to be aware of their hypertension (24).

The burden of hypertension and other cardiovascular diseases is increasing in developing countries (25).
In Africa, hypertension is both the leading risk factor for CVD and the number one cause of death. The
increasing epidemics of hypertension and CVDs in Africa are important public health problems resulting
in a big economic impact. This is because a significant proportion of the productive population is
affected by hypertension and its complications (26). Almost three-quarters of people with hypertension
(639 million people) live in developing countries (with limited health resources) where people have a
very low awareness about hypertension and BP control. The prevalence of hypertension is increasing in
Africa rising from 19.7% in 1990 to 30.8% in 2010(13, 15). For example, in Nigeria, the prevalence of
hypertension ranges from 8%-46.4% depending on the study target population (27); in Zimbabwe, the
prevalence of uncontrolled hypertension is 67.2%. In Mozambique, prevalence, awareness, treatment
and control of hypertension were found to be 33.1%, 14.8%, 51.9%, 39.9% respectively with higher

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prevalence in men, higher awareness, treatment and control in women (25, 29). Hypertension. Unlike
Mozambique, Cameroon had considerably lower prevalence rates of 16.4% in men and 12.1% in women
in urban area and 5.4% and 5.9% in rural men and women respectively (30).

In sub Saharan Africa (SSA) countries like Ethiopia, published information on the prevalence of
hypertension is sparse. However, It is estimated to cause 7.5 million deaths and about 12.8% of the total
annual deaths (13). The Federal Ministry of Health of Ethiopia has committed to the prevention,
detection and control of non-communicable diseases, of which hypertension is among the leading, and
has produced a National Strategic Action Plan (NSAP) for Prevention and Control of Non
Communicable Disease in Ethiopia for the years 2014-2016 to tackle the problem (16). From the studies
done in Ethiopia, Kenya, Nigeria and Tanzania, the reported prevalence of hypertension ranged
from 10.1% in Southern Ethiopia to 23.7% in Tanzania (12). Previous reports from Ethiopia on
prevalence of hypertension were as high as 31.5% and 28.9% among males and females
respectively in Addis Ababa (Lim SS., et al. ―A comparative risk assessment of burden of disease and
injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic
analysis for the Global Burden of Disease Study 2010‖. Lancet380.9859 (2012): 2224-2260) and 28.3%
from Gondar(31).

1.3. Conceptual Framework

According to the American Heart Association (AHA) the level of blood pressure is determined by
genetic and familial factors, socio-demographic factors, lifestyle factors and genetic and family related
factors as shown on Figure 1 below.

Figure 1: Modifiable and non-modifiable determinants of the level of blood pressure

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 Lifestyle
diet, alcohol
consumtion,
cigarette,
smoking, physical
activity

Genetic & family

Prevalenc related factors
Socio-graphic e of BP Family history of
Age, sex, marital HTN and DM &
status,
educational comorbidity of
statuswork status other medical
,religion diseases

Genetic and family related factors:- Presence of a family member who had a history of raised
blood pressure and DM with their complications.

Socio-demographic factors:-Age, marital status, income, work status, educational status and
religion

Lifestyle factors:-Habits and behaviors that increase the risk of hypertension such as excessive
alcohol Consumption, cigarette smoking, sedentary life style, intake of high fat food, high salt diet, low
Intake of fruits and vegetables.

Co-morbidity:-Presence of medical disease or conditions such as diabetes mellitus, kidney disease

heart failure and other chronic diseases.

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3. OBJECTIVES

3.1. General objective

 To asses prevalence and associated risk factors of hypertension among patients visiting
outpatient unit of Assosa general hospital and Assosa health center, Assosa town, Ethiopia

3.2. Specific objective

 To determine prevalence of hypertension among patients visiting outpatient units of Assosa

general hospital and Assosa heath center, Assosa town.
 To identify risk factors associated with hypertension among patients visiting outpatient units of
Assosa general hospital and Assosa health center, Assosa town.

3.3. Significance of the study

This study was aimed to improve community health problem toward hypertension through it‘s serious
assessment of prevalence & risk factors associated with. The following points are indicators of necessity
of assessment of prevalence & associated risk factors of hypertension among outpatients of Assosa
general hospital & Assosa health center.

 For researchers; since there was no previously conducted study on that population with the
same topic. Hence, this research was used as footstep & base information for further study to be
done on a similar problem
 For health care provider; after careful assessment of prevalence & associated risk factors, it was
intended to provide brief health education regarding the hypertension & methods of prevention
within an available time & purposely communicate with local health institutions, concerning
NGO‘s & other related bodies to do their best upon the identified problem. It will identify
previous undiagnosed patients & link the cases to the hospital for further diagnosis & treatment
in order to prevent potential ‗silent killer‘ trait of hypertension.
 For policy makers; it is also used as avital to initiate governmental & non-governmental
organization to make and update policy based on the newly exposed shortages

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4. METHODS & MATERIALS

4.1. Study Area

This study was be conducted in Assosa General Hospital and Assosa health Center which is found in
Assosa town, capital city of Benishangul Gumuz regional state. Assosa town is located on the North
western of Ethiopia by the 675km distance from Finfinnee, capital of the country. It shares a boundary
with the Amhara region in the East, Sudan in North-East & Oromia region in the South. According to
mid-2008 census, population size of the Benishangul Gumuz regional state is 656,000 among which
90% are lived in the rural area. According to this census, Population size of Assosa zone is 310,822
among which 30,544 are population of the Assosa town.. Annual minimum and maximum temperature
of Assosa zone is 12.4 & 27.8 degree Celsius respectively. Benishangul Gumuz Region & Assosa
zone has area of 51,000 km 2 and 14, 1666 km2 respectively. About 75% of Assosa zone is classified
under low land (Kola) which is below 1500m above the sea level. Assosa region as well as Assosa zone
consists many ethnic groups like Berta, Gumuz, Mao-Komo, Boro-Shinash, Oromo, Amhara, Tigre,
SNNPS, and etc.

