Knowledge and Awareness of Hypertension in Ghana. Management of Hypertension

TABLE OF CONTENTS

DEDICATION

ACKNOWLEDEGEMENTS

ABSTRACT

TABLE OF CONTENTS

LIST OF TABLES

LIST OF FIGURES

CHAPTER ONE
INTRODUCTION
1.0 Background to the Study
1.1 Statement of the Problem
1.2 Purpose of the Study
1.3 Objectives of the Study
1.3 Research Questions
1.4 Research Hypotheses
1.5 Significance of Study
1.6 Structure of the Thesis

CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
2.1 Definition of hypertension
2.1.1 Blood Pressure Measurement
2.1.2 Mild Hypertension
2.1.3 Severe Hypertension
2.1.4 Types and Causes of Hypertension
2.1.5 Other Types of Hypertension
2.1.6 Hypertension and Pregnancy
2.1.7 Risk Factors of Hypertension
2.1.8 Complications of Hypertension
2.1.9 Hypertension Management
2.2 Prevalence and burden of hypertension
2.3 Pathophysiology of Hypertension
2.4 Knowledge and Awareness of Hypertension
2.5 Theoretical Perspectives of the Study

CHAPTER THREE
METHODOLOGY
3.0 Introduction
3.1 Research Design
3.2 Research Area
3.3 Sampling Techniques
3.4 Inclusive Criteria
3.5 Exclusive Criteria
3.6 Data Collection
3.7 Reliability and Validity Testing
3.8 Data Processing and Analysis
3.9 Dependent Variable
3.10 Independent Variables
3.11 Ethical Considerations

CHAPTER FOUR
DATA ANALYSIS, PRESENTATION OF RESULTS AND DUSCUSIONS
4.0 Introduction
4.1 Demography of Respondents
4.2 Religion
4.3 Awareness on Hypertension
4.4 Information on Hypertension
4.5 Knowledge of Hypertension
4.6 Hypertension and Average Normal Reading
4.7 Signs and Symptoms of Hypertension
4.8 Risk Factors Contributing to Hypertension
4.9 Organs that Hypertension Affects
4.10 Complications of Hypertension
4.11 Preferred Management Option
4.12 Hypothesis Testing
4.13 Discussion

CHAPTER FIVE
SUMMARY, CONCLUSION AND RECOMMENDATION
5.0 Introduction
5.1 Summary
5.2 Conclusion
5.3 Recommendation
5.4 Avenue for future studies

References

DEDICATION

This project is dedicated to my all in all - Jesus, to my precious and wonderful mother Diana Kyei (late), and to my wonderful family. Without you, I believe the pathway would have been very tough and scary. I am so happy to have you all as part of my motivating factors. God bless you all.

ACKNOWLEDEGEMENTS

I will thank the almighty God for keeping me safe throughout the period of undertaking this course irrespective of the difficult time.

My sincere gratitude goes to my research field assistants for helping during the data collection and my academic supervisor Dr. Kwesi Frimpong for his exclusive and exhaustive checks and remarks which enabled the production of this project work.

I am very grateful to the Ga West Municipal Director of health service, Dr. Doris Arhin for given me access to undertake this study in her environment and also to my participants and various institutions that avail themselves for the success of this study.

Finally, to the authors and publishers whose journal, articles and books were used as reference for this work, I will acknowledge your effort and may God richly bless you all.

ABSTRACT

The spike in incidence of adult related hypertension is now among the significant public health problems globally. Prevention of hypertension-related complications can be achieved when individuals become aware of the condition and have much knowledge on the importance of better control of blood pressure. This study aims to assess the knowledge and awareness of hypertension among people in Ga west municipal, Greater Accra. Descriptive cross-sectional survey was used to carry out the study, which a total of 408 participants were recruited from the municipality. The instrument used for data collection was a structured questionnaire, which assessed their awareness level on hypertension and knowledge level on hypertension. Statistical package for the social science (SPSS) version 23 was used for the analysis of data.

With the total of 408 who participated in the study, 48.3%were female and 51.7% were male. Hypertension awareness was 89% among the participants. There was significant level of awareness on hypertension among the respondents /from the hypothesis t-valve (0.994) and p-valve (0.044). Most of the participants 70% and 68.1% were able to determine BP 120/80mmHg as the average blood pressure and BP>140/90mmHg as hypertension respectively. Headache and dizziness as a symptom of hypertension were 35% and 27% respectively. When it comes to management option, 60% preferred orthodox treatment and 44% knew stroke as a risk factor of hypertension.

