Self-care practices and associated factors among adult hypertensive patients in Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia, 2018

Objectives To assess self-care practices and associated factors among hypertensive patients in Ayder Comprehensive Specialized Hospital 2017/2018. Result Good self-care practice was found only among 20.3% of respondents. Adherence to not smoking, anti-hypertensive medication, alcohol abstinence, dietary management, physical exercise and weight management was found to be 99.1%, 74.10%, 67.20%, 63.10%, 49.4% and 40.6% respectively. Sex (AOR = 2.254, 95% CI 1.092–4.653), age (AOR = 3.265, 95% CI 1.030–10.355), educational status (AOR = 4.205, 95% CI 1.304–13.559), disease duration (AOR = 3.124, 95% CI 1.204–8.105), BP status (AOR = 2.728, 95% CI 1.256–5.926) and knowledge (AOR = 6.196, 95% CI 2.906–13.214) showed significant statistical association with self-care practice.


Introduction
Hypertension known as "the silent killer" is a major public health problem both in developed and developing countries [1]. It affects 22% of the world's population aged ≥ 18 years [2] and 1.13 billion adults [3] and this number is expected to increase to 1.56 billion by 2025 [4]. Hypertension is the leading cause of death and disability accounting for 9.4 million annual deaths [5].
Hypertension related death and disability stem primarily from cardiovascular disease (CVD), renal failure and dementia [6]. For every 20 mmHg increase in systolic blood pressure (BP) to > 115 mmHg or 10 mmHg increase in diastolic BP to 75 mmHg, the risk of cardiovascular and stroke events doubles [7]. Besides, hypertension costs about 10% of the global health expenditure [8].
Self-care practices have been proved as the determinants of hypertension prevention and control [9][10][11]. Major self-care practices for hypertension include medication adherence, maintenance of healthy body weight (body mass index (BMI) 18.5 to 24.9, and waist circumference 102 cm for men and 88 cm for women), 30-60 min of moderate intensity exercise 4-7 days/week in addition to the routine activities, dietary approach to stop hypertension (DASH) and low salt diet, moderation of alcohol consumption (men ≤ 2 and women ≤ 1 alcoholic drink), cessation of smoking and stress management [10][11][12][13]. Hypertensive clients should also monitor their BP [14].
Despite the availability of anti-hypertensive drugs and optimal hypertension self-care practices are proved to decrease BP and all cause mortality rate and cardio-vascular morbidities [15,16], hypertensive patients are suffering from unfavorable self-care practices. Many studies have shown that hypertensive patients have poor selfcare practices [17][18][19][20][21]. World health organization (WHO) develops Global Action Plan on; (1) 25% reduction in non-communicable diseases (NCDs); (2) 10% reduction in alcohol use; (3) 10% reduction in insufficient physical activity; (4) 30% reduction in mean population salt intake; (5) 30% reduction in tobacco use; (6) 25% reduction in prevalence of raised BP; (7) 0% increase in obesity and diabetes; (8) at least 50% rate of eligible people receiving drug therapy to prevent heart attack and stroke to be achieved by 2025 using the year 2010 as the baseline [22].

BMC Research Notes
To achieve this, cost-effective and research supported health care services drawing on the best available evidence are essential. Thus, the purpose of this study is to assess self-care practices and associated factors among hypertensive patients.

Methods
Study area and period: The study was conducted in Ayder Comprehensive Specialized Hospital (ACSH), Tigray, Ethiopia [23] from November 2017 to June 2018.
Study design and population: Hospital-based crosssectional study design was conducted. All adult hypertensive patients who had at least 6 months follow-ups were included as a source population. However unconscious and critical ill patients and pregnant mother were excluded.
Sample size determination: Sample size was determined using single population proportion formula considering: Prevalence (p) of lifestyle modification practice 0.273 [21] 95% confidence interval and 5% margin of error. Adding 5% none response rate the total sample size was 320.
Sampling procedure and techniques: Sampling frame was created and participants were selected using simple random sampling technique.

Study variables
Independent variables: socio-demographic variables (age, sex, income, educational status, occupation and residence), health profile of patients (family history, BMI, BP monitoring, BP status, co-morbidity, disease duration and number and type of medication) and knowledge of hypertension and its management.
Dependent variable: self-care practice. Data collection tool: data were collected using interviewer administered structured questionnaire. Self-care practice was assessed using Hypertension Self-Care Activity Level Effects (H-SCALE) which includes medication adherence, dietary management, smoking status, physical activity, weight management and alcohol intake. H-SCALE has provided detailed description of the scoring method of each component [24]. Hypertension evaluation of lifestyle and management (HELM) scale was used to assess respondents' knowledge [27].

Operational definitions
Good self-care practice: adherence to all the components of the H-SCALE.
Poor self-care practice: non-adherence to at least one component of the H-SCALE.
Good knowledge: scores of above mean value on HELM scale.
Poor knowledge: scores of below mean value on HELM scale.
Data quality assurance: training was given to data collectors and supervisors. Pretest was conducted in 5% of the samples in Axum comprehensive specialized hospital. Supervision was made, and data were checked at the spot.
Data processing and analysis: data were entered to Epi-Info and exported to SPSS for analysis. Descriptive statistics was done and binary logistic regression model was used to identify the associated factors. Significance was declared using adjusted odds ratios with 95% confidence interval (CI) at p-value < 0.05.

