Self-care practice among adult hypertensive patients at ambulatory clinic of tertiary teaching Hospital in Ethiopia: a cross-sectional study

Globally, hypertension is a major public health problem and a strong predictor of cardiovascular disease complications. To reduce and prevent complications from hypertension, it is important to adapt self-care behaviors. This study aimed to assess the self-care practices of adult hypertensive patients at a tertiary teaching hospital in Ethiopia. A health facility-based prospective cross-sectional study was conducted at Jimma Medical Center in Ethiopia between February 2021 and July 2021. Binary and logistic regression was performed to assess the strength of associations between independent and dependent variables. Data entry and analysis were done using Statistical Package for social science (SPSS) software version 22.0. A p-value < 0.05 was considered to declare statistical significance. From a total of 422 respondents included to the study, male accounted 55.7% and the mean ± SD age of the respondents was 58.7 ± 9.75 years. About 53.1% of patients had poor self-care practices toward hypertension. Not attending formal education [AOR = 2.15; 95% CI (1.74, 6.39); p ≤ 0.001], uncontrolled blood pressure [AOR = 2.14 95% CI (1.27, 3.61); p = 0.003], chronic disease co-morbidity [AOR = 1.48; 95% CI (0.25, 7.73); p ≤ 0.001], unfavorable attitude toward hypertension[AOR = 3.13; 95% CI (1.95, 7.52); p ≤ 0.001], and poor social support [AOR = 2.75; 95% CI (1.45, 6.43); p ≤ 0.001] were independent predictors of poor self-care practice. The level of self-care practices for hypertension in the study area was low. In particular, the level of adherence to the DASH diet, exercise, and weight control was very low. Patient-specific targeted interventions are required to improve self-care practices for hypertension.

In Ethiopia, hypertension is the most common noncommunicable disease (NCD) with a prevalence rate of 19.6% [7,8]. Uncontrolled high blood pressure can lead to heart attack and eventually heart failure and stroke, kidney failure, blindness, blood vessel rupture, and cognitive impairment [9]. HTN complications are estimated to cause about 9.4 million deaths each year, representing 17% of all deaths worldwide [10,11]. The main cause of poor control of HTN is the inability to comply with HTN's self-care practice [12,13]. Self-care practices have been an important and cost-effective tool in the management and prevention of hypertension and its complications. Self-care of hypertension includes adherence to medication, intake of a low-fat diet, daily exercise, restriction of alcohol intake, smoking cessation, weight loss, self-monitoring of blood pressure (BP), regular health checkups, and reducing stress [14,15].
Lifestyle changes, formerly known as non-drug therapies, play an important role in people with and without hypertension. It may serve as an early intervention before initiating medication in people with high blood pressure and maybe an adjunct to medication for those already on medication [16,17]. Lifestyle changes can lower systolic blood pressure by about 4-11 mmHg. It is also estimated that for every 1 kg weight loss, blood pressure decreases by 1 mmHg [9,17].
Although high blood pressure can be modified and treated, there is little knowledge about the treatment of hypertension in developing countries. In developing countries, more than three fourth of the burden of hypertension is attributable to a lack of knowledge and inadequate practice of self-care measures [10,18,19]. In previous studies conducted in Ethiopia, the prevalence of inadequate self-care practices reaches 77% [20,21], which is very high as compared to the World Health Organization (WHO) recommendation.
Several factors have been associated with adherence to self-care activities, including socio-economic status, age, gender, educational status, place of residence, co-morbidity, access to health care, level of health literacy, length of therapy, culture, social support, self-efficacy, source of information on self-care and knowledge of disease and treatment [22][23][24][25][26].
Adhering to self-management practices in hypertension is essential for patient management to achieve desired treatment goals by improving quality of life, preventing complications, and reducing health care costs, but self-care practices remain low in developing countries [26][27][28]. Measuring the level of self-care activity for hypertension, along with determinants, is important for establishing a successful strategy for the treatment of hypertension. The literature recommends different self-care practice evaluation methods. One of the validated assessment scales routinely used is Hypertension Self-Care Activity Level Effects (H-SCALE) [29]. It addresses most of the self-care behaviors of the patients which are expected to affect glycemic control. There are studies in Ethiopia on HTN self-care practices. However, the level of hypertension self-care practices and contributing factors have not been well studied in the southwestern part of Ethiopia. Therefore, the study aimed to evaluate the self-care practices of adult hypertensive patients in an outpatient clinic of a tertiary teaching Hospital in Ethiopia.

Study setting
The current project was conducted at Jimma Medical Center in Ethiopia. Jimma Medical Center (JMC) is one of the oldest public hospitals in the country. Geographically, it is located in Jimma city 352 km southwest of Addis Ababa, the capital. With a bed size of 800, JMC is the only teaching and tertiary hospital in the southwestern part of the country. It provides services for approximately 15,000 inpatients, 160,000 outpatient attendants, 11,000 emergency cases, and 4500 deliveries per year coming to the hospital from the catchment population of about 20 million people. The medical center has over 1500 health workers. Besides serving as a referral center, the hospital serves as a teaching and research center for several health professionals at the undergraduate and postgraduate levels. The hospital has different general departments and specialty units like surgery, pediatrics and child health, internal medicine, oncology, gynecology-obstetrics, ophthalmology, dentistry, and other subspecialty clinics. The hospital provides screening and treatment services for people living with chronic disease at different specific ambulatory clinics.