Though majority of the participants were educated and hypertensive but more than half were not able to mention drugs for management of hypertension. In general, the knowledge and awareness level of hypertension was good. More research needs to be done to further explore this. Keywords: Blood Pressure, Awareness, Knowledge, Hypertension.

LIST OF TABLES

Table 1 British Hypertension Society Classification of Hypertension

Table 2. Demography of Respondents

Table 3 Knowledge and Awareness on Hypertension Risk Factors, Controls, Cure and Treatment

Table 4 Average Normal Level

Table 5. What is Hypertension

Table 6 Known Drugs for Management of Hypertension

Table 7 Model Summary

Table 8 ANOVA

Table 9: Level of Knowledge of Hypertension

LIST OF FIGURES

Figure 1.1 Conceptual Framework

Figure 2. Religion

Figure 3. Existence of Hypertension

Figure 5: Source of Information

Figure 6: How Often People Get Information

Figure 8. Risk Factors of Hypertension

Figure 9. Being Aware that Hypertension Affect Majority of People

Figure 10. Organ that Hypertension affects

Figure 11. Complication of Hypertension

Figure 12. Preferred Treatment Option for Hypertension

CHAPTER ONE

INTRODUCTION

1.0 Background to the Study

Recently, the pattern of diseases has changed from communicable to non-communicable diseases; this alteration in disease pattern happened as a result of industrialization or modernization (McKeown, 2009). According to the ranking globally, hypertension was place among the first ten cause of mortality (World Health Organization, 2014). Clinically, hypertension is defined as a systolic blood pressure> 140mmHg and / or a diastolic blood pressure> 90mmHg (Jawad et al., 2005).

Hypertension can either be classified as Secondary or primary (essential). Most cases which happen to primary occur when the exact cause cannot be found and its percentage is about 90- 95% (Carretero and Oparil, 2000). Obesity, body fat, decreased physical exercise, family history, increased stress level are the risk factors linked with hypertension (Mohan et al., 2004). Similarly, a research by Awuah et al. (2016) linked the increase prevalence of hypertension to inadequate exercise, poor diet, obesity, and rise in waist-to-hip ratio and alcohol consumption in Ghanaian based-population. Various results from many Africa countries concerning hypertension risk factors is very high leading to the increase burden of high blood pressure (Addo et al., 2012).

Being hypertensive increase the chances of haven cerebrovascular disease seven times; two times high with respect to coronary artery development and four-folds with respect to congestive cardiac failure (Galav et al., 2015). Hypertension is a significant risk factor for cardiovascular complications, justification of 60% of heart failure mortalities, 40% end stage renal, 75% of myocardial infarction deaths (Biritwum et al., 2005) and 41%of stroke deaths in an autopsy report (Anim, 1990). Lifestyle factors and increase number of people in the urban centers has been predicate to the mountainous burden of hypertension (Cappucio et al., 2006).

In Africa it has been estimated that over 40% the total number of cases of increase blood pressure are in both man and women (WHO, 2013). In Nigeria 37.6% of cases of hypertension was reported from rural area (Isara et a l ., 2015). The number of hypertensive cases in most developing countries recently is much high as those observed in the developed countries (Saha et al., 2008). It is widely reported in Africa and also known to be the greater factor for adult mortality in sub-Saharan Africa (WHO, 2002). In Ghana, hypertension is one of the foremost Non-Communicable Diseases. It accounted for 55.3% of Non - Communicable Diseases in 1975 and 63% in 1996. (Biritwum et al., 2005). 28.3% (crude) and 27.3% (age-standardized) are the various rate for the urban hypertension cases in Greater Accra region of Ghana. Taken the various out-patient departments among the teaching hospitals, regional hospitals, district hospitals, health centers and clinics in Ghana, hypertension is the number one cause of high attendance (Amoah, 2003). There is a public health interest on low level of awareness, control and treatment of hypertension (de-graft Aikins et al., 2010). Most hypertensive have little level of awareness and knowledge on the risk factors and its related complications as a hypertensive patient, and such people with little awareness are not on medication and their blood level is not well managed (Hendricks et al,, 2012). In Ghana, researches have reported that most people with hypertension don’t know they are suffering from that. For example, in Accra 34% was the prevalence of hypertension which 15% and 19% stand for previously diagnosed and undiagnosed respectively (Aryeetey et al, 2011). Proper control, awareness and treatment of hypertension are relevant for prevention of cardiovascular disease (WHO, 2014). Awuah et al, (2014) made comparison hypertension in some poor Accra urban community, which he has 46% and he indicate that awareness was 7.4% higher in his study of Standard cardiovascular health becomes possible when ideals on inclined risk factors which is important key for lifestyle modification behavior is improved (Vartianinem et al, 1994; Dowse et al, 1995). Plans to reach the lowest blood pressure level mostly in young once are a tangible public health interest for hypertension. Quantifying and propagating risk factors that can be modify into young people is a tangible method of educating on prevention (Shaikh et al, 2011).

