KNOWLEDGE, ATTITUDE AND PRACTICE TOWARDS RISK …

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KNOWLEDGE, ATTITUDE AND PRACTICE TOWARDS RISK

FACTORS OF HYPERTENSION AMONG OUTPATIENTS AT

BUGESERA DISTRICT HOSPITAL

RUTAGENGWA Alfred

MPH/0342/13  

A Thesis Submitted in Partial Fulfillment for the Award of a Degree in

Master of Public Health (Epidemiology) of Mount Kenya University  

MARCH 2018  

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DECLARATION

This thesis is my original work and has not been presented to any other Institution. No part

of this thesis should be reproduced without the authors’ consent or that of Mount Kenya

University.

Students Name: Alfred Rutagengwa

Sign ____________________ Date _____________

Declaration by the supervisor(s)

This research has been submitted with my approval as The Mount Kenya University

Supervisor.

Name: Dr Erigene Rutayisire, PhD

Senior Lecturer, Mount Kenya University Rwanda, Public Health Department

Sign : …………………….. Date:…………………………

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DEDICATION

To my lovely wife and children, without your love and support, my dreams would never have

been reached.

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ACKNOWLEDGEMENT

In first instance, I thank the almighty God for what I am and for this achievement.

My special thanks go to MKU entire administration, the School of Health Science and in

particular to the Department of Public Health. The realization of this work is a result of their

combined efforts in one way or another.

I am very grateful to my supervisor Dr Erigene RUTAYISIRE, for the paramount role he

played throughout this research. He has always been available and committed to all necessary

assistance.

I am thankful to my whole family, especially my lovely wife and children for their

irremplaceable moral support during my studies.

My sincere thanks go to Ministry of Health and Belgian Technical Cooperation top

management for their sponsorship in my Masters studies and all persons who contributed to

make this study a success.

My thanks also go to Bugesera District Hospital entire administration and clinical staff for

accepting me to carry out this study by providing all necessary information.

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ABSTRACT

Currently hypertension is a growing public health problem in many developing countries including Rwanda. However, its knowledge among patients has not yet investigated in Rwanda. Therefore, the present study aims to assess the patient’s knowledge, attitude and practice towards risk factors of hypertension in Bugesera District Hospital. Patients knowledge, attitude, and practice are critical in controlling hypertension.Therefore, the findings of this study will provide evidence, which could be used to set up new long-term strategies to educate patients or community about poor health outcome related with hypertension. This study was conducted under descriptive cross-sectional research design by using quantitative approach. The target population in this study was outpatients who were seeking health care at Bugesera District Hospital during data collection period. Target population was 24515 outpatients who annually attend outpatient’s department of Bugesera district hospital. The sample size was estimated according to a standard method by using Cochran formula for single cross-sectional survey. Sample size for the current study was 340 outpatients from Bugesera District Hospital. A face-to-face structured questionnaire was used to collect data for all participants at the outpatient department. Data entry and analysis was done using SPSS. Prevalence of hypertension was estimated, knowledge, attitude and practices about hypertension were analyzed by looking hypertension threshold, hypertension risk factors, and complications as a result of hypertension. Logistic regression analysis was used to examine the lifestyle factors associated with hypertension. Odds ratio and 95% confidence intervals was estimated. Two-tailed p-values less than 0.05 was considered significant. The study was approved by Mount Kenya University. Written informed consent was obtained from all study participants. After data quality check and missing remove, out of 340 study participants, data from 272 outpatients from were used for analysis. Of them 77 (28.3%) were aged 26-35 years. The majority of respondents 172(63.2%) were female, 180(66.2%) married, and 207(76.1%) lived in rural area. The prevalence of hypertension was 22.1%. Lower knowledge about the risk factors of hypertension was strongly observed where 216 (79.4%) participants reported low knowledge on the risk factors of hypertension. 23.2% patients knew that stress or anxiety can increase the risk of hypertension. This finding showed that 44.9% of respondents had good attitude towards hypertension prevention measures. Respondents revealed that stress reduction, lifestyle change, regular medication, and regular BP measurement should be followed as hypertension prevention measures. Our study revealed significantly higher odds for hypertension among smokers and individuals with less physical activity as compared to high level of physical activity. Smoking [AOR=1.16; 95%CI: (1.26-2.65), p=0.025] and lack of physical exercises [AOR=2.48; 95%CI: (2.15-5.49), p=0.009] were significantly associated with increased risk of hypertension. Health facility programs that consider the identified risk factors might help the prevention of hypertension not only among patients but also entire community.  

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TABLE OF CONTENTS

Contents Page

DECLARATION ...................................................................................................................... ii

DEDICATION ......................................................................................................................... iii

ACKNOWLEDGEMENT ....................................................................................................... iv

ABSTRACT .............................................................................................................................. v

TABLE OF CONTENTS ......................................................................................................... vi

LIST OF TABLES ................................................................................................................... ix

LIST OF FIGURES .................................................................................................................. x

LIST OF ACRONYMNS AND ABBREVIATIONS .............................................................. xi

DEFINITION OF KEY TERMS ............................................................................................ xii

CHAPTER ONE: INTRODUCTION ....................................................................................... 1

1.0 Introduction ..................................................................................................................... 1

1.1Background of the study .................................................................................................. 1

1.2 Problem Statement .......................................................................................................... 3

1.3 Objectives of the Study ................................................................................................... 4

1.3.1 General objective ..................................................................................................... 4

1.3.2 Specific Objectives .................................................................................................. 4

1.4 Research Questions ......................................................................................................... 5

1.5 Significance of the Study ................................................................................................ 5

1.6 Limitations of the Study .................................................................................................. 6

1.7 Scope of the Study .......................................................................................................... 7

1.8 Organization of the Study ............................................................................................... 7

CHAPTER TWO: LITERATURE REVIEW ........................................................................... 8

2.0 Introduction ..................................................................................................................... 8

2.1 Theoretical Literature ...................................................................................................... 8

2.1.1 Hypertension ............................................................................................................ 8

2.1.2 Diagnosis and treatment of Hypertension .............................................................. 10

2.2 Empirical literature ....................................................................................................... 12

2.2.1 Prevalence and risk factors of hypertension in developed countries ..................... 12

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2.2.2 Prevalence and risk factors of hypertension in developing counties ..................... 13

2.2.3 Hypertension in East Africa ................................................................................... 15

2.2.4 Knowledge, attitude and practices on hypertension .............................................. 17

2.3 Critical Review and Research Gap identification ......................................................... 19

2.4 Theoretical framework .................................................................................................. 21

2.5 Conceptual framework .................................................................................................. 23

2.6 Summary ....................................................................................................................... 24

CHAPTER THREE: RESEARCH METHODOLOGY ......................................................... 26

3.0 Introduction ................................................................................................................... 26

3.1 Research Design ............................................................................................................ 26

3.2 Target population .......................................................................................................... 26

3.3 Sample design ............................................................................................................... 27

3.3.1 Sample size ............................................................................................................ 27

3.3.2 Sampling Techniques ............................................................................................. 28

3.4 Data collection Methods ............................................................................................... 28

3.4.1 Data Collection Instruments .................................................................................. 28

3.4.2 Administration of Data Collection Instruments ..................................................... 29

3.4.3 Validity and Reliability .......................................................................................... 30

2.5 Data Analysis Procedure ............................................................................................... 30

3.6 Ethical consideration ..................................................................................................... 31

CHAPTER FOUR: RESEARCH FINDINGS AND DISCUSSION ...................................... 32

4.0 Introduction ................................................................................................................... 32

4.1 Socio-demographic characteristics of respondents ....................................................... 32

4.2 Presentation of findings ................................................................................................ 35

4.2.1 Knowledge of hypertension among outpatients at Bugesera District Hospital ..... 37

4.2.2 Attitude towards hypertension control, treatment and prevention among

outpatients at Bugesera District Hospital ........................................................................ 39

4.2.3 Lifestyle practices associated with hypertension .................................................. 41

4.3 Discussion ..................................................................................................................... 43

CHAPTER 5: SUMMARY, CONCLUSION AND RECOMMENDATION ........................ 47

5.0 Introduction ................................................................................................................... 47

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5.1 Summary of the findings ............................................................................................... 47

5.1.1 Knowledge about hypertension risk factors ........................................................... 47

5.1.2 Attitude towards hypertension prevention ............................................................. 48

5.1.3 Lifestyle practices associated with hypertension ................................................... 48

5.2 Conclusion .................................................................................................................... 48

5.3 Recommendations ......................................................................................................... 49

REFERENCES ....................................................................................................................... 50

APPENDICES ........................................................................................................................ 57

Appendix 1: Informed consent form ................................................................................... 58

Appendix 2: Medical Examination ..................................................................................... 60

Appendix 3: Questionnaire ................................................................................................. 61

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LIST OF TABLES

Table 4. 1: Socio-demographic characteristics of respondents ............................................... 32

Table 4. 2 : Ever heard and knowledge about hypertension measurement ............................. 37

Table 4. 3: Knowledge about the risk factors of hypertension ............................................... 38

Table 4. 4: Attitude towards hypertension control and treatment ........................................... 40

Table 4. 5: Attitude towards hypertension prevention measures ............................................ 41

Table 4. 6: Unadjusted analysis of lifestyle practices/factors associated with hypertension .. 42

Table 4. 7: Adjusted analysis of lifestyle practices/factors associated with hypertension ..... 43

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LIST OF FIGURES

Figure 2. 1: Conceptual framework ........................................................................................ 23 Figure 4. 1: Prevalence of Hypertension among outpatient at Bugesera District Hospital .... 35

Figure 4. 2: Sex and age specific prevalence of hypertension ................................................ 36

Figure 4. 3: Consider hypertension as serious disease ............................................................ 39

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LIST OF ACRONYMNS AND ABBREVIATIONS  

AHA American Heart Association

BMI Body mass index

BP Blood pressure

CDC Center for disease control and prevention

CDV Cardiovascular diseases

CI Confidence interval

CVI Content Valid index

DBP Diastolic blood pressure

DM Diabetes mellitus

HTN Hypertension

JNC-7 Joint National Committees-7

KAP Knowledge, Attitude and Practice

LMIC Low and Middle Income Countries

MKU Mount Kenya University

NCD None Communicable Diseases

NHANE National Health and Nutrition Examination Survey

OR Odd ratio

SBP Systolic blood pressure

SSA Sub-Saharan Africa

SPSS Statistical package for social science

WHO World Health Organization

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DEFINITION OF KEY TERMS  

Hypertension refers to a blood pressure of 140/90 mmHg or more, based on at least two

readings on separate occasions.