Assosa General Hospital was established in 1977 E.C as a central hospital for the peoples of
Benishangul Gumuz region, Peoples of West Oromia , and other neighboring peoples. Since its‘
establishment it has serving population of more than 750,000. Now, it has 22 Medical doctors, 96
nurses, 15 midwifes, 4 IESOs, 2 Anesthesia‘s, 2 Psychiatrics, 12 Pharmacicts and 3 general Specialists.
And it has 4 wards namely, Medical ward (30 beds), Surgical ward (24 beds), Pediatric ward (25 beds )
and Maternity ward (26 beds). It has also 13 OPDs which is serving averagely 300-500 outpatients daily.
Assosa Health Center was established in 1960 E.C & has 31 Nurses, 9 Midwifes, 5 HO, 3 Pharmacists
and 3 Medical doctors. It has 10 OPDs which is serving averagely 80 outpatients daily and serving more
than 30,000 populations.

4.2. Study design & period

An institution based cross sectional study was conducted at Assosa general hospital & Assosa health
center from March to June 2018

4.3. Population

4.3.1. Source population

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All patients of Assosa general hospital & Assosa health center during the study period.

4.3.2. Study population

All patients visiting outpatient units of Assosa general hospital & Assosa health center.

4.4. Inclusion & exclusion criteria

4.4.1. Inclusion criteria

All out patients aged 18 years or older attending the outpatient department of Assosa general hospital
and Assosa health center for various reasons during the study period was enrolled in to study
consecutively based on their willingness and eligibility to participate in the study.

4.4.2. Exclusion criteria

All out patients with severe and critical illnesses, acute life-threatening conditions, mental disorder and
severe injury, including patients with head injuries, were excluded from the study.

4.5. Variables
4.5.1. Dependent variable
Prevalence of hypertension

4.5.2. Independent variable

Socio-demographic factors: Like Age, sex, marital status, work status, work status, religion and
income

Genetic and family related factors: Presence of a family member who had a history of raised blood
pressure and DM with their complications

Lifestyle factors: Habits and behaviors that increase the risk of hypertension such as excessive alcohol
consumption, cigarette smoking, sedentary life style, intake of high fat food, high salt diet, low intake of
fruits and vegetables

Co-morbidity: Presence of medical disease or conditions such as diabetes mellitus, kidney disease heart
failure and other chronic diseases

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4.6. Operational definitions

 Hypertension: Is a condition in which arterial blood pressure is increased beyond it‘s normal
value i.e., above 140/90mmhg
 Physical activity: A condition in which body is move at least 10 minutes continuously to
increase breathing rate and heart beat.
 Prevalence: the number of all new and old cases of a disease or occurrences of an event during a
particular period. Prevalence is expressed as a ratio in which the number of events is the
numerator and the population at risk is the denominator.
 Risk factor: is a variable associated with an increased risk of disease or infection. Sometimes,
determinant is also used, being a variable associated with either increased or decreased risk.
.

4.7. Sample size determination

Sample size was determined by using Dobson formula.

Accordingly,

n =Z2Pq/∆2

Where, n = sample size

z = standard z score

p = prevalence of hypertension (proportion of people with hypertension)

q = 1-p (proportion of people without hypertension)

∆= absolute precision

Using this formula, taking confidence interval 95%(1.96), Proportion of hypertension 13.2% (0.132)
which was taken from hospital based cross sectional study conducted on Jimma university specialized
hospital (JUSH) (32) & margin of error as 0.05;

n = (1.96)2[0.132(1-0.132)]

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 (0.05)2
n=176

Assuming non-response rate as 10%, the final sample size would become,

n=176+17.6=194

4.8. Sampling technique & sampling procedure

Proportional allocation was made for each health institution and quota non-probability sampling
technique was used to include all patients visiting outpatient unit of AGH and AHC. Assosa general
hospital and Assosa health center has 23,867 and 6,608 registered patients respectively within past three
months which have highest patient flow.

Assosa General Assosa health

hospital center
23,867
patients,
6,608 patients, 194
42 samples
152 samples

4.9. Data collection procedure

4.9.1. Data collection instrument
Face to face questionnaire was composed of open-ended and close-ended questions which was
administered to collect data of socio-demography life style, genetic and family related factors &
presence of other medical diseases or condition. The questionnaire was prepared by the English
language and then translated to Amharic version as the most respondents are speaker of Amharic
language. Questions included in the questionnaire are adapted from World Health Organization STEP

- 13 -
wise approach to surveillance (STEPS) instrument for collecting data on Chronic diseases and their risk
factors. After the interview, the study participant was allowed to rest (relax) for 15 minutes then two
blood pressure measurements were taken three minutes apart in a sitting position. The blood pressure
was measured on the left upper arm. The participant was positioned in such a way that the left upper arm
was at the same level with the heart. To minimize measurement and inter observer variability, digital BP
machine was used throughout the study and all blood pressure measurements was done by one qualified
person.

4.9.2. Data quality control

After reviewing the literature the questionnaire was prepared first in English and then translated to local
language. Data collectors was instructed to check the completeness of each questionnaire whether
each and every question has been completely answered and the advisors was rechecked the
completeness of the questionnaire immediately after submission.