Numerous households spend a considerable proportion of their financial earn on hospitalization which send ten million (10,000,000.00) of population into poverty due to the management of hypertension complications, that is kidney failure, heath failure and cardiovascular accidents (strokes). Since the complications of hypertension are long term, families mostly face disastrous expenditure on health care (World Health Organization, 2013). Ghana government in collaboration with the Nation public health reference laboratory, Ghana statistical service and Ghana health service, in 2014 agreed on taken a unique hypertension data, thus Ghana demographic and health survey. The purpose of this data collect was to monitor Ghanaians hypertensive status which will help deciding on the plans that can be used to cut down the burden of hypertension in Ghana. (Ghana Statistical service, 2014). This study assesses the knowledge and awareness of hypertension among people in Ga west municipality, Greater Accra. The outcome of this particular study will assist Monitoring, evaluation, policy planning and decision makers on the type of health events they should organize for the people in Ga west municipal and also for the Ghanaian population.

1.1 Statement of the Problem

Hypertension prevalence in Ghana, specifically Volta region was reported to be 30.7% in females and 32.8% in males (Burket, 2006). The number of cases of hypertension among adolescents is raising and this has become a huge problem for health workers with prevalence rate reported to be 28% in the Ashanti region (Cappucio et al., 2004). A study done at the Adansi South district in the same region recorded prevalence rate of hypertension to be 27.1% (Duah et al., 2012). Research by Ngminkuma, (2015) revealed that 3.9% was the prevalence rate of hypertension within adolescents in the Upper west region of Ghana and 1.3% are females and 2.6% are males. Childhood high blood pressure has been related with hypertension during adulthood (Klumbiene et al., 2000). The nature of the risk factor of hypertension is either biological or behavioral. Some risk factors of hypertension are known and there are some conditions that are known to raise the chance of getting hypertension. Biological factors such as age and gender with some behavioral factors such as consumption of more fruits and vegetables, exercise, avoidance of smoking, alcohol, and loss of weight can help control or prevent hypertension among individuals (Wilcox et al, 1982; Halbert et al., 1997; Fagard, 2001: Meltzer & Jena, 2011: Cristine et al., 2013; Cornelissen & Smart, 2013). Studies have revealed that in Ghana, one out of four adults are hypertensive while globally too one out of three adults have hypertension (Addo, Amoah, & Koram, 2006; Addo, Smeeth, & Leon, 2008; Cappuccio et al., 2004). Hypertension was the second principal cause of cases in the out-patient department among adults above 45years in Ghana (MOH, 2005). The third most commonly seen case in 2011 at the out-patient clinic at the Korle-Bu polyclinic was hypertension (KBTH, 2011). Improperly managed hypertension has grave implications. Globally hypertension is accountable for 51% of death cause by stroke and 45% of death cause by heart disease, with 12.8% of all cause of death (Ezzati et al., 2005). Hypertension is accountable for 51% of death cause by stroke and 45% of death cause by heart disease, with 12.8% of all cause of death (Ezzati et al., 2005). Hypertension is accountable for 51% of death cause by stroke and 45% of death cause by heart disease, with 12.8% of all cause of death (Ezzati et al., 2005). Many management protocols for hypertension is available, however, they totally concord on the principles of management which are early treatment and detection to the projected measurements of blood pressure to prevent unchanging and multiple organ damage (James et a l., 2013; NICE, 2011; Quinn et al., 2010).