Outpatient refers to a patient who comes to Bugesera District Hospital for diagnosis or

treatment but is not admitted for an overnight stay.

A heart disease is a number of abnormal conditions affecting the heart and the blood vessels

in the heart.

Knowledge refers to understanding of or information about hypertension that a person get

from media, community or life experience.

Attitude refers to a set of emotions, beliefs, and behaviors toward risk factors of

hypertension.

Practice refers to the action or process that a person doing to prevent or control

hypertension.

Risk factor refers to the variables associated with an increased risk of hypertension for a

patient with or without hypertension

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CHAPTER ONE: INTRODUCTION  

1.0 Introduction

The present study investigated the knowledge, attitude and practices towards the risk factors

of hypertension among outpatients at Bugesera District Hospital, Rwanda. Chapter one

describes the background of the study, problem statement, objectives, research questions,

significance of the study, limitations, scope of the study and the organization of the study.

1.1Background of the study    

Cardiovascular disease is the leading cause of death in both industrialized and developing

nations and high blood pressure is a major independent risk factor for cardiovascular disease

and stroke; indeed, 5.8% of all deaths in western countries are directly linked with

hypertension (Lozano, et al., 2012; Rohla, et al., 2016). Globally, 80 % of cardiovascular

disease (CVD) mortality occurs in low- and middle-income countries (LMIC)(Lopez, et al.,

2006). A report from World Economic Forum suggested that non-communicable diseases

(NCD), such as CVD, are a severe threat to global economic development due to the long-

term costs of treatment and the negative effects on productivity (Bloom DE, 2011). The

burden of NCD is expected to increase substantially in LMIC and to represent a greater

burden of disease compared to communicable diseases by 2030 (Mathers & Loncar, 2006)

and the most common form of CVD is hypertension.  

Hypertension is one of the five chronic diseases (psychological illnesses, diabetes, heart

disease, asthma), which are responsible for half the expenditure of the health system. With

the fact that most hypertensive patients are asymptomatic, makes this disease called the silent

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killer. Previous report from World Health Organization (WHO) estimated 972 million people

with hypertension in the year 2000. Of them 65% lived in developing world with the number

predicted to grow to 1.5 billion by 2025 (WHO, 2013). Specifically, in 2008, worldwide,

approximately 40% of adults aged 25 and above had been diagnosed with hypertension; the

number of people with the condition rose from 600 million in 1980 to 1 billion in 2008.The

prevalence of hypertension is highest in the African Region at 46% of adults aged 25 and

above, while the lowest prevalence at 35% is found in the Americas (WHO, 2011).

The increasing prevalence of hypertension (HTN) and associated burden on the population

and health systems in sub-Saharan Africa (SSA) coincides with socio-economic changes and

the ‘nutrition transition’ associated with poverty alleviation, this have been led to the shift in

increase from communicable to non-communicable diseases (Kuller, 2007).   The

epidemiological transition from communicable to non-communicable diseases could partially

be explained by the rapid urbanization with changes in lifestyles, especially dietary habits

and lack of physical activity among individuals of medium to high socio-economic status in

urban areas. Several risk factors for hypertension have been well documented including age,

gender, ethnic origin, diet, stress, sedentary lifestyle, degree of urbanization, family history,

blood cholesterol, diabetes mellitus, pre-existing vascular diseases (de Ramirez, et al., 2010).  

In Africa as well as in Rwanda, the shift of many people from rural to urban areas has

rendered hypertension an epidemic and with it comes “the burden of civilization”. The

modifiable risk factors associated with hypertension in the group of people from medium to

high socioeconomic status include obesity, smoking, lowered physical activity, high alcohol

consumption and hyperglycemia and are attributed to increased life expectancy, urbanization

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and its associated lifestyle changes characteristic of economic progress in developing

countries (Akinlua, et al., 2015).

Previous study conducted in Rwanda among 100 adults aged 27 to 67 years at an urban

tertiary education institution in Rwanda showed that 36 participants were classified as being

hypertensive, giving a crude prevalence of 36%. Of these only 3% were aware of their

hypertensive status, 33% were not aware (Banyangiriki & Phillips, 2013). The increasing

prevalence of hypertension in Rwanda is of great concern. Assessment of knowledge,

attitudes, and practices (KAP) is a crucial element of hypertension control, but little

information is available from developing countries including Rwanda where hypertension

has lately been recognized as a major health problem. Therefore, the present study will

investigate the knowledge, attitude and practices towards risk factors of hypertension among

patients at Bugesera District Hospital.

1.2 Problem Statement

Hypertension has become a significant problem in Rwanda like in any other developing

countries experiencing epidemiological transition from communicable to non communicable

chronic diseases (Tibazarwa & Damasceno, 2014). The emergence of hypertension and other

CVDs as a public health problem in these countries is strongly related to the aging of the

populations, urbanization, and socioeconomic changes favoring sedentary habits, obesity,

alcohol consumption, and salt intake, among others (Bener & Saleh, 2013; Tavassoli, et al.,

2011). Many studies have demonstrated that knowledge and attitudes toward NCDs and risk

factors as well as healthy living practices are associated with CVD morbidity and mortality

(Oguoma, et al., 2014; Tibazarwa & Damasceno, 2014).

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The effect of inadequate knowledge, attitudes, and practice regarding hypertension and its

prevalence has been reported in many studies but not in Rwanda. A KAP study on

hypertension in Seychelles concluded that participants had good knowledge, but attitudes and

practices toward healthy lifestyle were inadequate (Aubert, et al., 1998).

The level of awareness of hypertension is relatively low in Rwanda. One study conducted in

Rwanda showed that more than 33% of Rwandan did not have enough knowledge about

hypertension (Banyangiriki & Phillips, 2013). Studies on the knowledge, attitude and

practice towards hypertension among outpatients in Rwandan hospitals are lacking.

Therefore, the present study will assess the patient’s knowledge, attitude and practices

towards risk factors of hypertension in Bugesera District Hospital.

1.3 Objectives of the Study

1.3.1 General objective

To assess the patient’s knowledge, attitude and practice towards risk factors of hypertension

in Bugesera District Hospital.

1.3.2 Specific Objectives

(i) To assess the knowledge of hypertension among outpatients at Bugesera District

Hospital

(ii) To evaluate the attitude towards hypertension control, treatment and prevention

among patients at Bugesera District Hospital

(iii) To explore the lifestyle practices about the risk factors of hypertension among

outpatients at Bugesera District Hospital.

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1.4 Research Questions

The present study tried to respond to the following questions:

(i) What is the knowledge of hypertension among outpatients at Bugesera District

Hospital?

(ii) What are the attitude towards hypertension control, treatment and prevention among

patient’s at Bugesera District Hospital?

(iii) What are the lifestyle practices associated with hypertension among outpatients at

Bugesera District Hospital?

1.5 Significance of the Study

The present study assessed the knowledge, attitude and practice towards risk factors of

hypertension among outpatients at Bugesera District Hospital.

As a clinician at Bugesera District Hospital, after long-term observation on the increased

number of people with hypertension attending Bugesera District Hospital, I decided to

conduct this study in order to investigate the level of knowledge, attitude and practice

towards risk factors of hypertension among outpatients at Bugesera District Hospital.

Moreover, this study improved my research methodology and other skills related to research.

Improved knowledge of the effects of hypertension in an individual, family, society that I

gained from the present study can help me to suggest evidence based strategies in

hypertension prevention and control.

The findings from this study will be used by the management of Bugesera district Hospital to

improve or set new strategies to educate people about the hypertension and its risk factors.

Also, the present study report the prevalence and risk factors associated with the increase of

hypertension in Bugesera District, this information will help to reduce hypertension

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prevalence. During the data correction patients were allowed to ask more questions about

hypertension, therefore, study participants were aware on the role of weight reduction,

reduction of heavy alcohol intake, salt restriction, regular physical exercises, and avoid

smoking for the patient with or without hypertension.

The results from this study generated useful information about the patients’ knowledge,

attitude and practice towards risk factors of hypertension among outpatients at Bugesera

district which can be used as literature for further studies. Future researcher in this field may

investigate the KAP of several cardiovascular diseases among patients from several health

facilities in Rwanda.

The results will for sure provide necessary information which shall be used by Rwanda

Ministry of Health to set new policy or strategies towards the reduction of prevalence of

hypertension in general population. Today, there is no study conducted in any district

hospital in Rwanda reported the KAP of outpatients about the risk factors of hypertension in

Rwanda. Therefore, the findings of this study provide evidence, which could be used to set

up new long-term strategies to educate patients or community the poor health outcome

related with hypertension.

1.6 Limitations of the Study

The present study was conducted in one district hospital with a limited sample from

outpatient at Bugesera district Hospital, therefore from that reason and other methodological

aspects used in this study, the results from the present study were generalized to the whole

Rwandan. This study only involves patients who have accepted to participate. It will not

involve healthy hospital health care employees or other persons who come to hospital for

other purposes. Inpatients were not included in the study. Furthermore, as other observational

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study, this cross-sectional study does not provide information about cause-and-effect

relationships.

1.7 Scope of the Study

This study was conducted among outpatients attending Bugesera District Hospital located in

Bugesera District, Eastern Province, Rwanda.

After examining the prevalence of hypertension the study focus on knowledge, attitude and

practices towards risk factors of hypertension for both patients with or without hypertension.

Several previous studies investigated the patients’ knowledge; attitude and practice towards

the risk factors of hypertension were consistently reviewed. The rationale behind this study is

to sensitize people to be aware of risk factors of hypertension in the context of prevention

and control. This was designed and manuscript writing started from 2014. The data was

carried out from April 2017 to June 2017, while data analysis was carried out from June-July

2017. 1.8 Organization of the Study

This research proposal is divided into five chapters, chapter one presents introduction of the

study with deep explanation on the rationale of the study. Chapter two presents the review of

related literature including theoretical, empirical literature as well as conceptual framework.

