Study area and period
The study was conducted in Durame and hosanna towns. Durame is the administrative town of Kembata Tembaro Zone which is found SNNPR and located 285 km from Addis Ababa and 125 km from Hawassa which is the capital city of the region. The zone has seven Weredas and three town administration with the estimated population of 857,084. The durame hospital is the general hospital found in the zone. Hosanna town is also the administrative town for Hadiya zone that is 232kms from the capital Addis Ababa and 194 km west of Hawassa. The zone has estimated population of 1,506,733. Nigist Ellen Mohammed memorial General Hospital is a governmental hospital which is found in the Hosanna town. The study was conducted from March 1to April 30, 2016.
The facility-based cross-sectional study was conducted in Durame and Nigist Elleni Mohamed memorial general hospitals.
The source population was all hypertensive patients who were treated in Durame general hospital and Nigist Ellen Mohammed memorial general hospitals. The study population was randomly selected hypertensive patients who came for follow up during the study period.
Inclusion and exclusion criteria
All hypertensive patients’ age ≥ 18 years were included in the study. Patients who were severely ill and not able to communicate were excluded from the study.
Sample size determination
The sample size was determined using a single population proportion by assuming that 50% proportion of the patients practiced lifestyle modifications with 95% confidence interval and 5% margin of error. Using population correction formula and adding 10% non-response rate the sample size was 210.
Total adult hypertensive follow-up patients are 165 in Durame and 210 in Nigist Ellen Mohammed memorial hospital. Therefore, the total patients registered for follow up in both hospitals were 375. The sample size was allocated to both hospitals proportionally. All previously, registered 375 patients were included in the sampling frame. Then the study respondents were selected using random sampling technique. The list of patients (sampling frame) was obtained from the registration books of the patients registered for follow up in hospitals and study subjects were selected by lottery method.
Variables of the study
The practice of lifestyles modifications.
Socio-Economic variables; Age, sex, income, marital status, educational status, religion, occupation, ethnicity, residence.
Health profile of the patients; Duration of diagnosis, presence of co-morbidity, family history of hypertension.
Source of information about lifestyles; − medical personnel, media, friends, and family.
Individual factors; knowledge of hypertension.
Data collection instrument
The questionnaire has socio-Economic, questions related with the source of information about lifestyles, knowledge on hypertension and lifestyles, questions related to lifestyle modification practices and questions about health profile of the patients. The lifestyle modification practices were measured using questionnaires adapted from hypertension self-care practice questions which are recommended by joint national committee on detection, prevention evaluation and treatment of hypertension (JNC7) and WHO STEPS questionnaires [18, 28].
Low-salt diet - ten items were used to assess practices related to eating a healthy diet, avoiding salt while cooking and eating, and avoiding foods high in salt content. A mean score was calculated. Scores of five or better indicate that patients followed the low-salt diet and considered as having good low salt diet practice.
Physical activity - Physical activity was assessed by two items. “How many of the past 7 days did you do at least 30 minutes total of physical activity?” and “how many of the past 7 days did you do a specific exercise activity (such as swimming, walking, or biking) other than what you do around the house or as part of your work?” Responses were summed (Range 0–14) patients who scored eight and above were coded as a having good physical activity practice. All others coded as poor practice.
Smoking - Smoking status was assessed with one item, “How many of the past 7 days did you smoke a cigarette?” Respondents who reported 0 days were considered a nonsmoker.
Weight management - ten items assessed using activities undertaken to manage weight through dietary practices such as reducing portion size and making food substitutions as well as exercising to lose weight. Items assessed agreement with weight management activities during the past 30 days. Response categories ranged from strongly disagree (1) to strongly agree (5). Responses were summed creating a range of scores from 10 to 50. Participants who report that they agreed or strongly agreed with all ten items (score ≥ 40) were considered to have good weight management practice.
Alcohol - Alcohol intake was assessed using 3-item Participants who report not drinking any alcohol in the last 7 days or who indicated that they usually did not drink at all were considered abstainers. All others were considered as not having a good practice of alcohol consumption.
Height was measured using portable stadiometer without participant wearing shoes to the nearest 0.5 cm. reading was taken after the participant was requested to have feet together heals against the back board, knees straight and look straight forward. In addition, weight, to the nearest 0.1 kg. Body mass index (BMI) was calculated from the weight and height. BMI (kg/m2) was categorized as normal weight (18.5 ≤ BMI < 24), overweight (24 ≤ BMI < 28), and obese (BMI ≥ 28) using the using WHO recommendations .
Data collection procedures
Data were collected by two trained diploma nurses and using face to face interview method. One BSc nurse supervisor was assigned to each hospital. The socio-demographic, health profiles of participants, knowledge on hypertension, and source of information of the study participants were collected using an interview based structured questionnaire adapted from the WHO manual and reviewing different literatures . Physical characteristics (height and weight) were measured. The lifestyles practices were measured using a tool adapted to the local context from hypertension self-care activity scales .
Lifestyle modification practice was measured using physical exercise, low salt diet, alcohol consumption, smoking and weight management practices. The lifestyle modification practice was classified as a ‘good practice’ and ‘poor practice’. Respondents were labeled to have “good” ‘lifestyle modification practices if they scored above the mean in all recommended lifestyle questions. Weight and height of the patients were measured and BMI was calculated and classified using WHO guideline as normal weight, overweight and obese. Weight and height measurements were taken during data collection.
Data quality control
The questionnaire was prepared in English then translated into Amharic language and was back translated into the English language by another person to check its consistency.
The questionnaire was pre-tested in 5% of total eligible patients in Butajira hospital for their accuracy and consistency prior to actual data collection. Furthermore, the supervisor and the investigator were given feedback and corrections on daily basis to the data collectors. Completion, accuracy, and clarity of the collected data were checked carefully on a regular basis. The data was carefully entered and cleaned before the beginning of the analysis.
Data processing and analysis
After collection, data were checked for completeness and were entered into Epidata 3.1 version and exported to SPSS 20.0 version for further analysis. Descriptive statistical analysis such as Proportion, frequency distribution, means, and the measure of dispersion was used to describe data and analytical statistics including bivariate and multivariable logistic regression analysis was done. Bivariate logistic regression was done to examine the association between dependent and independent variables. After running bivariate logistic regressions, all variables with p < 0.25 was considered as a candidate for the final model and corresponding p-value of <0.05 was considered as statistically significant. Adjusted odds ratio at 95% CI was considered to declare the independent effect of independents variables on the outcome. Finally, results were presented using charts and tables.
Good lifestyle modification Practice: when patients respond the mean or above the mean score on practice questions.
Poor lifestyle modification practice: when patients respond below the mean score on practice questions.