1.2 Purpose of the Study

The general goal of this study is to assess the knowledge and awareness of hypertension among people in Ga west municipal at Greater Accra.

1.3 Objectives of the Study

i. To determine the knowledge and awareness level of hypertension.
ii. To investigate the knowledge, they have on management of hypertension.
iii. To explore about the knowledge, they have on complications of hypertension.

1.3 Research Questions

i. What is the knowledge and awareness level of hypertension?
ii. What knowledge do the people have on hypertension management?
iii. What knowledge do the people have on complications of hypertension?

1.4 Research Hypotheses

- Ho: There is no level of knowledge and awareness of hypertension among the people in Ga west municipality

HA: There is level of awareness of hypertension among the people in Ga west municipality

- Ho: The people have no knowledge on hypertension management.

HA: The people have knowledge on the management of hypertension

- Ho: The people have no knowledge on complications of hypertension Ha: The people have knowledge on complications of hypertension

1.5 Significance of Study

The research will provide important data which will assist the municipal health directorate to provide health information which would be culturally acceptable by the people about hypertension. Also, it will serve as a guidance for Non-governmental organizations (NGOs) who aim to help countries and communities fight hypertension and it related complications to focus their attention not only on the antihypertensive medication, but also go down to the communities or rural areas to provide a comprehensive health education on the consequence of some lifestyle behaviors and health in general and specifically on blood pressure.

Again, it will serve as a guide lines that will be relevant to policy makers in bringing up an important policy which will upgrade health education on knowledge and awareness on hypertension strategies . Aside all this, it will also provide foundation for future research in the municipal assembly.

1.6 Structure of the Thesis

This study is organized into five (5) chapters. The introductory part of the study is presented in the first chapter which comprise study background, problem statement, Goal of the study, research objective, research question, hypothesis, and significance of the study. Chapter Two focuses on literature review in which empirical context of the study is laid out including the conceptual framework and theoretical perspective of the study. Chapter Three discusses the methodology employed in the study. It also contains general background of the study area, sampling, population, research design and sampling size, method of data acquisition and instrument used ethical consideration, reliability and validity testing. Chapter Four, deals with data analysis, presentation and discussed finding against the evidence in the empirical literature. Finally, in Chapter Five, a summary of the major discoveries of the research, limitations, conclusion, recommendations and areas for further study are presented.

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter reviews relevant literature on knowledge and awareness of hypertension among the people of Ga west municipality

2.1 Definition of hypertension

The medical term for increase in blood pressure is called hypertension (Buckman & Westcott, 2006). In hypertension (increased blood pressure), there is a constant high pressure in the blood vessel, which pumps blood which is transported to all the blood vessels in the body. The amount of blood supply to the blood vessels depends on the heart beats. When blood is pumped by the heart, the force against the walls of the blood vessels generates blood pressure. The stronger the heart pumps have a link with the higher the blood pressure (WHO, 2013).

Since hypertension causes damage to large blood vessels, it is known to be a silent killer (Tortora & Derrickson, 2006). Because of the symptomless nature of the condition, the name hypertension was given: someone can have raised blood pressure for years without haven ideal about it (Kowalski, 2007).

Perry (2002) Indicates that in hypertension there is lack of warning signs and therefore individuals don’t feel sick. From a longitudinal and cross-sectional survey in adults, it has been proved that as human aged, diastolic and systolic blood pressures go high progressively. WHO MONICA cited example that systolic blood pressure goes high by 0.29-0.91mmHg, 0.6- 1.31mmHg per year in men and women respectively (Wolf et al., 1997).

Akinboboye et al., (2002), affirm that the commonest cardiovascular disease is hypertension caused by rheumatic heart disease and cardiomyopathy, non-rheumatic heart diseases, pulmonary heart disease, coronary heart disease and pericardial disease. In clinical practice, the diagnosis is usually made by using two or three blood pressure measurements done one week apart, this excludes people with a blood pressure reading of aboove 220/110 mmHg or when there is end organ damage (Chobanian et al., 2003, NICE, 2011). However, the National Institute of Clinical Excellence (NICE) and the Canadian Guidelines on Hypertension recommends that individuals with BP of 140/90mmHg or increase be offered Ambulatory Blood Pressure Monitoring to confirm the diagnosis, and for those who cannot do Ambulatory Blood Pressure Monitoring home blood pressure monitoring must be done (NICE, 2011; Quinn et al., 2010).