Chapter three describes the research methodology by discussing research design, target

population, sample design, data collection methods, data analysis procedure and ethical

consideration. Chapter four presents study findings and discussion while chapter five focus

on summary, conclusion and recommendations.

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CHAPTER TWO: LITERATURE REVIEW

2.0 Introduction

This chapter deals with literature related to the knowledge, attitude and practices towards risk

factors of hypertension among outpatients at Bugesera District Hospital. It includes the

theoretical literature, empirical literature, critical review and research gap identification,

theoretical framework, conceptual framework and summary ok key points was discussed in

this chapter.

2.1 Theoretical Literature

Hypertension has become a significant public health problem in both developed and

developing countries. Hypertension as major CVDs in many developing countries is strongly

related to the aging of the populations, urbanization, and socioeconomic changes favoring

sedentary habits, obesity, alcohol consumption, and salt intake, among others. A cost-

effective use of health services to control these emerging chronic diseases is particularly

needed in developing countries because resources are limited and generally must be shared

with the concurrent burden of persistent communicable diseases.

2.1.1 Hypertension

Hypertension is defined as having a blood pressure higher than 140 over 90 mmHg. With a

consensus across medical guidelines.Blood pressure is the force exerted by the blood against

the walls of blood vessels, and the magnitude of this force depends on the cardiac output and

the resistance of the blood vessels(Kaplan, 2005).

Blood  pressure  is  measured  in  millimeters  of  mercury  (mm  Hg)  and  is  recorded  as  two  

numbers   usually   written   one   above   the   other. The upper number is the systolic blood

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pressure - the highest pressure in blood vessels and happens when the heart contracts, or

beats. The lower number is the diastolic blood pressure - the lowest pressure in blood vessels

in between heartbeats when the heart muscle relaxes (August, 2004). Normal adult blood

pressure is defined as a systolic blood pressure of 120 mm Hg and a diastolic blood pressure

of 80 mm Hg. However, the cardiovascular benefits of normal blood pressure extend to lower

systolic (105 mm Hg) and lower diastolic blood pressure levels (60  mmHg).Normal  levels  

of  both  systolic  and  diastolic  blood  pressure  are  particularly  important  for  the  efficient  

function  of  vital  organs  such  as  the  heart,  the  brain  and  kidneys  and  for  overall  health  

and  wellbeing((Cushman, 2001).

Blood is carried from the heart to all parts of the body in blood vessels. Each time the heart

beats, it pumps blood into the vessels. Blood   pressure   is   created   by   the   force   of   blood  

pushing   against   the   walls   of   blood   vessels   (arteries)   as   it   is   pumped   by   the   heart  

Hypertension,  also  known  as  high  or  raised  blood  pressure,  is  a  condition  in  which  the  

blood  vessels  have  persistently  raised  pressure. The higher the pressure in blood vessels

the harder the heart has to work in order to pump blood. If left uncontrolled, hypertension can

lead to a heart attack, an enlargement of the heart and eventually heart failure. Blood vessels

may develop bulges (aneurysms) and weak spots due to high pressure, making them more

likely to clog and burst. The pressure in the blood vessels can also cause blood to leak out

into the brain. This can cause a stroke. Hypertension can also lead to kidney failure,

blindness, rupture of blood vessels and cognitive impairment (Thomopoulos, et al., 2015).

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2.1.2 Diagnosis and treatment of Hypertension

Diagnosis of high blood pressure is usually measured with a device called

sphygmomanometer which is the familiar upper-arm cut device. This consist of an inflatable

rubber cuff, an air pump and a column of mercury or a digital readout reflecting pressure in

an air column as well as electronic blood pressure machines. The readings are widely

expressed in millimeters of mercury or mmHg. Diagnosis of high blood pressure is not based

on a single reading except when it is extremely high (Sarafidis & Bakris, 2008). An  isolated  

high  reading  is  not  taken  as  proof  of  hypertension.  Rather,  diagnosis  can  be  made  after  

elevated  readings  are  taken  on  at  least  three  separate  days.  

The   reliability   of   blood   pressure   readings   may   be   improved   by   having   a   patient   or  

someone   else   take   a   series   of   measurements   outside   the   doctor’s   office   using  

standardized   devices.   In   addition   to   measuring   blood   pressure   using  

sphygmomanometry,   a   clinician   take   patient   history   by   asking   questions   about  

cardiovascular   problems   and   do   a   physical   examination   before   diagnosing  

hypertension.These  questions  and  additional  tests  can  help  to  identify  the  cause  of  high  

blood  pressure  and  determine  whether  there  have  been  any  complications.Such     tests  

may   include   urine   tests,   kidney   ultrasound   imaging,   blood   tests,   an  

electrocardiogram(ECG)  and/or  an  echocardiograph  (Rau  &  Rao,  2015).  

 American Heart Association (AHA) defines the following ranges of blood pressure (in

mmHg): Normal blood pressure is below 120 systolic and below 80 in diastolic,

Prehypertension is 120-139 systolic or 80-89 diastolic, Stage 1 high blood

pressure(hypertension) is 140-159 systolic or 90-99 diastolic, Stage 2 high blood

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pressure(hypertension) is 160 or higher systolic or 100 or higher diastolic and Hypertensive

crisis (a medical emergency ) is when blood pressure is above 180 systolic or above 110

diastolic (AHA, 2015). However, medical experts consider high blood pressure as having a

continuous relationship to cardiovascular health.They believe that , to a point , the lower the

blood pressure the better (down to levels of 115-110 mmHg systolic, and 75-70 mmHg

diastolic)(Thomopoulos, et al., 2016).

Primary  hypertension  is  unlikely  to  have  a  specific  cause  but  is  instead  usually  a  result  

of  multiple  factors,  including  blood  plasma  volume  and  activity  of  the  renin-­‐angiotensin  

system,  the  hormonal  regulator  of  blood  volume  and  pressure.Primary  hypertension  is  

also   influenced  by  environmental   factors,   including   lifestyle-­‐related   issues  as  outlined  

above.One  example,  now  thought  to  be  one  of  the  most  common  causes  of  treatment  –

resistant   hypertension,   is   primary   aldosteronism,   a   hormone   disorder   causing   an  

imbalance  between  potassium  and  sodium   levels,   thus   leading   to  high  blood  pressure  

(Paiva,  et  al.,  2012).  

Lifestyle changes are important for both treatment and prevention of high blood pressure, and

they can be as effective as a drug treatment. These lifestyle changes can also have wider

benefits for heart health and overall health. The lifestyle measures shown to reduce blood

pressure and recommended by experts include: salt restriction, moderation of alcohol

consumption, high consumption of vegetables and fruits and low-fat, reducing weight and

maintaining it, regular physical exercise as well as stress reduction. In addition to these

factors, previous studies revealed that smoking can also raise blood pressure, and because of

its wider effects on heart health and the rest of the body, giving up smoking is highly

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recommended for people with high blood pressure (Dickinson, et al., 2006; James, et al.,

2014).

2.2 Empirical literature

The number of people living with hypertension is predicted to be 1.56 billion worldwide by

the year 2025. In the US. Around 75 million people have hypertension, with more people

dying of hypertension-related cardiovascular disease than from the next three deadliest

diseases combined.In 2011-2012 in the US, about a third of all people over the age of 20

years had hypertension(CDC, 2013).The prevalence of hypertension in Africa ranged from

2.3 to 41.1% among rural populations (Ataklte, et al., 2015). In both developed and

developing countries, the increasing prevalence of the hypertension is blamed on lifestyle

and dietary factors, such as physical inactivity, alcohol and tobacco use, and a diet high in

sodium.

2.2.1 Prevalence and risk factors of hypertension in developed countries

In the last two decades the prevalence of hypertension was estimated as 59 million among

US adults. There were an additional 6 million persons twice told, yielding a total estimate of

65 million persons based on the National Health and Nutrition Examination Survey

(NHANES) 1999–2000 data. There was an 8.3% relative increase in the prevalence rate

during the 1990s, partially attributable to the epidemic of overweight and obesity occurring

in the United States during the past 2 decades.  The most recent National Health and Nutrition

Examination Survey indicate that only about 30% of individuals with hypertension have their

BP controlled (Cutler, et al., 2008).

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Several studies conducted in US reported that the age-standardized prevalence rate of

hypertension increased from 24.4% to 28.9%, with the largest increases among non-Hispanic

women. Although Healthy People 2010 has established a target of 50% for hypertension

control. The prevalence of hypertension in the United States is increasing despite increased

awareness of the importance of controlling blood pressure (CDC, 2015). The growing

prevalence of obesity is a major factor in the increased prevalence of hypertension; the aging

of the population is another factor. It is well known that age, weight, and ethnicity are strong

predictors of hypertension. Several investigators demonstrated that hypertension prevalence

is higher among African Americans than it is for any other race/ethnic group in the US

(Crim, et al., 2012; Solomon, et al., 2015).

The prevalence of hypertension in China is witnessing an ascending trend since 1992. From

1992 to 1994 the prevalence rate was at 22.7%, and in 1998 the prevalence rate reached to

24.0% (Z. Wang, et al., 2004). Overall prevalence of hypertension in 2014, it was reported

that the prevalence of among Chinese adults population (aging 35 to 74 years) has increased

to 27.4% and specifically increased up to 48.8% among people older than 65 years (X.

Wang, et al., 2014)

The higher prevalence of hypertension was also noted in Europe, for example in Spain, the

prevalence of hypertension is about 35% in the adult population and 60% in people older

than 60 years (Ho, et al., 2016); in Austria, approximately 25–30% of the adult population

have been diagnosed with hypertension (Rohla, et al., 2016).

2.2.2 Prevalence and risk factors of hypertension in developing counties

The prevalence of hypertension is increasing rapidly in developing countries mainly due to

the social and economic changes taking place in many developing countries including

14    

Rwanda. This socioeconomic changes influence the pace at which hypertension and its risk

factors are expanding. Substantial evidence suggests an increasing burden of hypertension in

Africa. However, data on HTN prevalence in Africa are sparse. The prevalence of

hypertension in Africa ranges from 29.7% in Cameroon (Kingue, et al., 2015) to 47% in

South Africa (Steyn, et al., 2001). Only 10% receive treatment in Cameroon while 32% are

on medications in Ghana (Agyemang, et al., 2006).