4.9.3. Data processing and analysis

Data was entered, cleaning & analyzing by using SPSS version-20. The raw data was handled carefully
from loosing of valuable data using computer password. Data cleaning was performed by running
frequency of each variable to check accuracy, inconsistency and missed value of the data. Before
analysis of the data, recoding of variables was conducted to make easy for analysis.

Descriptive statistics like frequency, mean and media with standard deviation to all variables which are
related to the objective of the study was computed. Binary logistic regression model was used to test
association between dependent and independent variables. The degree of association between dependent
and independent variables was assessed using odds ratio with 95% confidence interval or with respective
to p-value <0.05. Finally, data was presented in the form of text, tables and figures.

Averages of two systolic and diastolic blood pressure measurements was calculated and will used as
variables in the analysis. The classification on Table 2 was used to classify average systolic and diastolic
blood pressure.

- 14 -
Table 1: Classification of BP

Classification Systolic value(mmhg) Diastolic value(mmhg)

Hypotension <90 <60
Normal BP 90-119 60-79
Prehypertension 120-139 80-89
HTN stage 1 140-159 90-99
HTN stage 2 ≥160 ≥100

5. Ethical considerations
The study was conducted after getting ethical clearance from Assosa University, college of health
sciences, research coordinator. Support letter was obtained from Assosa University to B/G/ health
bureau, Assosa, Benishangul-Gumuz region and from B/G/ health bureau to the respective woreda
health office and AGH and then to health center. In addition, informed consent was obtained from study
participants to confirm willingness for their participation after explaining the objective of the study. For
the respondents it was notified that they have the right to refuse or terminate at any point of data
collection. The information provided by each respondent was kept confidential.

- 15 -
6. Result

6.1) Identified result

6.1.1 Socio demographic characteristics

Out of the 194, 102(52.6%) are male & 92(47.4) are females. Only 41(21%) was below 25 age and 79%
are above 25 age with maximum and minimum age of 72 and 19 respectively. Median of the age is 33,
mean age for the male and female are 39 and 34 respectively with the total mean of 37. most study
participant(58.8%) was married with the greater number of female(51.8%). All finding of socio-
demographic was described on the following table.

The socio-demographic characteristics of study are shown on the following tables

- 16 -
Table 2: Socio-demographic characteristics of patients visited outpatient unit of AGH AND AHC,
2018(n=194)

- 17 -
S Variable Frequency Percent
/
n
o
1 Educational level 1-8 13 27.3
9-12 39 20.1
University degree 44 22.7
Masters degree 11 5.7
Above masters degree 4 2.1242.7
None 83

2 Religion Orthodox\ 69 35.6

Protestant 59 30.4
Catholic 10 5.2
Muslim 56 28.9
3 Sex Male 102 52.6
Female 92 47.4
4 Monthly income 100-1000 40 20.6
1100-2000 47 24.2
2100-3000 54 27.8
3100-4000 28 14.4
4100-5000 14 7.2
>5000 11 5.7
5 Marital status Single 44 21.6
Married 114 58.8
Divorced 25 12.9
Separated-coexisted 11 5.7
Widowed 2 1

6 Work status Gov‘t employee 35 18

- 18 -
 Non-gov‘t employee 27 13.9
Self-employee 42 21.6
House wife 34 17.5
Peasant 27 13.9
Other 29 14.9
7 Age 18-25 41 21.1
26-33 57 29.4
34-41 31 16.0
42-49 24 12.4
≥50 41 21.1

6.1.2) Lifestyle

a) Alcohol consumption

Prevalence of alcohol consumption was 24.2%(47) with 33 males (70.2%) and 14 females(29.8%).
Median number of standard alcoholic drinks consumed per drinking occasion was 1. Number of
participants who had at least one heavy drinking episodes/month (≥5 standard drinks/day in males or ≥4
in females) was 31 (66%) and median number of heavy drinking episodes per month was 2. The
frequency of drinking alcohol was generally low. For more description see the following table.

b) Smoking

Prevalence of smoking was 2.6%. All current smokers were males. For current smokers, the median
duration of smoking was 3 years and the median number of duration of smocking was 1 hour. All
current smokers (5(2.6%)) was mostly using cigars.

c) Physical inactivity

The overall prevalence of current physical inactivity was 49.5% (96), with 45(46.9%) in male and
51(53.1% ) in female. Among 98(50.5%) that was physically active, 57(58.2%) was male and
41(41.8%) was female. Those 98 current physical active was doing vigorous vigorous intensity activity
that increases heart rate such as carrying or lifting heavy loads digging or construction work, moderate
intensity activity such as, walking or carrying light loads for at least 10 minutes per day continuously.
- 19 -
 These physical activity was practicable during both regular work and recreation. Daily duration of the
time spent was shown on the following table

Table 3: Daily duration of time spent by sitting among patients visited outpatient
units of Assosa General hospital and Assosa Health Center (n=194).
Duration of time(hour) Frequency Percent
1 27 13.9
2 75 38.7
3 69 35.6
4 15 7.7
5 1 0.5
6 2 1
7 3 1.5
8 2 1

d) Diet

Majority of the participant 120 (61.9%) was eating fruits and vegetables 2 times/day .. Prevalence of of
adding salt to the food was 90.2% (92 male) and (83 female). Regarding the type of usually using oil,
prevalence of usually using vegetable oil was high (63.9%). Frequency and percentage of diet was
described by the following table and pie chart

- 20 -
Table 4: Frequency of daily eating both fruit and vegetable among patients visited outpatient unit
of Assosa General Hospital and Assosa Health Center 2018,(n=194)
S/no Variable Daily frequency Frequency Percent
1 Daily < 1 time/day 6 3.1
frequency of 1 time/day 65 33.5
using table 2 time/day 120 61.9
salt ≥3 times/day 3 1.5
2 Number of Always 175 90.2
days using Not eat 19 9.8
table salt

- 21 -
- 22 -
6.1.3) Family history
Prevalence of family history of HTN was 35.1(68)% and prevalence of family history of DM was
17.1%(33). The following table shows prevalence and complication of Hypertension in the family.