2.1.1 Blood Pressure Measurement

The instrument use in measuring of high blood pressure in called Sphygmomanometer. This comes in a form of digital or manual. It’s recommended to avoid talking when measuring blood pressures as a patient, sit comfortably with both feet on the ground, the forearm maintained at heart level on a firm surface (Smeltzer et al., 2010).

The use of automated Sphygmomanometers is an accepted way to measure valid blood pressure measurement in a case of primary care because it does not provoke like the manual that people complained that when they see the nurse or health worker, they get provoke which shoot their blood pressure (Myers et al., 2011). In addition, wrong Korotkoff interpretation, incorrect deflation speeds and threshold avoidance, which can occur during blood pressure measurement using the manual, make it user-bias (Hezelgrave & Shennan, 2012).

2.1.2 Mild Hypertension

We say hypertension is mild when the systolic blood pressure is 140-159mmHg with diastolic been 90-99mmHg. And also, hypertension is said to be mild when there is no risk of organ involved (Department of Health, 2008).

2.1.3 Severe Hypertension

Hypertension is said to be severe when the systolic blood pressure is > 180mmHg and the diastolic blood pressure is > 110mmHg (Department of Health, 2008).

2.1.4 Types and Causes of Hypertension

i. Primary Hypertension

Primary or essential hypertension comprises 90-95% of all hypertensive cases in adults (Carretero & Oparil, 2000). The cause of primary hypertension cannot be recognised and this type of hypertension most comes with constantly high blood pressure (Tortora & Derrickson, 2006:798).

ii. Secondary Hypertension

There should be initiation of diagnostic investigation for patient with clinical signs and symptoms or laboratory results pointing severe hypertension or hypertension with multiple drug resistant. Secondary hypertension comprises of 5-10% of the rest of the hypertension cases recorded (Daskalopoulou et al., 2012). kidney disease, pregnancies, Cushing syndrome, certain drugs and alcohol consumption causes secondary hypertension (Serfontein, 2003).

2.1.5 Other Types of Hypertension.

iii. Malignant Hypertension

Malignant hypertension is when there is abrupt upsurge in blood pressure with the diastolic pressure 120-130 mmHg (Casey & Benson, 2006). Kowalski, (2007) confirm that malignant hypertension is serious medical emergency that put individuals at risk of cardiac failure, brain bleeding, stroke, heart attack and kidney failure which is permanent. It was further stated that it is the most common form of blood pressure, and it is often detectable by remarkably abrupt increased in blood pressure at level which is dangerous.

2.1.6 Hypertension and Pregnancy

From World Health Organisation (2005), during pregnancy hypertension is defined as rise blood pressure of two measurements of at least four hours apart reading >140/90mmHg, or >110mmHg diastolic pressure at any time during and up to 6weeks during postpartum. It can be classified into five categories and it affects 10% of pregnancies.

i. Chronic Hypertension; high blood pressure that occur before 20weeks gestation or hypertension occurring previously before pregnancy. And last for more than 12 weeks after giving birth.
ii. Pre-Eclampsia; is said when Protein in urine (proteinuria) is (>300 mg/24hours) with associated hypertension, developing after 20 weeks of cyesis. It is commonly found in multiple gestations, nulliparous gestation, those with a family history of pre-eclampsia, hypertensive women with 4 years or more history, hypertension in renal disease and previous pregnancy. Seizure (eclampsia) can occur when it progresses .
iii. Chronic Hypertension with Superimposed Pre-Eclampsia; this occur when hypertensive woman gets new onset of protein in her urine (proteinuria) after 20weeks of pregnancy. When hypertensive woman with protein in urine prior to 20 weeks of gestation, it is known by abrupt 2-4 times rise in progression of thrombocytopenia, protein in urine (proteinuria), elevated aspartate aminotransferase or alanine aminotransferase.
iv. Gestational Hypertension; this is defined as woman who develop hypertension without proteinuria after 20 weeks of gestation. It may stand for a recurrence of chronic hypertension that abated in mid­pregnancy or pre-protein uric phase of pre-eclampsia, and may develop into pre-eclampsia.
v. Transient Hypertension; In transient hypertension, the blood pressure gets back to normal after twelve weeks of delivery. It may be present in the proceeding pregnancies and predict progression of primary hypertension in the future .