In a cross-sectional study conducted in Malawi, Rwanda and Tanzania with more than 1485

participants aged above 18 showed that the prevalence of HTN were 22% in those three

countries (de Ramirez, et al., 2010). A recent study observed that the age-standardized

prevalence of hypertension was 19.3% in rural Nigeria, 21.4% in rural Kenya, 23.7% in

urban Tanzania, and 38.0% in urban Namibia (Hendriks, et al., 2012). Earlier study showed

that he age-standardized prevalence of hypertension in Seychelles was 36% in men and 25%

in women aged 25 to 64 years (Aubert, et al., 1998).

The higher rates of hypertension prevalence in children, adolescent and adult population

were consistently reported in Asia. More recently, a study conducted in Bangladesh showed

that hypertension prevalence increased between 1992 and 2015 from 11.0% to 20.4% in 2015

in men, and from 14.0% (10.3-19.0) to 21.3% in women (Rahman, et al., 2017).

The prevalence of hypertension is also increasing rapidly in Ethiopia, institutional based

cross sectional study conducted in Ethiopia among civil servants found that the prevalence of

hypertension to be 27.3 %. Similar study revealed that civil servants of age 48 years and

above, age 38-47 years and age 28-37 years were more likely to be hypertensive. On other

hand, ever cigarette smoking, family history of hypertension, self-reported Diabetes Mellitus

15    

(DM), and body mass index (BMI  >  25 kg/m2) were found to be significantly risk factors

associated with hypertension (Angaw, et al., 2015).

2.2.3 Hypertension in East Africa

Hypertension is as prevalent in many East Africa countries, as in the developed world and is

the leading cause of cardiovascular morbidity and mortality in East Africa.

A cross-sectional study conducted at Makerere University comprising 180 medical students

aimed to assess cardiovascular disease risk factors among university students revealed that of

the 180 students surveyed, 25 (14 %) had hypertensive ranges of blood pressure. Participants

with elevated systolic blood pressure were more likely to be older, overweight, and with a

personal of cardiovascular disease. Cardiovascular risk factors with the highest prevalence

were alcohol consumption (31.7 %); elevated systolic blood pressure (14 %); and excessive

salt intake (13 %) (Nyombi, et al., 2016). Another Ugandan study with a large community

sample form Rukungiri district observed that of the 842 study participants, 252 were

hypertensive. The age-standardized prevalence of hypertension was 30.5%. Similar to other

studies, factors found to be associated with hypertension included: Past alcohol use, present

alcohol use, being overweight, obesity, female sex, having attained tertiary education, and

older age (Wamala, et al., 2009).

Previous study conducted in Tanzania which included 570 adults from Mafia Island, of them

154 (27%) were aged 41–50, this study revealed that almost half (49.5%) of the participants

fit into the criteria of hypertension. Out of the 118 participants who were aware of having

hypertension, 68 (57.6%) were currently taking medication. From those taking medication,

only 14 (20.6%) had controlled hypertension (Muhamedhussein, et al., 2016). Earlier study

16    

done in Kilimanjaro Tanzania showed prevalence of hypertension to be 30% in males and

28.6% in females of which under 20% of the patient with hypertension were aware of their

status. Only 10% were on medication and less than 1% had optimal controlled blood pressure

(Edwards, et al., 2000).

Hypertension is an emerging public health problem in Sub Saharan Africa and urbanization

is considered to favor its emergence in Kenya. A recent community based cross-sectional

survey among adults 35 years and older living in Nairobi, Kenya. A total of 1528 adults were

surveyed with a mean age of 46.7 years. The age-standardized prevalence of hypertension

was 29.4 %. Among the 418 participants classified as hypertensive, over one third (39.0 %)

were unaware they had hypertension (Olack, et al., 2015). Another study which enrolled

2061 adults from Nairobi found that the age-standardized prevalence of hypertension was

22.8%, of them 20% (53/258) were aware of their hypertensive status; 59.3% had pre-

hypertension; 80% reported high levels of physical activity and 52% were classified as

harmful alcohol drinkers; 10% were current smokers and 5% had diabetes (Joshi, et al.,

2014).

A study conducted in three African countries including Rwanda found that the overall

prevalence of hypertension of 22%. Male participants had higher HTN prevalence compared

with female participants (24% vs 20%). Most participants with HTN had Stage I HTN (70%).

Moreover, 44% of study participants, 49% of males and 40% of females, had pre-HTN.

Apparent variation in HTN prevalence in Rwanda was found to be (16–27%). The mean SBP

(mmHg) and DBP (mmHg) among 535 Rwandan participants were 123.5 and 73.3

respectively (de Ramirez, et al., 2010). Only one cross-sectional study was previously

conducted in Rwanda, this study found high prevalence (36%) of hypertension among

17    

employees in Rwanda and high prevalence (33%) of individuals not aware of their

hypertension (Banyangiriki & Phillips, 2013).

2.2.4 Knowledge, attitude and practices on hypertension

Knowledge, attitudes, and practices (KAP) is a crucial element of hypertension control, but

little information is available from developing countries where hypertension has lately been

recognized as a major health problem. Knowledge of the cause, course and consequences of

HBP by the general community may have an influence on its control just as the practice by

the community.

A study designed to evaluate the perception, knowledge and practices of Nigerian

hypertensive patients regarding hypertension and lifestyle modification measures revealed

that many of those in the survey had knowledge about lifestyle measures and their effects on

hypertension: 54.5% knew that tobacco use, 66.5% knew that alcohol use, 76.9% knew that

foods high in saturated fat and oil; and 76.3% knew that exercise and weight reduction were

among risk factors associated with hypertension (Ike, et al., 2010). Another study conducted

in Nigeria observed that 48% and 51.8% knew that smoking increases the propensity to

develop complications and that exercise is beneficial for the control of blood pressure

respectively. Knowledge of the possible complications of hypertension was very poor as

58.9% of the patients scored less than average. Only 41.1% and 1.8% of the patients were

aware that excessive salt and fat intake could adversely affect the control of hypertension

respectively (Katibi, et al., 2010).

In Seychelles, a study found that most non-hypertensive persons were unaware hypertension,

however, they had good basic knowledge related to hypertension determinants and

consequences, and this was due to an effect of a nationwide cardiovascular disease

18    

prevention program established in Seychelles. However, favorable outcome expectation,

positive attitudes, and appropriate practices for hypertension and relevant healthy lifestyles

were found in smaller proportions of participants, with little difference between aware

hypertensive, unaware hypertensive, and non-hypertensive (Aubert, et al., 1998).

It was previously documented that much of the preeminence of hypertension in the global

burden of disease stems from a lack of awareness, treatment, and control of the disease. Dong

et al. reported figures from rural China as low as 29.5%, 20.2%, and 0.9%, respectively.

Another Chinese study reported a higher proportion of hypertensive participants showed

adequate knowledge on complications in comparison to knowledge about HTN risk factors.

Participants with controlled BP were more knowledgeable about threshold, risk factors, and

complications as a result of hypertension, had increased awareness, and took medications and

BP measurements on regular basis with more inclination to follow or initiate treatment

(Zhang, et al., 2009).

In India, a previous study found that at least around 62% of respondents had heard of blood

pressure as well as hypertension. This awareness reported in Indian study was comparatively

more among women and settled-migrants. Similar study found that less than half of the

respondents considered hypertension a serious condition, and a considerable proportion did

not perceive that hypertension leads to other diseases. Thus, in these communities, more than

a half possessed the knowledge, less than a half perceived that hypertension can be

prevented, and less than a half of these followed at least one of the lifestyle changes

mentioned by them(Kusuma, et al., 2009).

19    

Higher knowledge and awareness about hypertension was consistently observed in Spain

where among the study participants 48% to 99% knew the definition of hypertension (blood

pressure 140 mmHg and/or 90 mmHg) (Ho, et al., 2016). Hajjar & Kotchen report, from the

USA, that hypertension awareness remained static between 1990 and 2000 at about 69%,

while treatment rates improved from 52.4% to 58.4% and control rates from 24.6% to 31.0%

(Hajjar & Kotchen, 2003).

Several studies conducted in east Africa demonstrated inadequate knowledge of hypertension

in patients with Hypertension or in general population, in addition, these studies revealed that

attitude and practices towards risk factors of hypertension are poor among people from East

Africa community in our study population (Joshi, et al., 2014; Muhamedhussein, et al.,

2016). For example, in Rwanda, a study found that 33% of Rwandan was not aware about

hypertension in 2013 (Banyangiriki & Phillips, 2013).

2.3 Critical Review and Research Gap identification

Several studies and international reports highlighted hypertension or raised blood pressure as

one of the key risk factors for cardiovascular disease. Hypertension already affects one

billion people worldwide, leading to heart attacks and strokes. Researchers have estimated

that raised blood pressure currently kills nine million people every year (WHO, 2013).

Hypertension is a silent, invisible killer that rarely causes symptoms. Investigating patient’s

knowledge, attitude and practices towards the risk factors of hypertension is key strategy for

hypertension control and prevention. Currently, raised blood pressure is a serious warning

sign that significant lifestyle changes are urgently needed in both developing and developed

countries.

20    

High-income countries have begun to reduce hypertension in their populations through

strong public health policies such as reduction of salt in processed food and widely available

diagnosis and treatment that tackle hypertension and other risk factors together (Bloom DE,

2011; Cutler, et al., 2008). In contrast, many developing countries including Rwanda are

seeing growing numbers of people who suffer from heart attacks and strokes due to

undiagnosed and uncontrolled risk factors such as hypertension (de Ramirez, et al., 2010).

People from developing countries demonstrated poor knowledge on hypertension and its risk

factors (Katibi, et al., 2010).