Study design and period
A hospital-based cross-sectional study was conducted from February 2021 to July 2021.

Study population
The study population for the current study was all adult hypertensive patients on follow-up at the ambulatory clinic of JMC during the study period and fulfills the inclusion criteria.

Inclusion and exclusion criteria
All adult hypertensive patients aged 18 years and above on follow-up for greater than 3 months were included in the study. We excluded patients who were seriously ill and unable to respond to interviews during the data collection period.

Sample size determination and sampling procedure
The sample size was determined using a single population proportion formula based on the following assumptions: considering 95% of confidence level, 5% margin of error, and 51% prevalence of poor self-care practice [30]. A minimum sample size was 384. Considering a 10% non-response rate, we recruited a total of 422 study participants consecutively over the study period. Participants were selected using a simple random sampling technique.

Data collection tools and methods
Pretested structured questionnaires adapted from validated scales, published articles [30][31][32][33][34], and modified to the context of the study were used to collect data from participants. The tool contains socio-demographic information, clinical profile of patient, Self-efficacy measure, Social support, self-care practices, knowledge and attitude related information, and questions. Data were collected by the interviewer-administered questionnaire. Data were collected by three trained nurses with a Bachelor of Science degree. Blood pressure was considered when an average systolic BP > 130 and diastolic BP > 80 mmHg for at least three consecutive follow-up appointments in patients younger than 60 years old [35].

Outcome measures and validating methods
A Self-efficacy The patient's self-efficacy is confidence in his or her ability to perform tasks. It is drawn from a five-item scale. Feedback options range from 0 (completely not confident) to 5 (completely confident). Respondents who scored 4 or higher were classified as having good self-efficacy, and if they scored below 4, it was considered poor self-efficacy [34] B Social support Social support is when the patient has friends and others, including family, present in times of need or crisis to give them a bigger picture and a positive image of themselves. The Multidimensional Perceived Social Support Scale (MSPSS) was used to measure social support. The MSPSS is a 12-item measure that rates the adequacy of social support on a 7-point Likert-type scale ranging from 1 = strongly disagree to 7 = strongly agree. Total score from 12 to 84; with scores higher and equal to 64 indicates better (good) social support [36] C Self-care practice Self-care practice was assessed using the impact of hypertensionrelated self-care activity level [29]. The H-SCALE is a self-report questionnaire that includes six categories of self-care behaviors, which include medication adherence, a low-salt diet, physical activity, smoking cessation, weight management, and abstinence from alcohol.  [5]. Summarize the responses to calculate a score in the 10-50 range. Participants reporting a score of 40 or higher were considered adherent to good weight management practices [33,42] I Alcohol intake The amount of alcohol consumed was evaluated on a 3-item scale. The participant who stated that they did not drink alcohol at all in the last 7 days, or generally did not drink alcohol at all, are considered abstainers [43] J Knowledge Hypertension evaluation of lifestyle and management (HELM) scale was used to assess the knowledge of respondents. If a participant answers above the median knowledge question, it is considered "knowledgeable" or good knowledge [32] K Attitude A "favorable attitude" is considered when a patient answers a question about attitude with an average or higher score

Data processing and analysis
Data were entered into epi info and exported to the Statistical Package for Social Science (SPSS) version 22.0 for analysis. Descriptive statistics were used for the analysis of patient characteristics. Chi-square tests and logistic regression analysis were done to determine the presence of a statistically significant association between explanatory variables and the outcome variable. Factors associated with self-care practices were identified using bivariate and multivariable logistic regression analysis. Before analysis factors such as independence of errors, linearity in the logit for continuous variables, multicollinearity, and outliers were checked. Odds Ratio (OR), p-value, and their 95% Confidence Intervals (CI) were calculated, and the result was considered statistically significant at p < 0.05.

Data quality management
The quality of the data was ensured through the development of appropriate data collection materials. Two-day training on study objectives, data retrieval, and the collection was given for the data collectors. Overall activity was monitored by the study's lead investigator.

Ethical considerations
Ethical clearance was collected from the institutional review board of the institute of health, Jimma University. A permission and support letter were also obtained from the management committee of the hospital. Patients signed an informed consent form to participate in the study. The raw data were not made available to anyone and were not used as the determinant of the subjects. All steps in data collection and compilation were conducted and supervised by the principal investigator. Strict confidentiality was assured through anonymous recording and coding of questionnaires and placed in a safe place.

Socio-demographic characteristics of participants
From a total of 422 respondents included in the study, males accounted for 55.7% and the mean ± SD age of the respondents was 58.7 ± 9.75 years. Nearly one-third (65.9%) of the respondents were married. About 33.9% of respondents had no formal education and 63% of the participants reside in an urban area. One-fifth of the participants had no regular income. About 278 (65.9%) of patients live with immediate family (Table 1).  Table 3).