2.1.7 Risk Factors of Hypertension

Blood levels of cholesterol which is abnormal, consumption of alcohol, diabetes, being male, physical inactivity, smoking of cigarette, ageing, and hereditary are the main risk factors which forecast the likelihood of hypertension. If an individual has more of the risk factors, then there is greater chance of getting heart disease (American Heart Association, 2010). Essential hypertension has numerous risk factors which can be group into non-modifiable and modifiable. The modifiable once include smoking of cigarette, dyslipidaemia, alcohol consumption, physical inactivity and obesity with the non-modifiable risk factors being black race, hereditary, male gender and advancing in age. The independent risk factor for dyslipidaemia, diabetes mellitus and hypertension is obesity (Prugger et al., 2006).

i. Obesity or Overweight

Landsberg et al, (2013) stated that obesity is straightforward connected to not less than 75% of the incidence of hypertension incidence. Body mass index > 30 kg/m2 is defined as obesity; it is a highly predominant risk factor for development of heart disease and high blood pressure. The pressure on the walls of the artery walls will rise when the blood volume circulating through the blood vessel rises. The bigger the weight, the more blood is needed to supply nutrients and oxygen to tissues and organs in the whole body (Kaplan, 2008). Even losing as little as 10 pounds can lower one risk for heart disease, many overweight and obese may have challenges in losing weight (American Heart Association, 2010). As many as three hundred thousand (300,000) deaths each year, which prematurely occurs as a result of obesity and its complication. Obesity makes the heart to tussle to resource the excess tissue with blood (Beers et al., 2006).

The prevalence of body mass index > 30.0 kg/m2 was 36%, 10% in women and men respectively. In men with recent socio-economic or high pre-adult level generally had increase waist circumference and body mass index. In women those with lesser socio-economic position like lower education and less pre-adult wealth has higher mean of body mass index, but there was no substantial variance between body mass indexes of socio-economic groups (Addo et al, 2008). The obesity prevalence among Senior High School has been found to be 47.06% in a study that was conducted in Ghana (Amoh et al., 2017).

According to a WHO report, adolescents between the ages of 15-19 were obese and overweight and 18% of children in 2016 (WHO fact sheet, 2016). Increase in the number of overweight adolescents worldwide is alarming. In United State their national survey report from 1960 to 1990 showed that children from age 12-19 prevalence have advance from 5% to 11% (Ogden et al., 1997). Davy and Hail (2004), unfold that overweight adolescent with hypertension can be objected to adiposity. An increased waist and body mass index show exceed weight and it is linked with pre-hypertension and hypertension. He also found connection amongst raised blood pressure and body mass index. It was seen that individual who are obese and overweight have the chance of developing pre­hypertension and hypertension (Pang et al. 2008). Kumar et al., (2016), revealed that about 4% were overweight, with 16% of them being underweight in a study among hypertensives. 4.2% of obese with 17% of the adolescence population was reported to be overweight in South Africa (Reddy et al, 2003). Obesity is particularly common among the urban dwellers, elderly and females in Ghanaian adults. 4.6% and 20.2% for men and women was the prevalence of obesity that is, body mass index >30kg/m2 in a survey in Greater Accra region involving one rural and two urban communities respectively. Obesity rises with age, 13.6% was the obesity prevalence in adult age- standardized. 55-64 years is the age group with obesity peak (Amoah, 2003). Overweight adolescence and children were 2.4- and 4.5-times fold to have increase diastolic blood pressure and systolic blood pressure respectively (Freedman et al, 2007).

ii. Smoking and Alcohol Consumption

Smoking of cigarette causes hypertensive impact, mainly through the sympathetic nervous system stimulation. Cessation of cigarette smoking is one of the actual lifestyle measures for the prevention of a huge number of heart diseases because it is a powerful risk factor for cardiovascular diseases. Weakness of endothelial function, inflammation, arterial stiffness, modification of lipids as well as changing of prothrombotic and antithrombotic factors are smoking-linked major element of starting, and quickening of the atherothrombotic process, resulting in cardiovascular events.