More recent existing meta-analysis found that the overall prevalence of hypertension in

middle and low income countries was estimated to be 32.3%, with the Latin America and

Caribbean region reporting the highest estimates (39.1%). Pooled prevalence estimate was

also highest across upper middle income countries 37.8% and lowest across low-income

countries 23.1%. Prevalence estimates were significantly higher in the elderly (65 years)

compared with younger adults (<65 years) overall and across the geographical regions;

however, there was no significant sex-difference in hypertension prevalence. Persons without

formal education, overweight/obese, and urban settlers were also more likely to be

hypertensive, compared with those who were educated, normal weight, and rural settlers

respectively (Sarki, et al., 2015). However, no study from Rwanda was included in this meta-

analysis, this show the lack of studies related to hypertension and other CVD in Rwanda.

However, there is a dearth of evidence providing up-todate estimates of the occurrence of

hypertension and its risk factors across the country. The existing literature focused on

African populations from other countries rather than Rwanda (Akinlua, et al., 2015; Angaw,

et al., 2015; Joshi, et al., 2014). Therefore, the present study aims to fill this gap in the

21    

evidence by providing overall hypertension prevalence and investigating the knowledge,

attitude and practices towards risk factors of hypertension among outpatients attending

Bugesera District Hospital, Rwanda.

2.4 Theoretical framework

The present study is based on theories about the origin and development of hypertension

developed in 1970s by several researchers, and summarized by Dr Milton Mendlowitz in one

published study in Hypertension Journal in 1979 (Mendlowitz, 1979), some of these theories

have been used in many recent studies investigated awareness, control and prevention of

hypertension (Rahman, et al., 2017; Rau & Rao, 2015)

On the basis of Page vast experience in the field of CVD, that essential hypertension will

prove to be not one disease, but many different diseases of different origin and development,

all of which produce hypertension and its consequences in a kind of mosaic of causes, some

of which may occur singly or together. This "Mosaic Theory," however, does not account for

such things as hereditary predisposition and the interrelationships and dynamics of

hypertensive disease. It also leaves about 85% of patients with hypertension still in the

"essential" or "of unknown origin" category (Page, 1977).

Pickering, however, addresses himself to the importance of the genetic factors. As in late

onset diabetes, he believes that environmental factors must act on the hereditary substrate to

produce clinical hypertension late in life and therefore perpetuate it; since like late onset

diabetes, hypertension does not seem to interfere with procreation. The occurrence of

hypertension in families must be carefully studied, separating factors transmitted by the

chromosomes from those that are attributable to such factors as culture, diet, and other

environmental impacts. Pickering, however, assigns only 25% of the rise in blood pressure to

22    

genetic and 75% to environmental factors(Pickering, 1977). The exact nature of the genetic

and environmental factors remains unclear.

Dahl and Freis attribute essential hypertension almost entirely to excessive ingestion of salt.

This was and still is a rare commodity in many primitive societies and has become abundant

in more advanced societies thus, it is thought, leading to the development of essential

hypertension (Dahl, 1977; Freis, 1976). Laragh et al. along with other earlier investigators,

on the basis of their work in man and in animals (particularly the two-kidney model, in which

one renal artery is constricted, versus the one-kidney model, in which one kidney artery is

constricted and the other kidney ablated) say that essential hypertension is either due to

excessive retention of salt and water or to a high production of renin, angiotensin and

aldosterone (Gavras, et al., 1976; Laragh JH & ED, 1979).

They have not investigated genetic factors, as such, in human essential hypertension. It is

possible that genetic factors, for example, contribute to plasma volume and/or endocrine

mechanisms, but this has not been proven. The divisions of essential hypertension into high,

normal and low renin classes has been subjected to persistent attack and counter attack but

addresses only possible mechanisms and does not explain the origin of essential hypertension

or what is primary and what is secondary.

23    

2.5 Conceptual framework

Independent variables Dependent variables

                                                                                                                               Intervening variables

Figure 2. 1: Conceptual framework

Source: Literature

Figure 2.1 presented the conceptual framework, which links the study variables. Under

independent variables there are two major variables including knowledge of hypertension,

and attitude and practice towards hypertension risk factors this variable have some indicators

such unhealthy diet, tobacco use, physical inactivity, harmful use of alcohol and body mass

index. Dependent variable is the prevalence of hypertension among outpatient at Bugesera

District; this will be measured by taking SBP and DBP of all study participants. Intervening

variables are those variables in which may affect both independent and dependent variables.

Knowledge of hypertension Attitude and practice towards hypertension risk factors

• Unhealthy diet • Tobacco use • Physical inactivity • Harmful use of alcohol • Body mass index

• Ageing • Income • Education

level • Gender • Occupation • Diseases

history

Prevalence of hypertension

• Systolic blood pressure

• Diastolic blood pressure

24    

According to literature these variables may include but not limited to age, income, education

level, gender, occupation and history of diseases.

The constructed conceptual framework is based on in literature review; this indicates

interconnection on how knowledge of hypertension, and attitude and practices towards the

risk factors of hypertension may have impact on the prevalence of hypertension among

outpatients. It was observed that awareness about treatment and control of hypertension is

extremely low among outpatients from many developing countries including Rwanda.

Therefore, the present conceptual framework will help to deeply understand what outpatient

know about hypertension, what they know about the risk factors associated with

hypertension.

2.6 Summary

Current estimates reflect the significant burden of hypertension and previous studies provide

evidence that hypertension remains a major public health issue in both developed and

developing counties where on average, about one-third of the adult population in these

countries are hypertensive. Hypertension is one of the most modifiable risk factors for CVD.

However, little is known about the knowledge of hypertension, and attitude and practice

towards the reduction on hypertension is poorly understood in developing countries including

Rwanda.

However, most of these evidence originates from studies form developed nations while very

few come from developing counties limited by high risk of selection bias and substantial

between study variations in the results. Poor knowledge of hypertension was reported among

population form several African countries compared to population from other countries.

25    

Increasing age, low educational level, diabetes mellitus, obesity, and central obesity were

consistently reported as the risk factors for hypertension in many reviewed studies. This

study will provide the most comprehensive evidence and first analyses on hypertension

prevalence and knowledge of hypertension as well as its risk factors.

26    

CHAPTER THREE: RESEARCH METHODOLOGY

3.0 Introduction

This chapter presents the methodology of the study. It describes the research design, target

population, sample design including sample size and sampling technique, data collection

methods, data collection instruments, administration of data collection instruments, reliability

and validity, data analysis procedure and ethical consideration.

3.1 Research Design

This study was conducted using descriptive cross-sectional research design with quantitative

method. Structured questionnaire were administered to outpatients seeking care at Bugesera

district hospital, after their blood pressure and anthropometric measurements. A cross-

sectional study design was chosen because; the present study compared a single point in time

data. Also it is used for examining phenomena expected to remain static through the period

of interest such as blood pressure data and anthropometric measurement. This cross-sectional

study allows the researcher to compare many different variables at the same time. For

example, look at age, gender, education level in relation to blood pressure levels.

3.2 Target population

The target population in this study was outpatients seeking health care at Bugesera District

Hospital. A recent report from Bugesera district hospital showed that 24515 patients use

outpatients department annually. Therefore, this was considered as the target population in

the present study.

Inclusion criteria

Every patient present at outpatient department of Bugesera district hospital during the period

of data collection was considered eligible to participate in the study.

27    

Exclusion criteria

Patients less than 18 years were not included in the study, because of rigorous process of

getting consent form from their parents or guardians, which delayed the study. In addition,

patients in critical medical conditions including those with serious injuries or mental

problems were excluded from the study.

3.3 Sample design

This includes sample size and sampling techniques used in the study.

3.3.1 Sample size

A sample size is the number of observations used for calculating estimates of a given

population. Cochran (1963:75) formula used to determine proportions in single cross-

sectional surveys was used for sample size determination (Cochran, 1963). A study

conducted by Banyangiriki in 2013 reported that the level of knowledge about hypertension

in Rwanda was about 33%. Therefore, this was used as estimate proportion of level of

knowledge about hypertension to calculate the sample size for the present study.

2

2 )1(d

ppzn −=  

Where:

n= sample size with finite population correction

Z = Z statistic for a level of confidence, Z=1.96 for a confidence limit of 95%,

P= estimated proportion of level of knowledge about hypertension from a previous study

conducted in Rwanda (33 %)

d= degree of desired precision or margin of error (in this study, it will be 0.05 or 5%)

34005.0

)33.01(33.096.12

2

=−××

=n  

28    

Therefore, the sample size for the current study was 340 outpatients at Bugesera District

Hospital. After removing missing data as well as incomplete questionnaires, a final sample of

272 outpatients were used for analysis.

3.3.2 Sampling Techniques

All outpatients attending the outpatient department at Bugesera District Hospital on each day,

and willing to participate in the study after a formal explanation of the purpose of the study

were consecutively recruited. They were also informed that they have the option to opt out

without any negative consequences. A total of 340 outpatients were enrolled into the study

during 2 months of data collection. To avoid inconsistence all questionnaires with one or

more missed variables were excluded in final analysis. Therefore 272 samples fill full all

required were included in final analysis.

3.4 Data collection Methods

This section describes the methods that were used during data collection. This includes data

collection instruments, administration of data collection instruments as well as validity and

reliability of research tools.

3.4.1 Data Collection Instruments

Quantitative data were collected by using structured interviewer-administered questionnaire

including question about blood pressure examination, and anthropometric measurements.

According to JNC-7(Chobanian, et al., 2003), normal blood pressure was defined as a

systolic blood pressure (SBP)<120 mmHg and a diastolic blood pressure (DBP)<80mmHg,

prehypertension as SBP 120-139 mmHg and/or DBP 80-89 mmHg, Stage I hypertension as

SBP 140-159 mmHg and/or DBP 90-99 mmHg and Stage II hypertension as ≥160 mmHg

29    

and/or DBP≥100 mmHg. In the present study, subjects in Stage I and Stage II were

considered as hypertensive. Subjects taking anti-hypertensive treatment were considered to

have definite hypertension regardless of their measured blood pressure, though JNC-7 has

not included this fraction of hypertensive population in its classification. A standard mercury

sphygmomanometer was used for recording blood pressure. Before the measurements were

taken, the patient was requested to seat comfortably for at least 5 minutes. Care was taken

that an arm muscle was relaxed and the arm was supported at heart level. The cuff was

applied to the right upper arm and inflated until the manometer reading shows 30mmHg

above the level at which the radial pulse disappears, and then slowly deflated at

approximately 2mmHg/second. During this time, the Korotkoff sounds were monitored using

a stethoscope placed over the brachial artery. The first (appearance) and the fifth

(disappearance) Korotkoff sounds were recorded as the systolic and diastolic blood pressure,

respectively. In order to avoid misleading, blood pressures were measured twice and their

mean value was used in final analysis.