Table 5: Prevalence of HTN & DM and complication of HTN in the family among patients visited Assosa
General Hospital and Assosa Health Center, 2018(n=194)
S/n Variable Frequency Percent
o
1 Family history of Yes 68 35.1
HTN No 126 64.9
2 Complication of Yes 23 11.9
HTN in the family No 171 88.1

3 Family history of Yes 33 17.1

DM No 61 83
4 Presence of HF 13 6.7
complication Stroke 2 1
diseases of HTN Kidney disease 7 3.6
Other 1 0.5
4 Family member who Father 14 7.7
have history of HTN Mother 21 11.2
Sibling of father 15 8.2
Sibling of mother 11 6.2
Child 1 1
Parent of father 5 3.1
Parent of mother 1 1
1 1

- 23 -
Prevalence of HTN

Prevalence of hypertension was 17.5%. Of these 17.5%, 18(52.9%) was male and 16(47.1%) was
a female. 22(64.7%) was diagnosed two years back, 8(23.5%) was diagnosed three years back and
4(11.77%) was diagnosed in this year. Among hypertensive patients, Prehypertension stage 1
HTN and stage 2 HTN accounted accounted 64.7%, 20.5% and 14,7% respectively.
Out these 34 hypertensive patients, 15(44%) had the following disease complications

Table 6: Frequency and percentage of disease complication of HTN among patients

visited OPD units of Assosa General Hospital and Assosa Health Center, 2018(n=194)
Diseases of hypertension complication Frequency Percent

Acute abdominal pain and HF 1 0.5

Acute gastritis 6 3.1
Asthma 1 0.5
DM 2 1.0
Gastritis, anemia, renal disease 1 0.5
Heart failure 1 0.5
HF & Kidney disease 1 0.5
psychotic disorder 1 0.5
renal diseases and gastritis 1 0.5

- 24 -
 6.2) Risk factors for hypertension

6.2.1. Socio-demgraphic factors and family history of HTN

Private employees were 0.0017 times likely to be hypertensive than government employee, Those who
have history of hypertension in their family were 4.497 more likely to be hypertensive than those who
have not family history of HTN. See the following table

Table 7: Multivariate association between Socio-demography and Family history of HTN with
HTN among patients visited outpatient unit of AGH and AHC, 2018(n=194)
Variable Hyperte Non- 95% CI 95%
nsive hypert COR AOR P-
ensive value
1 Work Gov‘t employee 5 30 1
Status Non-gov‘t employee 2 25 2.083(0.377-11.676) 0.415
Self-employee 11 31 0.470(0.146-1.5141) 0.783
Housewife 6 28 0.778(0.213-2.836) 0.681
Peasant 5 22 0.733(0.189-2.846) 0.996
Private employee 5 24 0.800(0.207-3.088) 0.0017(0.001-0.407) 0.012

2 Family
history Yes 20 48 0.300(0.204-1.178) 4.497(1.133-17.844) 0.033
of HTN No 14 112 1
3 Marital Single 3 39 1
status Married 23 91 0.304(0.086-1.073) 0.251
Divorced 5 20 0.308(0.067-1.420) 0.779
Separated & 2 9 0.346(0.050-2.386) 0.364
coexisting 1 1
widow 0.077(0.004-1.561) 0.629

- 25 -
4 Educati 1-8 grade 9 44 1
onal 9-12 grade 2 37 3.784(0.769-18.618) 0.996
st
status 1 Degree 9 35 0.795(0.285-2.217) 0.239
2nd degree 4 7 0.385(0.086-1.484) 0.559
>masters degree 1 3 0.614(0.057-6.591) 0.254
Illiterate 9 34 0.773(0.277-2.157) 0.337

5 Monthl 100-1000 5 35 1
y 1100-2000 9 38 0.603(0.184-1.974) 0.531
income 2100-3000 9 45 0.714(0.220-2.322) 0.315
3100-4000 3 25 1.190(0.260-5.446) 0.330
4100-5000 3 11 0.524(0.108-2.552) 0.413
>5000 5 6 1.171(0.038-0.778) 0.116
6 Age 19-25 3 38 1
26-33 4 53 1.046(0.221-4.997) 0.819
34-41 9 22 0.193(0.47-0.787) 0.162
42-49 5 19 0.300(0.065-1.3991) 0.329
≥50 13 28 0.170(0.044-0.654) 0.100

7 Using Yes 20 155 21.700(7.604-66.680) 0.996

salt No 14 5 1
8 Smokin Yes 2 3 0.306(0.049-1.904) 0.127
g No
32 157 1

9 Alcohol Yes 11 36 0.607(0.270-1.363) 0.909

drinkin No 23 124 1
g
1 Family Yes 9 24 0.490(0.204-1.178) 0.563
0 history No 25 136 1
of DM

- 26 -
6.3) Strength and limitations
6.3.1) Strength
 Primary data was used
 100% response rate was obtained
 Direct interview of questionnaire was carried out
 SPSS version-20 was used for data analysis

6.3.2) Limitation
 Time constraint
 lack of resource
 Number of alcohol drinkers and cigarrete smokers was not large enough to compare with
dependent variable
 Prevalence of complication disease of HTN was not large enough to compare with prevalence of
HTN