Chronic smoking has effect on blood pressure; data available do not indicate a direct incidental relationship between hypertension and chronic smoking. Smokers, who are hypertensive, have the chance to develop serious forms of hypertension such as renovascular hypertension and malignant hypertension, because of accelerated atherosclerosis (Virdis et al., 2010). Houston (2012) also explains that, smoking escalates the likelihood of hypertension, blood clotting, introduction of free radicals with unlimited damage to the cardiovascular system. American Heart Association, (2010) states it clear that, tobacco smoking has been attributed to substantial number of deaths, which raises the risk of dying from cerebrovascular disease and coronary heart disease 2-3 times.

Among men national data on smoking prevalence ranges from 20%-60% in sub-Sahara Africa. There is documentation on cigarette smoking among youth in some sub-Sahara African. A prevalence rate of 34.4% in Cape Town, 1.5% in Zimbabwe, 1.4% in Nigeria, South Africa which shows a gradual rise and that requires an attention (Townsend et al., 2006). Another study looking at the determinants and prevalence of adolescent cigarette smoking in Ethiopia, Addis Ababa shows a total prevalence rate of 2.9% of which 1% were females and 4.5% male who were current smokers. That particular study also publishes an estimated 5.7% females and 15.1% males past smoking status amongst the populace ( Emmanuel et al., 2007).

Among men national data on smoking prevalence ranges from 20%-60% in sub-Sahara Africa. There is documentation on cigarette smoking among youth in some sub-Sahara African. A prevalence rate of 34.4% in Cape Town, 1.5% in Zimbabwe, 1.4% in Nigeria, South Africa which shows a gradual rise and that requires an attention (Townsend et al., 2006). Another study looking at the determinants and prevalence of adolescent cigarette smoking in Ethiopia, Addis Ababa shows a total prevalence rate of 2.9% of which 1% were females and 4.5% male who were current smokers. That particular study also publishes an estimated 5.7% females and 15.1% males past smoking status amongst the populace ( Emmanuel etal., 2007).

The single most harmful effects of excessive consumption of alcohol is linked with high blood pressure. The positive connection between the blood pressure and the quantity of alcohol consumed is one of the strongest associations of potentially modifiable hypertension risk factor. The hypertension effect of alcohol consumption usually decreases within several days of abstinence in alcoholics. Weekend drinkers have significantly higher blood pressures at the beginning of the week than towards the end of the week. Antihypertensive therapy resistance also has been associated with alcohol intake. These could be due to poor compliance among heavy drinkers or interaction of alcohol with medications (O"Keefe et al., 2007). Many studies show progressively higher blood pressure levels with increasing levels of alcohol intake and decreases in blood pressure over time when consumption of alcohol reduces (Husain et al., 2014).

iii. Lack of Exercise

Centre for Disease Control, (2001) reported that, physical inactivity is serious public health issues in 2000, as the physical activity level of the individuals of all ages tended to reduce. In the USA, Guo et al., (1994), observed that about 50% of American young once between the ages of 12-21 years did not engross in serious physically active lifestyles on a daily basis. Activities such as walking help to maintain normal body weight. Frequent exercise has been identified to control cholesterol levels and hence the prevention of atherosclerosis. This was in lined with findings of a cross- sectional study among a Japanese population that revealed that high HDL cholesterol levels were accompanying with high frequencies of physical activity (Hedge et al., 2015).

About 15 studies have been announced in the English literature with results indicating exercise and training reducing blood pressure in approximately 75%, in people with hypertension of which systolic lessening is about 11mmHg and diastolic reduction of about 8mmHg. Women may diminute blood pressure more with exercises than middle-aged people. And men with high blood pressure may gain higher benefits than young or older people. Little data shows that African Americans decrease blood pressure with exercise training. Some evidence also points regression of pathological left ventricular hypertrophy with exercise training as well as improvement in plasma lipoprotein-lipid profile. These findings continue to help the requisition that, exercise and training plays beneficial role in the adjunctive or initial step in the treatment of mild to moderate hypertension (Haqberg et al., 2000). Moderate-to-vigorous regular physical activity aids in preventing blood vessel disease and heart disease as well. The more vigorous activity done, the greater the benefits. Moderate-intensity activities even aid if done regularly and long term. Obesity can be control with physical activity, diabetes mellitus and blood cholesterol, as well as reduce blood pressure in some individuals (American Heart Association, 2010).