Anthropometric measurement for body mass index calculation, body weight was measured to

the nearest 0.5 kg using standard weighing machine with subject standing motionless on the

weighing scale. Height was measured to the nearest 0.5 cm with the subject in an erect

position against a vertical surface and with the head positioned. Body mass index was

calculated as weight in kilograms divided by the square of the height in meters.

3.4.2 Administration of Data Collection Instruments

A group of five medical intern students specially trained for the present study administered

the questionnaires, conducted the interviews, and took all medical records examination.

Approximately, each survey session with a participant took about 10–20 min. As the study

30    

location was a district hospital, and patients may be used to be clerked by medical intern

students, matching of the interviewers was not necessary. At the end of each day the

researcher himself cross checked the questionnaires for completeness.

3.4.3 Validity and Reliability

Research tools used in this study were used in other several studies (Aubert, et al., 1998;

Katibi, et al., 2010; Kusuma, et al., 2009). These instruments were adopted after matched

with Rwandan context. However, to be sure that this tools still consistent with Rwandan

patients, the questionnaire was pre-tested on another group of at least 25 patients similar to

the study group. Data for final analysis were collected using a pre-tested structured

interviewer-administered questionnaire.

Validity and reliability of research tools were assured as well as approved after analysis of

pilot study findings. For reliability, Cronbach’s Alpha coefficient was calculated by using

SPSS software. Cronbach’s Alpha coefficient gives 0.71 which is greater than 0.7 thereafter

the research instrument was proven reliable. Validity was estimated by use of Content Valid

Index ( CVI), which is a scale developed by computing or ranking the relevant items in the

instrument or questionnaire by checking their clarity, their meaningfulness in line with all

objectives stated, dividing by the total number of items. CVI is widely used index in

quantitative research, in this study CVI was 0.69 which is greater than 0.6, therefore the

research instrument for quantitative study considered valid.

2.5 Data Analysis Procedure

Data entry and analysis were done using SPSS version 13 for windows. Prevalence of

hypertension was given as percentage. Knowledge, attitude and practices about hypertension

were analysed by looking hypertension threshold, hypertension risk factors, and

31    

complications as a result of hypertension. Overall, knowledge was assessed by transforming

all variables used to assess individual knowledge on the risk factors of hypertension into one

variable. Thereafter, the scores were given (1= for correct response, 0= for incorrect

response). The total score was 12, respondent who scored 9-12 were classified into higher

knowledge, 3-8 scores into moderate knowledge, 0-2 into poor knowledge. Overall attitude

were assessed by transforming all variables used to assess attitude towards hypertension

control and treatment into one variable. Thereafter, the scores were given (1= for correct

response, 0= for incorrect response). The total score was 8, respondents who scored 3-8 were

classified into positive attitude, 0-2 scores into negative attitude. Overall attitude towards

hypertension prevention measures were assessed by transforming all variables used to assess

attitude towards prevention measures into one variable. Thereafter, the scores were given (1=

for correct response, 0= for incorrect response). The total score was 4, respondents who

scored 2-4 were classified into positive attitude, 0-1 scores into negative attitude. The

significance of various risk factors of hypertension was calculated by multivariate logistic

regression analysis with presence of hypertension as dependent variable and risk factors as

independent variables. Odds ratio and 95% confidence intervals were estimated. Two-tailed

p-values less than 0.05 was considered significant.

3.6 Ethical consideration

Approval to conduct the study was sought from the Mount Kenya University (MKU) School

of Postgraduate studies. Study participants were informed that the information to be collected

will be used for study purposes only; and their right to decline participation or withdraw any

time during data collection process. Written informed consent was obtained from all study

participants. Anonymity was ensured by non-inclusion of self-identifying characteristics.

32    

CHAPTER FOUR: RESEARCH FINDINGS AND DISCUSSION

4.0 Introduction

This study was conducted at Bugesera district hospital to evaluate the knowledge, attitude

and practice towards the risk factors of hypertension among outpatients. The present chapter

presents the findings from the study as well as discussion where the current findings are

compared to the previous findings from the studies related to the present. A total of 272

outpatients responded to all questions according out of the 340 outpatients proposed during

the sample size estimation, giving a response rate of 80 % which is acceptable in single

cross-sectional studies.

4.1 Socio-demographic characteristics of respondents

Demographic characteristics of respondents asked in this study were age, gender, marital

status, religion, occupation, education, income, and weight status measures based measured

weight and height of respondents. The results for all these characteristics are presented in

table 4.1.

Table  4.  1:  Socio-­‐demographic  characteristics  of  respondents

Variables Frequency Percentage (%) Age 18-25 42 15.4 26-35 77 28.3 36-45 40 14.7 46-55 41 15.1 56-65 42 15.4 >66 30 11.0 Gender Male 100 36.8 Female 172 63.2 Marital status Single 47 17.3

33    

 Source, primary data, 2017

Out of 272 participants, 77 (28.3%) were aged 26-35 years, while only 30 (11.09%) were

aged 66 and above. The majority of respondents 172(63.2%) were female, 180(66.2%)

married, 207(76.1%) live in rural area and 262 (96.1%) were Christians. Regarding the

respondents education level, 120 (44.1%) had completed only primary school education, very

few number of them 23 (8.5%) had university degree. The farmer’s respondents dominated

the study 155(13.0%), small number of respondents 38 (13.9%) were employed. Concerning

Married 180 66.2 Widow/separated 45 16.5 Residence Rural 207 76.1 Urban 65 23.9 Religion Christian 262 96.3 Muslim 10 3.7 Education No formal education 56 20.6 Primary education 120 44.1 Secondary education 73 26.8 College and above 23 8.5 Occupation Employee 11 4.0 Self-employed 27 9.9 Farmer 155 57.0 Housewife 9 3.3 Student 16 5.9 Unemployed or retired 54 19.9 Monthly income <20,000 207 76.1 20,000-<40,000 21 7.7 40,000-<60,000 10 3.7 60,000-<80,000 2 0.7 80,000-<100,000 2 0.7 100,000-<120,000 6 2.2 120,000->140,000 2 0.7 >140,000 22 8.1 Weight Status Normal weight 188 69.1 Overweight 63 23.2 Obese 21 7.7

34    

the monthly income, 207 (76.1%) demonstrated very low income where they gain less than

20000 Rwandan francs per month, very few of respondents 24(8.8%) earned an income of

more than 120,000 Rwandan francs a month. The high prevalence of overweight and obesity

was observed among studied patients; overweight was 23.2%, and obesity was 7.7% (Table

4.1).

35    

4.2 Presentation of findings

To better understand the knowledge, attitude and practice towards risk factors of

hypertension among outpatients at Bugesera District hospital, the prevalence of hypertension

was estimated. The findings presented in figure 4.1 showed that 22.1% of respondent had

hypertension, 34.6% were at pre-hypertension stage. Therefore, the prevalence of

hypertension according to WHO reference at Bugesera District Hospital was 22.1%.

Figure  4.  1:  Prevalence  of  Hypertension  among  outpatient  at  Bugesera  District  Hospital

36    

To further understanding age and gender difference in terms of being hypertensive, the

prevalence of hypertension was estimated according to age, and gender as shown in figure

4.2. Of the patients with hypertension, 27.4% were female, 13.0 were male. Similarly, more

female 36.0% were at pre-hypertension stage. Regarding the age group and prevalence of

hypertension, the higher prevalence (46.6%) of hypertension was observed among older

patients (aged 65 and above), the prevalence was low (8.4%) among the young adults

compared with other age groups.

Figure  4.  2:  Sex  and  age  specific  prevalence  of  hypertension    

37    

4.2.1 Knowledge of hypertension among outpatients at Bugesera District Hospital

Regarding the knowledge about hypertension, the majority 207(76.1%) of patients responded

that they have heard about hypertension. However, only 7 (2.6) correctly answered the

statement that describe hypertension based on SPB AND DBP. A total of 245 (90.1%) don’t

know about any description of hypertension looking on SBP and DBP measurements. The

findings showed that heard about hypertension do not always correspond to particular

knowledge of knowing blood pressure corresponding to hypertension (Table 4.2).

Table  4.  2  :  Ever  heard  and  knowledge  about  hypertension  measurement Variable Description Frequency Percentage Ever heard about Hypertension

Yes 207 76.1 No 65 23.9

Statement describing high blood pressure

Blood pressure below 120 SBP and 80 DBP

5 1.8

Blood pressure between 120-139 SBP or 80-89 DBP

4 1.5

Blood pressure between 140-159 SBP or 90-99 DBP

11 4.0

Blood pressure of 160 or higher SBP or 100 or higher DBP

7 2.6

Don’t Know 245 90.1 SBP: Systolic blood pressure, DBP: Diastolic blood pressure

Knowledge about the risk factors of hypertension was also assessed and the results were

presented in table (4.3). Lower knowledge about the risk factors of hypertension was strongly

observed where 216 (79.4%) participants reported low knowledge, only very few 5 (1.8%)

patients reported the higher knowledge on the risk factors of hypertension. Regarding the

specific knowledge about the risk factors of hypertension, 23.2% patients knew that stress or

anxiety can increase the risk of hypertension. Less than 20% of patients knew that lack of

38    

physical activity, overweight, smoking, aging, diabetes, calcium deficient, malnutrition and

excess alcohol consumption may increase the risk of hypertension. Consumption of too much

salt was reported as risk factors of hypertension (27.6%), high cholesterol level was known

by 23.2% patients as risk of hypertension. Generally, patients from Bugesera district

demonstrated low knowledge on the risk factors of hypertension.