- 27 -
7) Discussion
The prevalence (17.5%) of hypertension among patients visited outpatient unit of Assosa General
Hospital and Assosa health center was higher than the prevalence reported in Cameroon 12.1% but
comparable to Tanzania which has prevalence of 23.7%(12) This may be due to family history of
hypertension. Regarding the sex difference, Like Mozambique and unlike Turkey, prevalence of
hypertension was higher in the male than in the female which was 52.9% (29), this slight difference may
be due to physical activity. Among Outpatients visited Assosa General Hospital and Assosa Health
Center, the prevalence of hypertension increased with age. This was the same as Turkey where then
prevalence of hypertension was found to be strongly linked to age, with 16.9% and 84.4% of the age
groups 20- 29years and 60-69 years respectively being hypertensive (20). Similar pattern was seen in
Egypt in which the youngest age group (25 to 34 years) hypertension was present in 7.8% of the
population, whereas the prevalence rate was 59.4% in the 65-74 age group (22). The increasing
prevalence of hypertension with age represents the biological effect of increased arterial resistance due
to thickening arterial wall that comes with age (3). In this study, Being private employee was one of the
significant factor for hypertension which may be related to high monthly income which will be
estimated to cause high consuming of vegetable oil and table salt. But in this study, high salt intake,
consuming vegetable oil and high monthly income were not statistically significant. Hence, there may be
some linkage factors behind high work status and prevalence of hypertension. It should need another
study. Even though it was not statistically significant, being married is another risk factor for HTN. This
suggests that there may be other factors that were not measured in this study such as psycho-social and
stress which may need to be explored by another study.

.
People who drink alcohol excessively (over two drinks per day) have a one and a half to two
times increase in the frequency of high blood pressure (hypertension). The association between
alcohol and high blood pressure is particularly noticeable when the alcohol intake exceeds five
drinks per day(33). In this study alcohol consumption was protective against hypertension though not
statistically significantly. It is well known that moderate alcohol intake reduce the risk of cardiovascular
diseases but excessive alcohol intake carries a risk of developing obesity, and subsequent cardiovascular
events. Because of the small number of people who consumed alcohol in this study, it was not possible
to stratify the amount of alcohol consumed and explore the effects of the different quantities consumed
on blood pressure.

- 28 -
The causal relation between habitual dietary salt intake and blood pressure has been established
through experimental, epidemiological, migration, and intervention studies(13), high although salt intake
a risk factor on bivariate analysis in this study, it was not a independent predictor for
hypertension. This may be because hypertensive patients were given advice to reduce salt intake
and as a result current salt intake may not be a good indicator. Even if salt content of the food prepared
at home can be reduced, it is estimated that about 80% of salt intake is in the form of processed food.
Hence, measurement of salt intake may not have been accurate and resulting in misclassification of salt
intake. Though physical inactivity was not statistical significance of this study, more than half of
physically inactive outpatients visited AGH and AHC was hypertensive. Accordingly, since prevalence
of physical inactivity was greater than of male, it may be estimated that future prevalence of
hypertension in female will be greater than of male in that population.
In this study, family history of hypertension was strongly associated with hypertension. This stresses the
importance of familial and genetic factors in susceptibility to hypertension and the need for regular
screening in this high risk group (8). The commonly reported family member were the mother of
participants and on stratified analysis, the association of hypertension and family history of hypertension
was stronger in males than males suggesting that inheritance of susceptibility to hypertension might be
linked to sex. However in hypertension prevention programs, more emphasis should be put on
behavioral factors which can be modified and yield greater impact than concentrating on familial and
genetic factors (12).

8) Conclusion
The prevalence of hypertension among patients visiting outpatient unit of Assosa General Hospital was
consistency with nearly one-fourth of that of U.S.A (Hypertension. 2008;51:650-656. 2008. American
Heart Association), ½ of that of Gondor(31) and twice of that of Southern Ethiopia(12). Prevalence was
higher in males than females and increased with age. The risk factors for hypertension were , family
history of hypertension and work status like being private employee.

- 29 -
9) Recommendation
The following recommendations was given for the Assosa General Hospital and Assosa Health Center to
Provide the following services:

 To conduct further study to identify associated factors that increase susceptibility of high work
status employee to be hypertensive.
 To provide health education on preventative methods of hypertension like decreasing salt in the
food, not using smoking, having regular body exercise.
 To set up a surveillance system for risk factors of hypertension which will be used to monitor
and evaluate health education and promotion activities.
 To provide the community recent information and update preventative strategy using posters,
medias and etc.
 Combining with the local NGO, to focus on the problem and initiate employees of every sectors
of work to direct their attention on associated risk factors of to prevent HTN and other related
Cardiovascular diseases and complication diseases .