Level of hypertension self-care practices
The median score for self-care practice was 77 with a maximum score of 131. Out of the total respondents, 224 (53.1%) patients had overall poor self-care practice with 95% CI (49.37%, 57.13%). The median score for adherence  (Fig. 1).

Factors associated with self-care practice
Bivariate analysis showed statistically significant associations between educational level, blood pressure control, disease co-morbidity, attitude to hypertension, adherence to follow-up schedule, and social support of the respondents. On multivariable logistic regression analysis revealed lack of formal education, disease comorbidity, uncontrolled blood pressure, unfavorable attitude to hypertension, poor adherence to following up schedule, and poor social support were determinants for self-care practices.  (Table 4).

Discussion
Self-management is an important non-pharmacological approach that facilitates blood pressure control. It is essential for the prevention and treatment of hypertension [44]. This study aimed to determine the level of self-care in hypertensive patients in relation to antihypertensive drug compliance and therapeutic lifestyle changes. The overall level of self-care practice in this study was 53.1% (49.37%, 57.13%). This is consistent with a study in Nigeria [45] (47.4%) and a previous study conducted in a research setting [46] (55.3%). However, the result of this study was lower than the results of studies conducted in Addis Ababa [20] (77%), Durame [27] (72.7%), and MizanTepi [47]. Meanwhile, the result of this study was higher than those of studies conducted not only in Iran [48] (27%), but also in Harar [49] (37.9%) and Nekemte [50] (31.1%). These discrepancies may relate to differences in the population's lifestyle, cultural, economic situation, access to health care facilities, and educational attainment. In this study, the rate of using a low-quality diet was 78% (69.66%, 84.47%). This result is higher than studies conducted in Durame [27], (42.5%) [27], Harar [49], (18.2%) [43], Saudi Arabia [45] (20.7%) [45] and Uganda [51] (24.4%). This may be due to differences in dietary perceptions on dietary management by region and country. In addition, differences in measurement tools, socio-economic and socio-cultural values may cause fluctuations in results. In this study, non-adherence to physical activity was 75.1% (68.77%, 88.90%). This is consistent with a study done in Durame [27] (83.9%) and Saudi [52] (76.8%). However, this result was higher than the studies conducted in Addis Ababa [12,53] (50.6% -68.6%) This may be due to limited facilities or the lack of a structural framework for exercise around the workplace as well as for the general public in the study area. In addition, patients' perceptions and attitudes toward physical activity may limit its practice.
The smoking rate in this study was 6.4%. This finding was lower than other studies done in Ethiopia [27,49], India [54], Kenya [55] Nigeria [56,57], Canada [58], Korea [59], and Iran [60]. In addition, the prevalence of alcohol use in this study was 15.2%. This was in line with other studies in Ethiopia [25,27], Ghana [61], Kenya [55]. However, this result was much lower than studies conducted in other regions of Nigeria [56,57] and Korea [59]. Differences in survey results may be related to differences in socio-cultural and religious viewpoints.
Smoking and drinking within the community are not encouraged in this area of study.
Educational level showed a statistically significant relationship with self-management practice. Patients who cannot read and write were twice more likely to have poor self-care than patients with higher education. This was in line with the other studies done in Ethiopia [27,62]. This may be due to cognitive differences between patients with formal education and those without formal education. Patients who cannot read and write overlook sources of information such as posters, flyers, and other written materials.
The probability of poor self-care practice was higher and statistically significant among patients with chronic disease co-morbidity. This finding was consistent with the other studies from Ethiopian settings [27,53,63]. This may be due to symptoms of co-morbidity that interfere with self-management of high blood pressure, or lifestyle changes caused by the co-morbidity. In addition, comorbid conditions exacerbate the patient's symptoms and prevent them from adapting to lifestyle changes [64]. In this study, people with uncontrolled blood pressure were twice as likely to be poorly self-managing as those with controlled blood pressure. This was in line with other studies [49,62,65,66]. This may be due to the fact that good self-care habits can help control blood pressure.
This study also showed the impact of social support on self-management practices in patients with arterial hypertension. Patients with poor social support were nearly three times more likely to have poor selfmanagement than patients with good social support. This was consistent with other studies [25,53,67]. This can be attributed to several aspects, of social support in stress management, and psychoactive self-help activities, that positively impact patients' lifestyle changes. This study also showed a statistically significant relationship between attitudes toward hypertension and self-management practices. Patients with unfavorable were three times more likely to have poor self-care than patients with positive attitudes. This may be because hypertensive patients understand the complications of the disease and can engage in effective self-management to prevent these complications.

Limitation of the study
As this is a one-hospital study, it will be difficult to generalize. Because the study participants' self-management practices were based on self-report, there may be memory bias and social desirability bias.

Conclusion
The level of self-care practices for hypertension in the study area was low. In particular, the level of adherence to the DASH diet, exercise, and weight control was very low. Not attending formal education, uncontrolled BP, poor social support, and unfavorable attitude, and living with chronic disease co-morbidity were independent predictors of poor self-care practices. Improving self-management practices for hypertension requires targeted, patient-specific interventions.