Table  4.  3:  Knowledge  about  the  risk  factors  of  hypertension Variables Description Frequency Percentage Overall knowledge about the risk factors of hypertension

Higher knowledge 5 1.8 Moderate knowledge 51 18.8 Lower knowledge 216 79.4

Knowledge on the specific risk factors

Stress or anxiety Yes 63 23.2 No 209 76.8

Too much salt intake Yes 75 27.6 No 197 72.4

Lack of Physical exercise Yes 18 6.6 No 254 93.4

Inheritance Yes 11 4.0 No 261 96.0

High cholesterol Yes 63 23.2 No 209 76.8

Overweight/Obesity Yes 25 9.2 No 247 90.8

Smoking Yes 20 7.4 No 252 92.6

Aging Yes 16 5.9 No 256 94.1

Diabetes Yes 16 5.9 No 256 94.1

Malnutrition Yes 28 10.3 No 244 89.7

Calcium deficiency Yes 29 10.7 No 243 89.3

Excessive alcohol drinking Yes 35 12.9 No 237 87.1

39    

4.2.2 Attitude towards hypertension control, treatment and prevention among outpatients at Bugesera District Hospital

The third specific objective of the study was to assess attitude towards hypertension control,

treatment, and prevention among outpatients. Overall, 22 (8.1%) patients demonstrated a

positive attitude towards hypertension control, treatment and prevention. Interestingly, 96.3%

considered hypertension as a serious disease (Figure 4.3).

Figure  4.  3:  Consider  hypertension  as  serious  disease

When respondents were asked about the specific attitudes towards the reasons for not taking

hypertension drugs (Antihypertensive) for someone with hypertension; 30.9% positively

responded some patients may stop taking drugs when they fill better, 14% reported that some

patients may not afford cost of hypertension drug, 16.5% reported side effects as reason,

29.6% said that hypertension patients may stop drug only because they do not like such

drugs, 30.1% reported that some patients may forget to take drugs, 23.9% reported that when

hypertensive patients are cured no need to continue to take the remaining drugs. The majority

210 (77%) respondents were aware that hypertension can be cured when diagnosed and treated

earlier (Table 4.4).

40    

Table  4.  4:  Attitude  towards  hypertension  control  and  treatment Variables Description Frequency Percentage Overall attitude towards hypertension control and treatment

Positive attitude 22 8.1 Negative attitude 250 91.9

Specific attitudes towards the reasons for not taking hypertension drugs (Antihypertensive) for someone with hypertension

Stopped when fill better Positive 84 30.9 Negative 188 69.1

Cannot afford cost Positive 39 14.3 Negative 233 85.7

Serious side effects Positive 45 16.5 Negative 227 83.5

Do not feel like it Positive 56 29.6 Negative 216 20.6

Forgetfulness Positive 82 30.1 Negative 190 69.9

Cured Positive 65 23.9 Negative 207 76.1

Hypertension can be cured when diagnosed and treated earlier

Positive 210 77.2 Negative 62 22.8

The attitude of respondents towards hypertension prevention measures as assessed. The

findings showed that nearly half 44.9% respondents had positive attitude towards

hypertension prevention measures. Some prevention measure mentioned by respondents

including stress reduction (22.1%), lifestyle change (57.4%), regular medication (55.5%),

and regular BP measurement (26.8%). Generally, outpatients from Busegera district

demonstrated positive attitude towards hypertension measures.

41    

Table  4.  5:  Attitude  towards  hypertension  prevention  measures Variables Description Frequency Percentage Overall attitude toward hypertension preventions measures

Positive attitude 122 44.9 Negative attitude 150 55.1

Specific attitude towards hypertension prevention

Avoid stress

Positive attitude 60 22.1 Negative attitude 212 77.9

Lifestyle Change

Positive attitude 156 57.4 negative attitude 116 42.6

Regular medication

positive attitude 151 55.5 Negative attitude 121 44.5

Regular BP measurement

positive attitude 73 26.8 Negative attitude 199 73.2

4.2.3 Lifestyle practices associated with hypertension

In the unadjusted logistic regression analysis, cigarette use [OR=2.25; 95%CI: (4.74-6.40),

P<0.001], often talking food with saturated fats [OR=1.30; 95%CI: (1.18-1.75), P=0.006],

often talking food with higher salts [OR=1.39; 95%CI: (1.20-1.77), P=0.007], lack of

physical exercises [OR=1.26; 95%CI: (1.96-5.40), p<0.001] were significantly associated

with hypertension. None of these factors were statistically significant to the development of

pre-hypertension.

42    

Table  4.  6:  Unadjusted  analysis  of  lifestyle  practices/factors  associated  with  hypertension Normal Prehypertension P value Hypertension P value OR (95% CI) OR (95% CI)

Smoking No 1.0 Yes 1.91(0.31-11.6) 0.483 2.25(4.74-6.40) <0.001 Drinking No 1.0 Yes 1.11(0.57-2.18) 0.748 0.92(0.41-2.05) 0.853 Take food with saturated fats Rarely 1.0 Sometimes 1.39(0.66-2.93) 0.382 0.41(0.16-1.06) 0.068 Often 0.80(0.42-1.50) 0.493 1.30(1.18-1.75) 0.006 Take food with higher salt Rarely 1.0 sometimes 3.47(1.25-9.62) 0.017 0.71(0.40-1.28) 0.855 Often 0.85(0.23-3.35) 0.855 1.39(1.20-1.77) 0.007 Physical exercises Yes 1.0 No 3.49(2.38-5.12) <0.001 3.26(1.96-5.40) <0.001 OR odd ratio

After adjustment for potential confounders, only smoking [OR=1.16; 95%CI: (1.26-2.65),

p=0.025] and lack of physical exercises [OR=2.48; 95%CI: (2.15-5.49), p=0.009] remain

statistically associated with hypertension (Table4.7).

43    

Table  4.  7:  Adjusted  analysis  of  lifestyle  practices/factors  associated  with  hypertension Normal Prehypertension P value Hypertension P value OR (95% CI) OR (95% CI)

Smoking No 1.0 Yes 0.81(0.09-6.67) 0.846 1.16(1.26-2.65) 0.025 Drinking No 1.0 Yes 1.98(0.87-4.49) 0.101 2.40(0.83-6.89) 0.103 Take food with saturated fats

Rarely 1.0 Sometimes 0.95(0.38-2.34) 0.916 1.15(1.09-1.56) 0.207 Often 1.35(0.53-3.44) 0.526 1.05(0.30-3.70) 0.931 Take food with higher salt Rarely 1.0 sometimes 5.58(1.63-19.09) 0.006 1.58(0.28-8.97) 0.603 Often 0.76(0.31-1.81) 0.537 0.49(0.14-1.61) 0.240 Physical exercises Yes 1.0 No 1.32(1.64-2.72) 0.049 1.48(2.15-5.49) 0.009 Adjusted for age, gender, marital status, residence, religion, occupation, income, and weight

status.

The present study revealed that hypertension is strongly associated with smoking and lack of

physical exercise.

4.3 Discussion

Hypertension as one of cardiovascular disease is becoming a major public health problem in

Rwanda. It contributes significantly to the high burden of cardiovascular diseases and

premature mortality and morbidity. This study assessed the knowledge, attitude and practice

of hypertension among outpatients at Bugesera hospital. The prevalence of hypertension and

its associated factors were also reported.

44    

The present study has demonstrated that approximately one in every four adults aged 18

years and above is hypertensive. According to age group, the prevalence of hypertension was

higher 46.6 % among respondents aged 65 and above. According to gender, female patients

demonstrated higher prevalence of hypertension than their male patients counterparts. The

present findings are comparable with what was previous reported by Kenyan researchers, in

their study they found that the prevalence of hypertension in the overall sample was 27.4 %.

The age standardized prevalence was 29.4 % (Olack, et al., 2015). Similarly to our study, the

prevalence of hypertension in kenyan study increased linearly with age. In contrast to our

study, the prevalence of hypertension was higher among males compared to females in

Kenya. In Ethiopia similar findings on the prevalence of hypertension was reported in

addition to that the higher prevalence 28.3% of hypertension were observed among female

respondents than males (Angaw, et al., 2015).

Nearly 80% of respondents demonstrated lower knowledge of hypertension risk factors. In

contrast, higher knowledge and awareness about hypertension was consistently observed in

Spain where among the study participants 48% to 99% knew the definition of hypertension

(Ho, et al., 2016). In a study conducted in Seychelles, a high proportion of participants

showed good basic knowledge on hypertension where 96% knew that salt and obesity were

associated with hypertension and that hypertension was associated with CVD occurrence

(Aubert, et al., 1998).

Physical exercise was less recognized as a risk factor of hypertension where only 6.6%

respondents knew that lack of regular physical exercises may increase the risk of

hypertension. Consumption of too much salt was reported as risk factors of hypertension

(27.6%), high cholesterol level was known by 23.2% patients as risk of hypertension. Most

45    

respondents reported that smoking causes high BP. Compared with other studies, a study

conducted in Nigeria observed that 48% and 51.8% knew that smoking increases the

propensity to develop complications and that exercise is beneficial for the control of blood

pressure respectively. Similar to our study knowledge of the possible complications of

hypertension was very poor in Nigeria Study. Similar study reported that only 41.1% and

1.8% of the patients were aware that excessive salt and fat intake could adversely affect the

control of hypertension respectively (Ike, et al., 2010).

Our findings showed that nearly half of respondents had positive attitude towards

hypertension prevention measures. Stress reduction, lifestyle change, regular medication, and

regular BP measurement were recognized as hypertension prevention measures.

Comparable to our findings, a study conducted in Sri Lanka showed that the mean attitude

score was high in the majority of participants. Nearly a third thought that weight reduction

was difficult, but 91.7% agreed with the necessity of reducing their current fat and oil

consumption. However, in Sri Lanka study, about 20% participants were not willing to

reduce salt and sugar consumption (Amarasekara, et al., 2016).

Regarding the life style practices, our study found smoking [AOR=1.16; 95%CI: (1.26-2.65),

p=0.025] and lack of physical exercises [AOR=2.48; 95%CI: (2.15-5.49), p=0.009]

significantly increased the risk of hypertension. In contrast a Kenyan study reported that

obesity [AOR = 1.8; 95 % CI, 1.1–3.1)] and moderate physical activity [AOR = 1.9; (95 %

CI, 1.2–3.0)] were significantly associated with hypertension (Olack, et al., 2015).