- 30 -
 10) References
1) Sharma S, Kortas C. Hypertension. Emedicine. Available on URL
http://emedicine.medscape.com/article/241381-overview (Accessed 5 February 2018)
2) Hypertension. Wikipedia, the free encyclopedia. Available on URL
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018)
3) Fauci S, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL et al. Harrison‘s
principles of Internal Medicine. 17th Ed. The McGraw-Hill Companies. 2008
4) World Health Organization, Regional Office for South East Asia, World Health day (2013)
5) ) Katherine T Mills., et al. ―Global Disparities of Hypertension Prevalence and Control: A
Systematic Analysis of Population-Based Studies from 90 countries‖. Circulation 134.6(2016):
441-450
6) ) Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of
hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23 available on
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the Lebanese population—a national, multicentric survey—I-PREDICT. BMC Public Health.
2014;14(11):1–9. (PMC free article) (PubMed)( accessed 22 April 2018)
8) Department of Health and Human Services (US). The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. NIH
Publication No. 04-5230 August 2004 available on URL
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf (Accessed 5 February 2018)
9) World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention
and Control of Non-communicable Diseases. World Health Organization, 2008
10) Prevalence and Risk Factors for Hypertension among Bulawayo City Council Employees, 2010
11) Available on https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5120816/ (Accessed 28 April
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12) Addo J, Smeeth L, Leon DA. Hypertension in sub-Saharan Africa: a systematic review.
Hypertension. 2007; 50: 1012–1018. Available on URL
http://hyper.ahajournals.org/cgi/content/full/50/6/1012#R16-093336 (Accessed 7 February 2018)
13) Blood pressure. Wikipedia, the free encyclopedia. Available on URL
http://en.wikipedia.org/wiki/Blood_pressure (Accessed 6 February 2018)
14) WHO(2005) Preventing chronic diseases: a vital investment: WHO global report. Geneva,
Switzerland

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15) Misganaw A, Mariam DH, Ali A, Araya T. Epidemiology of major non-communicable diseases
in Ethiopia: A systematic review. J Heal Popul Nutr. 2014;32(1):1–13. (PMC free
article)(PubMed )(Accessed 23 April 2018)
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of Hypertension May Be Close to 30%. Medscape Cardiology. 2004;8(1) available on
http://www.medscape.com/viewarticle/471536_8 (Accessed 9 February 2018)
17) Leung Ong, Bernard MY, Man YB, Lau CP, Lam SK. Prevalence, Awareness, Treatment, and
Control of Hypertension Among United States Adults 1999–2004. Hypertension. 2007;49:69-75
18) Wyatt SB, Akylbekova EL, Wofford WR, Coady SA, Walker ER, Andrew ME, et al.Prevalence,
Awareness, Treatment, and Control of Hypertension in the Jackson Heart Study. Hypertension.
2008;51:650-656. 2008. American Heart Association.
19) World Health Organization, Regional Office for South East Asia, World Health day (2013)
20) Erem C, Hacihasanoglu A, Kocak M, Deger O, Topbas M. Prevalence of prehypertension and
hypertension and associated risk factors among Turkish adults: Trabzon Hypertension Study.
Journal of Public Health 2009 31(1):47-58; doi:10.1093/pubmed/fdn078. Journal of Public
Health Volume 31, Number 1 Pp. 47-58, 2009
21) 17) Ibrahim M, Rizk H, Appel LJ, Aroussy W,Helmy S, Sharaf Y et al. Hypertension
Prevalence, Awareness, Treatment, and Control in Egypt. Hypertension. 1995;26:886-890.
22) ) Marques-Vidal P, Arveiler D, Amouyel P, Bingham A, Ferrieres J. Sex differences in
awareness and control of hypertension in France. Meeting of the French Hypertension Society
No 16, Paris , FRANCE (12/12/1996) 1997, vol. 15, no 11, pp. 1345-1364
23) Jiang H, Muntner P, Chen J, Roccella EJ, Streiffer RH, Paul K. et al. Factors Associated With
Hypertension Control in the General Population of the United States. Archives of internal
medicine.Vol. 162 No. 9, May 13, 2002
24) Muntner P, Dongfeng G, Xiqui W, Duan X, Wenqi G, Paul K. et al. Factors Associated With
Hypertension Awareness,Treatment, and Control in a Representative Sample of the Chinese
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25) Mufunda J, Mebrahtu G, Usman A, Nyarango P, Kosia A, Ghebrat Y, et al. The prevalence of
hypertension and its relationship with obesity: results from a national blood pressure survey in
Eritrea. J Hum Hypertens. 2006;20:59–65. doi: (10.1038/sj.jhh.1001924) (PubMed)(Accessed 24
April 2018)
26) Van de Vijver S, Akinyi H, Oti S, Olajide A, Agyemang C, Aboderin I, et al. Status report on
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 of Ministers of Health on NCD‘s. The Pan African medical journal. 2013. (PMC free
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27) ) Falase AO, Stewart S, Sliwa K. Blood pressure, prevalence of hypertension and hypertension
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28) Goverwa TP, Masuka N, Tshimanga M, Gombe NT, Takundwa L, Bangure D, et
al. Uncontrolled hypertension among hypertensive patients on treatment in Lupane District,
Zimbabwe, 2012. BMC Res Notes [Internet]. 2014;7(1):703. (PMC free article) (PubMed)
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29) Damasceno A, Azevedo A, Silva-Matos C, Prista A, Diogo D, Lunet N. Hypertension
Prevalence, Awareness, Treatment, and Control in Mozambique Urban/Rural Gap During
Epidemiological Transition. Hypertension. 2009;54:77-83.
30) Lim SS., et al. ―A comparative risk assessment of burden of disease and injury attributable to 67
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Burden of Disease Study 2010‖. Lancet380.9859 (2012): 2224-2260.
31) ) Factors that contribute to High Blood Pressure. The American Heart Association. Available on:
http://www.americanheart.org/presenter.jhtml?identifier=4650 (Accessed 8 February 2018)
32) Prevalence of hypertension and its risk factors in southwest Ethiopia, done at Jimma University
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33) Global burden of hypertension may reach 1.5 billion by 2025. Medscape Public Health and
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134.6(2016): 441-450

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10) Assurance of principal investigator
This proposal is the original work of Ayalnesh Ambissa, Gelane Biratu & Lalisa M Gadisa, which was
presented for the requirement of the fulfillment of first degree program in bachelor science of nursing. It
has not been discussed elsewhere for another degree at this or any other university. The main tittle of
this study is assessment of prevalence and associated risk factors of hypertension among patients visited
outpatient unit of Assosa General Hospital & Assosa Health Center.