Socio-demographic characteristics
A total of 320 respondents (100% response rate) were interviewed. Around 51.2% were females. The mean age of the respondents was 53.83 ± 14.52 years with a minimum age of 19 and a maximum age of 85 years. Majority of the respondents (70.9%) were < 65 years old. One hundred thirty-eight (43.1%) of the respondents were not able to read and write (Table 1).

Health profile related factors
Ninety-seven (30.3%) respondents had family history of hypertension. The mean duration of hypertension was 3.50 ± 3.07 with a range of 0.5-20 years. Majority of respondents (67.2%) had normal BMI and 50.3% of respondents had medically confirmed co-morbidity. Most of the respondents (76.2%) had ≥ 140/90 mmHg average BP of three consecutive follow-ups. Ninety-six respondents (30%) had ever missed follow-ups. Majority of respondents (71.2%) was taking ≤ 2 types of antihypertensive medications ( Table 2).

Information and knowledge
Most of the respondents (91.9%) got information about hypertension and its management. The mean score of knowledge was 4.3. Nearly 45.6% of participants had good knowledge and 33.56% of them had good self-care practice. However, only 9.1% of participants with poor knowledge had good self-care practice.  Respondents with ≥ 4 years of disease duration were 3.124 times more likely to practice good self-care as compared to those with < 2 years of disease duration (AOR = 3.124, 95% CI 1.204-8.105, p = 0.019). Controlled BP was found 2.7 times more associated to good self-care practice than uncontrolled BP (AOR = 2.728, 95% CI 1.256-5.926, p = 0.011). Good knowledge was found 6.196 times more positively associated to good self-care practice than poor knowledge (AOR = 6.196, 95% CI 2.906-13.214, p = 0.000) ( Table 3).

Discussion
Good self-care practice was found only among 20.3% [95% CI 15.9-24.7] of the respondents. This finding is consistent with the studies conducted in Addis Ababa (23%) [20] and Nigeria (16.4%) [19]. However, this finding is lower than the study conducted in south Ethiopia (27.3%) [21] and India (37.1%) [25]. This could be explained by socio-cultural variation that influences life style of individuals, sample size difference and variation in the components of self-care practice assessment tool.
Being female was 2.25 [AOR = 2.25, 95% CI 1.09-4.65, p = 0.028] more likely associated with good self-care practice. This is in line with the study conducted in Addis Ababa [20]. This consistency could be because of females are more adherent to the most components of the H-SCALE. It could also be due to socio-environmental and cultural reasons i.e. females may not smoke or use alcohol not essentially due to their hypertensive condition but could be attributed to societal culture.
Respondents < 65 years old had 3.26 [AOR = 3.26, CI 95, 1.03-10.35, p = 0.044] more good self-care practice than ≥ 65 years old respondents. This finding was in line with the study conducted in India which showed older age is associated with unfavorable self-care practice [25]. This was supported by the study conducted in South Ethiopia which showed patients aged ≥ 65 years were less likely to have good lifestyle modification practice than patients with < 65 years [21]. But this study finding is in contradict to the study finding conducted in Addis Ababa and Israel which showed younger age is less likely associated with self-care practice [20,26]. This might be due to the difference in participants' age categorization and sample size.
Respondents who had an educational status of college and above had 4.21 [AOR = 4.21, 95% CI 1.304-13.559, p = 0.016] more good self-care practice than those who cannot read and write. This is in line with the study conducted in India [17]. Having good educational status helps individuals to have good knowledge and thus promotes respondents' good self-care practices.
Greater than 4 years of disease duration was 3.12 [AOR = 3.12, 95% CI 1.20-8.10, p = 0.019] more likely associated with good self-care practice than < 2 years of disease duration. This is supported by the studies conducted Addis Ababa [20] and South Ethiopia [21] which showed that patients with longer disease duration had good life-style modification practice. This consistency could be due to the continued counseling' and health education on self-care practice.
Controlled BP was found 2.73 [AOR = 1.25.95% CI 5.92, p = 0.011] more likely associated with good self-care practice. This might be because of hypertension is essentially controlled and reduced by good self-care practices.
Good knowledge was 6.19 times more associated to good self care practice [AOR = 6.19, 95% CI 2.9-13.2, p = 0.000]. This is also backed by the study conducted in Addis Ababa [20]. This similarity could be due to having good knowledge promote patients to give more emphasis on self-care practice.

Limitations
There may have been recall bias and social desirability bias since the self-care practices of the study participants were based on self-reports. There are no adequate similar studies on self-care practice and most literatures used We would like to acknowledge Mekelle University for the priceless support in the accomplishment of this project. We are grateful to the data collectors for their cooperation in the data collection process. We would like also to give our heartfelt thanks to our study participants for their cooperation in provision of their information.
Authors' contributions GBG: conception, design, acquisition, data collection, analysis and interpretation of data and drafting the manuscript. KKB critically reviewed the design, analysis, interpretation and the drafted manuscript. BGB participate in reviewing of the design, data collection, analysis, interpretation and the drafted manuscript. KBG also participate in reviewing of the design, data collection, analysis, interpretation and the drafted manuscript. All authors read and approved the final manuscript.

Funding
Financial support was obtained from Mekelle University.

Availability of data and materials
Raw data can be made available on request to the corresponding author.