In comparison to other studies on KAP about hypertension and risk factors, our participants

demonstrated wide gaps in knowledge as well as a discrepancy between knowledge and

practices with attitude. The observed difference between this finding with others previous

46    

studies could be explained by many factors. First, previous studies were done in both urban

and rural areas where this study was conducted only in rural area. The other reason might be

due to the difference in study populations, our study was conducted among outpatients while

many other previous studies were conducted among general population. The reason for

different prevalence of hypertension as well as knowledge, attitude and lifestyle associated

factors in our study as compared to the previous studies might be the difference in socio-

cultural and socio-economic status between the study populations.

47    

CHAPTER 5: SUMMARY, CONCLUSION AND RECOMMENDATION    

5.0 Introduction

Chapter five deals with summary conclusion and recommendation, all of these points were

addressed according to study objectives.

5.1 Summary of the findings

A total of 272 out patients from Bugesera District Hospital had participated in the study. Of

them 77 (28.3%) were aged 26-35 years, while only 30 (11.09%) were aged 66 and above.

The majority of respondents 172(63.2%) were female, 180(66.2%) married, 207(76.1%) live

in rural area and 262 (96.1%) were Christians. Regarding the respondents education level,

120 (44.1%) had completed only primary school education, very few number of them 23

(8.5%) had university degree.

The overall prevalence of hypertension among outpatients at Bugesera District hospital was

22.1%. The prevalence of hypertension was higher 46.6 % among respondents aged 65 and

above. Female patients demonstrated higher prevalence 27.0% of hypertension compared to

men.

5.1.1 Knowledge about hypertension risk factors

Nearly 80% of respondents demonstrated lower knowledge of hypertension risk factors.

Specifically, less than 20% of patients knew that lack of physical activity, overweight,

smoking, aging, diabetes, calcium deficient, malnutrition and excess alcohol consumption

may increase the risk of hypertension. Consumption of too much salt was reported as risk

48    

factors of hypertension (27.6%), high cholesterol level was known by 23.2% patients as risk

of hypertension.

5.1.2 Attitude towards hypertension prevention

This finding showed that 44.9% of respondents had positive attitude towards hypertension

prevention measures. Respondent revealed that Stress reduction, lifestyle change, regular

medication, and regular BP measurement should be followed as hypertension prevention

measures.

5.1.3 Lifestyle practices associated with hypertension

Our study revealed significantly higher odds for hypertension among smokers and

individuals with less physical activity as compared to high level of physical activity.

Smoking [AOR=1.16; 95%CI: (1.26-2.65), p=0.025] and lack of physical exercises

[AOR=2.48; 95%CI: (2.15-5.49), p=0.009] were significantly associated with increased risk

of hypertension.

5.2 Conclusion

The present study has demonstrated that around a quarter of outpatients at Bugesera District

Hospital had hypertension. The overall, lower knowledge of hypertension risk factors were

observed among study participants. Specifically, physical exercise was less recognized as a

risk factor of hypertension. Consumption of too much salt was reported as risk factors of

hypertension, high cholesterol level was known as risk of hypertension. Our findings showed

that nearly half of respondents had good attitude towards hypertension prevention measures.

Stress reduction, lifestyle change, regular medication, and regular BP measurement were

49    

recognized as hypertension prevention measures. Within studied life style practices, smoking

[AOR=1.16; 95%CI: (1.26-2.65), p=0.025] and lack of physical exercises [AOR=2.48;

95%CI: (2.15-5.49), p=0.009] were statistically associated with increased risk of

hypertension.

5.3 Recommendations

The Ministry of Health with other stakeholders in health sectors needs to increase patient’s

awareness about hypertension. Health   facility   based   education   program   should   be  

introduced  in  all  hospital  in  order  to  increase  knowledge  of  patients  about  hypertension  

risk   factors.   This   health   education   program   may   take   place   in   every   morning   while  

patients   are   waiting   for   healthcare   services.   To take early prevention measures at

community level, hypertension screening program should be introduced in all district

hospitals.  Health facility programs that consider the identified risk factors might help the

prevention of hypertension not only among patients but also entire community.

Future intervention programs need to be well targeted and more informative to improve

knowledge and focus more on the behavioral as of risk reduction. Prevention measures

targeting the modifiable risk factors associated with hypertension are warranted to curb

hypertension and its progressive effects. The barriers to and opportunities for increasing

patient’s knowledge and practices on prevention or reduction of CVD risk factors need to be

further investigated.

50    

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APPENDICES  

58    

Appendix 1: Informed consent form

Title of study: Patient’s knowledge, attitude, and practices towards the risk factors of

hypertension at Bugesera District Hospital

Introduction

Good morning/afternoon, my name is Dr Rutagengwa Alfred, a student at Mount Kenya

University, pursuing Master of Public Health degree. I am carrying out a study on the

knowledge, attitude and practices towards risk factors of hypertension among outpatients at

Bugesera District Hospital, in partial Fulfillment of the Requirements for the Master’s degree

in Public Health- Epidemiology. The feedback from you and other participants will assist the

hospital and other stakeholders to come up a new strategies to reduce, prevent and control

hypertension in Rwanda.

Confidentiality

All the information collected was kept confidential and used only for the purpose of this

study. The dissemination of results will be by way of summarized information that has no

reference to any particular health unit staff.

Voluntary consent

You have been selected to participate in this Study; you are free to choose either to

participate or decline to participate in this study. Your participation is voluntary, and you

have the right to withdraw from participating at any time. Feel free to ask any question

before or after interview.

For further information, you are free to contact the Principal Investigator on the following

Telephone number: (+250) 738757389

59    

Statement of Informed Consent

The above information has been clearly explained to me and I have read and understood it.

Decision of the participant

1. The participant accepted to participate in this study

2. The participant refused to participate in this study

Name of participant……………………….…. …………………………………..

Signature……………. ………Date………………………………………………

Name of interviewer…………………………………...........................................

Signature...................................Date…………………………………………….

60    

Appendix 2: Medical Examination

Blood pressure measurement Anthropometric measurement

Systolic blood pressure

(mmHg)

1.

2.

Weight (kg) 1.

2.  

Diastolic blood

pressure (mmHg)

1.

2.

Height (cm) 1.

2.  

61    

Appendix 3: Questionnaire

Instructions:

ü use in the box corresponding to your answer,

You have right to ask additional explanation during the completion of this questionnaire

You may jump the question that you do not want to answer

Socio-demographic information of the respondents

1. Age of respondents (years)

(i) 18-25

(ii) 26-35

(iii) 36-45

(iv) 46-55

(v) 56-65

(vi) 66-75

(vii) >75

2. Educational level

(i) No formal education

(ii) Primary

(iii) Secondary

(iv) Tertiary

3. Religion of respondents

(i) Christian

(ii) Muslim

(iii) Others

4. Place of residence

(i) Rural

(ii) Urban

5. Marital status

(i) Single

(ii) Married

(iii) Widow

62    

(iv) Divorced

(v) Separated

6. Sex of respondents

(i) Male

(ii) Female

7. Occupation of respondents

(i) Employee

(ii) Self-employed

(iii) Farmer

(iv) Housewife

(v) Student

(vi) Unemployed or retired

8. Individual monthly income (Rwf)

(i) Less than 20,000

(ii) 20,000-<40,000

(iii) 40,000-<60,000

(iv) 60,000-<80,000

(v) 80,000-<100,000

(vi) 100,000-<120,000

(vii) 120,000-<140,000

(viii) 140,000 and more

Knowledge of hypertension

9. Did you heard about hypertension or higher blood pressure?

(i) Yes

(ii) No

(iii) No response

10. Which of the following statement describe the high blood pressure?

(i) Blood  pressure  below  120  systolic  and  below  80  diastolic

                       (ii)                Blood  pressure  between  120-­‐139  systolic  or  80-­‐89  diastolic  

63    

                         (iii)      Blood  pressure  between  140-­‐159  systolic  or  90-­‐99  diastolic  

                         (iv)    Blood  pressure  of  160  or  higher  systolic  or  100  or  higher  diastolic    

(ii) I don’t know

Knowledge about the risk factors of hypertension

10. What do you think is the risk factors (causes) of hypertension? (Multiple answers is

allowed)

(i) Stress or anxiety

(ii) Too much salt intake

(iii) Lack of physical exercises

(iv) Inheritance (Familial)

(v) High cholesterol

(vi) Overweight/obesity

(vii) Smoking

(viii) Aging

(ix) Diabetes

(x) Malnutrition

(xi) Calcium deficiency

(xii) Alcohol abuse

Attitude towards hypertension control, treatment and prevention

11. Do you consider hypertension as serious diseases?

(i) Yes

(ii) No

64    

12. What do you think are the reasons for not talking hypertension drugs

(Antihypertensive) for someone with hypertension?

(i) Stopped when fill better

(ii) Cannot afford cost

(iii) Serious side effects

(iv) Do not feel like it

(v) Forgetfulness

(vi) Cured

13. Do you think hypertension can be cured when diagnosed and treated earlier?

(i) Yes

(ii) No

14. What are the best majors to prevent or control hypertension? (Multiple answers are

allowed)

(i) Avoid stress

(ii) Lifestyle Change

(iii) Regular medication

(iv) Regular BP measurement

Lifestyle practices about the risk factors of hypertension

15. How many cigarettes do you smoke per day?

(i) 1 or less per day

(ii) 2-5 per day

(iii) 6-10 per day

(iv) 11 and more per day

(v) Do not smoke

65    

16. Do you take any of the following alcohol?

(i) Beer

(ii) Wine

(iii) Whisky

(iv) Local or homemade alcohol

(v) Do not take any alcohol

17. How much time do you take food with high saturated fats?

(i) Sometimes

(ii) Often

(iii) Rarely

18. How much time do you take food with higher salt?

(i) Sometimes

(ii) Often

(iii) Rarely

19. How much time do you take physical exercise per week?

(i) Once

(ii) Twice

(iii) Thrice

(iv) More than three times

(v) None

Thank you for your time

66