Name of investigators & advisors with their signature:

Ayalnesh Ambissa………………………………………………

Gelane Biratu…………………………………………………….

Lalisa M Gadisa…………………………………………………,

Name of Academic advisors…………………….

Date…………………………………………………………………

- 34 -
Annex 1: English version informed consent form

Dear participant,

This is research tittle named as ―Assessment of prevalence & risk factors associated with hypertension‖
which is aimed to conduct among patients Visited outpatient unit of Assosa General Hospital and
Assosa Health Center. It is intended to solve community health problem toward hypertension through
assessing prevalence & risk factors associated with it. After careful assessment, health education
regarding prevention of hypertension will be provided for the interested patients. This research is also
essential to initiate local NGO‘s and other concerned bodies to make related policies based on the new
findings & Assosa general hospital, to directly focus on that problem through focusing on identified
problem. Hence, you are due to respond our questionnaire & stay patiently while we do some physical
measurement throughout our study. If you find difficult to decide to participate, will never denied to not
to participate. If this is so, please tell us prior to start!

Thank you for your purposive participation and listening!

Are you willing to participate?

1. Yes = continue 2. No = thank you

Participant‘s Signature _________Date ____/___/____

Data collector‘s name __________________Signature _________Date ____/___/____

Advisor‘s name ____________________Signature __________Date____/____/___

- 35 -
Annex 2: English version Questionnaire

Questionnaire designed to assess prevalence & risk factors associated to hypertension

Our name is Lalisa M Gadisa, AyalneshAmbissa&GelaneBiratu. We are 4th year student of Bsc nursing
at Assosa University, college of health science, department of Nursing. We are carrying out a study on
high blood pressure among patients visited outpatient units of the Assosa general hospital & Assosa
Health Center. This involves asking you a number of questions on the risk factors for raised blood
pressure and taking measurement of your blood pressure. All the data collected will be treated with strict
confidentiality and anonymity. If you feel that you cannot continue participating in the study. You are
free to withdraw at any stage of the interview. The findings will give a better understanding of the
hypertension situation among admitted patients at the governmental health institutions which founds in
Assosa town. And also help in finding ways of addressing the hypertension problem in that region

 Are you volunteer to participate? 1) Yes 2) No

PART-1SOCIO-DEMOGRAPHIC CHARACTERISTIC

s/no Questions Options

1 How old are you? ……..year
2 What is your sex? 1=male, 2=female
3 What is your religion? 1=orthodox
2=protestant
3=catholic
4=muslim
5=other
4 What is the highest level of education you attained? 1=grade 1-8
2=grade 9-12
3=1st degree
4=2nd degree
5=above master degree
6=none

- 36 -
5 What is your marital status? 1=single
2=married
3=divorced
4=separated co-habiting
5=widowed
6 What is your current work status? 1=government
employee
2=non-government
employee
3=self-employee
4=house wife
5=peasant
6=private employee
7=student
7 What is your family‘s average monthly income? ………………birr
8 How many children do you have? ....... ……………….children

PART-2 LIFESTYLE

a) Alcohol

9 Have you ever consumed an alcoholic drink? 1=Yes, 2=No

10 In this year, how frequently have you had at least one alcoholic 1=daily
drink? 2=5-6 days per week
3=1-4 days per week
4=1-3 days per month
5=Less than once a
month
6=None

11 In this month, on how many occasions did you have at least one 1=Daily

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 alcoholic drink? 2=5-6 days per week
3=1-4 days per week
4=1-3 days per month
5=Less than once a
month 6= None

12 In this month, on average, how many alcoholic drinks do you 1=1-5 cups
drink on one drinking occasion? 2=6-10 cups
3=11-15 cups
4=16-20 cups
5=Above 20 cups
13 In this month, what was the maximum number of alcoholic ……………cups
drinks that you had on one drinking occasion?
14 In this month, how many times did you have 5 or more (4 or ………………time(s)
more for women) standard alcoholic drinks in a single drinking
occasion?

b) Smoking

15 Have you ever smoked any tobacco products? 1=yes, 2=No

16 Do you currently smoke any tobacco products, such as 1=yes, 2=No
cigarettes, cigars or pipes?
17 If stopped smoking, when you have stopped? ……………………
18 If yes to question 16, do you currently smoke tobacco products 1=Yes
daily? 2=No…..

19 If yes to Q18, for how long have you been smoking daily? ………………hour(s)
20 Most of the time which type of smoking do you use? a) Cigars ……..
b) Manufactured
cigarettes……….
c) Hand-rolled

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 cigarettes………..
d) others

Work

21 Does your work involve vigorous-intensity activity that causes

large increases in breathing or heart rate like (carrying or 1=Yes
lifting heavy loads, digging or construction work) for at least 2=No
10 minutes continuously?
22 If yes to the Q21, in a typical week, on how many days do you
do vigorous-intensity activities as part of your work? Number ………..day(s)
of day(s)
23 If yes to Q21, how much time do you spend doing vigorous- …..…….minutes
intensity activities at work on a typical day?
24 Does your work involve moderate-intensity activity, that
causes small increases in breathing or heart rate such as brisk 1=yes
walking [or carrying light loads] for at least 10 minutes 2=no
continuously?
25 If yes to Q24. in a typical week, on how many days do you do
moderate-intensity activities as part of your work?, ………..day(s)
26 If yes to Q24, how much time do you spend doing moderate-
intensity activities at work on a typical day? ………….minutes

c) Travel to and from places

27 Do you walk or use a bicycle (pedal cycle) for at least 10 1=Yes

minutes continuously to get to and from places? 2=No
28 If yes to Q27, in a typical week, on how many days do you
walk or bicycle for at least 10 minutes continuously to get to …………days
and from places?
29 If yes to Q27, how much time do you spend walking or

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 bicycling for travel on a typical day? …..minutes

d) Recreational activities

30 Do you do any vigorous-intensity sports, fitness or recreational

(leisure) activities that cause large increases in breathing or 1=Yes
heart rate like [running or football] for at least 10 minutes 2=No
continuously?
31 If yes to Q30, in a typical week, on how many days do you do
vigorous-intensity sports, fitness or recreational (leisure) ………..day(s)
activities?
32 If yes to Q30, how much time do you spend doing vigorous-
intensity sports, fitness or recreational activities on a typical ………..minutes
day?
33 Do you do any moderate-intensity sports, fitness or
recreational (leisure) activities that cause a small increase in
breathing or heart rate such as brisk walking, [cycling, 1=Yes
swimming, volley ball, etc] for at least 10 minutes 2=No
continuously?
34 If yes to Q33, in a typical week, on how many days do you do
moderate-intensity sports, fitness or recreational (leisure) ………..day(s)
activities?
35 If yes to Q33, how much time do you spend doing moderate-
intensity sports, fitness or recreational (leisure) activities on a …………minutes
typical day?
36 How much time do you usually spend sitting or reclining on a
typical day? (excluding sleeping) ………..hour(s)

e) Diet

37 In a typical week, on how many days do you eat fruits? ………….day(s)

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38 How often do you consume fruits and vegetables of all kinds 1= <1time /day
(fresh, canned, frozen, cooked, raw and juices)? 2= 1 time/day
3=2 times/day
4= >3times/day

39 How many servings of fruit do you eat on one of these days?

………………………
40 In a typical week, on how many days do you eat vegetables?
…………….day(s)
41 How many servings of vegetables do you eat on one of these Types of
days? fruit………………
42 On average, how many meals per week do you eat that were
not prepared at home? …………time(s)
43 How frequent do you eat food prepared by the following a) Boiling ………..
methods? b) Frying ………...
c) Grilling ……….
d) Stewing ………
e) Remove visible fat
before cooking…

44 In a typical week, how frequently do you add salt to your food

at the table? …………time(s)
45 In a typical week, how frequent do you eat the following a) Dried salted fish..
foods? b) Canned food ….
c) Dry salted nuts…
d) Bacon……….
e) Cheese……
f) Chips (if salt
added)……….
g) Ham………
h) Smoked meat and

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 fish……..

46 In a typical week, how frequently do you use the following a) Vegetable oil…..
oil/fat for preparing meals? b) Butter………….
c) Animal fat……..

PART-3 FAMILY HISTORY

47 Is there anyone from your family (father, mother or siblings) 1= Yes

who suffered or is suffering from hypertension? 2=No
48 If the answer is yes, who is this person? 1=Father 2=Mother
3=Father‘s sibling
4=Mother‘s sibling
5=Child 6=Father‘s
parents 7=Mother‘s
parents
8=Sibling‘s child
49 Is there anyone in your family who suffered from the a) Heart failure
following complications of hypertension? 1=Yes 2=No
b) Stroke
1=Yes 2=No
c) Kidney failure
1=Yes 2=No
d) Ischemic heart
disease i heart attack
1=Yes 2=No
e) Peripheral vascular

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 disease 1=Yes 2=no
50 If the answer is yes, who is this person? 1. Father
2. Mother
3. Sibling
4. Father‘s sibling
5. Mother‘s sibling
6. Child
7. Father‘s parents
8. Mother‘s parents
9. Sibling‘s child
51 52. Is there anyone from your family who suffered or is 1=Yes
suffering from diabetes? 2=No
52 If yes, which type of DM? 1=Type 1 DM
2=Type 2 DM
3=Not sure
53 If the answer is yes, who is this person? i. Father
ii. Mother
iii. Sibling
iv. Father‘s sibling
1= Mother‘s sibling
2= Child
3=Father‘s parents
4= Mother‘s parents
5= Sibling‘s child

54 Anyone from your family from had sudden death? 1=Yes

2=No
55 If yes to Q54, who was this person? 1. Father
2. Mother
3. Sibling
4. Father‘s sibling

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 5. Mother‘s sibling
6. Child
7. Father‘s parents
8. Mother‘s parents
9. Sibling‘s child
PART-4 HISTORY,COMPLICATION & CO-MORBIDITY OF HYPERTENSION

56 Have you ever been diagnosed of hypertension? 1=Yes, 2=NO

57 When was the last time you went to the clinic/your doctor for
any reason? Date…….
58 Was your blood pressure checked? 2= Yes 2=No
59 Have you ever been diagnosed of the following diseases? Heart failure
(Check medical records if available) 1=Yes 2=No
Periphral vascular
diseases
1=Yes 2=No
Renal disease
1=Yes 2=No
d) Ischemic heart
disease (heart attack)
1=Yes 2=No
e) Diabetes mellitus
1=Yes 2=No
60 If yes to any of the above diseases, was you on any treatment 1=Yes 2=No
of hypertension when you develop the complication?
61 Do you suffer from other chronic disease(s)/ condition(s)? 1=yes 2=no
62 If yes, what is(are) the diseases/conditions? …………

PART-5 MEASUREMENT OF OUTCOME VARIABLE

63 Measuring arterial blood pressure of the respondent BP=…………………

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 BP……………….

We would like to express our deep thank for you have patiently sacrificed your delicious time to our
purposive research….!!!

STAY BLESSED!!

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