iv. Stress

Stress can lead to hypertension through consistent blood pressure increase as well as by stimulation of the nervous system to release enormous amounts of vaso-constricting hormones that raise blood pressure. Overall study shows that stress does not directly leads to hypertension, but can have an effect on its progression. Although stress may not cause hypertension directly, it can cause too repeated blood pressure increase, which eventually may cause to hypertension (Virdis et al., 2010). Opie (2004) revealed that central stress causes increase medullary centre and hypothalamus activity and the raise of ephedrine gives rise to a sequence of events, namely tachycardia, increased cardia output, myocardial oxygen uptake and increased contractility. There is emerging proof that the various risk factors for hypertension do not work in isolation but tend to interact in clusters. So, exposure to stress will not only increase blood pressure levels but will also lead to increased alcohol and fat intake. A final common pathway for many of these risk factors is the sympathetic nervous system which is involved in the progression of primary hypertension in its early stages and in the hypertensive effects of salt, obesity, and possibly stress as well (Landsberg etal., 2013).

v. Age and Gender

Normally hypertension treatment is for life. And it has been insinuated that after several years of hypertension treatment, it is sometimes possible to continue with modification of lifestyle and remove the pharmacological therapy (Salako, 1979). There is a discretion that almost all those who were hypertensive in the past before management will get it again if they stopped treatment (Kaplan, 1999; WHO, 1999). The control level of sufficient in a third of clients is comparable with numbers for other developing country (Marques-vidal and Toumilehto, 1997; Jaddan et al.,2000). In china a study done showed only 10% patients with satisfactory control and it was seen that male gender and those in the developing country were some factors linked with poor control of blood pressure. According to the 6th reports from the Joint National committee it was stated that adequate controlled of blood pressure among those diagnosed as hypertensive were only about half of the total number (Joint National Committee, 1997).

There is rise in blood pressure level with ageing. This is linked with structural modification in the arteries; mostly stiffness of large arteries. According to the Framingham Heart Study, systolic blood pressure increases steadily from 30 years onwards. Diastolic blood pressure varies with ageing; it increases up to about 50 years of age but steadily decreases from 60 years onwards (Leitschuh etal., 1991; Pinto, 2007). A study amid adolescents in Chetla, India (Saha et al, 2008) showed that mean diastolic and systolic blood pressure was greater in males than females. Among females and males, average upturn of mean systolic blood pressure was notice to be 1.95mmHg and 2.26mmHg per year respectively.

Other studies show an increase in prevalence from age 13 to 18 years with more girls than boys (Harabi et al., 2006). Data on the influence of age in adolescent primary hypertension seem to be conflicting. Some studies revealed that adolescent hypertension in age 13 and above remain in the same range for a substantive period (Flynn and Alderman, 2005). Houston (2012) too reflects that cardiovascular disease ordinarily targets males more time than females until menopause, when the risk become even. Blood pressure in women after menopause is however comparable with that of men of similar ages or even higher. This is attributed to postmenopausal hormonal changes in women (Reckelhoff, 2001).

vi. Dyslipidaemia

A cluster of metabolic anomalies ending in combination of increased cholesterol in serum is term as hyperlipidaemia (Nettina, 2006). Adipose that are obtained from food that we consume or synthesized by the liver is called lipids. All lipids are hydrophobic (insoluble in water) and mostly cannot dissolve in blood (Beers et al., 2006). Lipids are part of the liberated risk factors for hypertension that uplift the risk of dyslipidaemic hypertension. Dyslipidaemia is mostly common in untreated hypertensive as compared with normal blood pressure. It has been seen that lipid parameters increase with increase in blood pressure. However, there is no pinpoint trend of dyslipidaemia in adolescents and hypertensive, the total cholesterol and triglycerides, as well as portions of lipoproteins are more frequently above the normal ranges, among hypertensive than in the populace in general (Osuji et al., 2012).

Populaces of African origin have greater risk of Diabetes and hypertension, however, have extra complimentary lipid profile. In United Kingdom, population-based study that look at the lipid profile of the general population and the minority ethnic groups, African Caribbean’s were practiced to have lesser total triglycerides and cholesterol, and increase levels of high-density lipoproteins and cholesterol (Erens et al., 2001).

vii. Race and Ethnicity

There is high number of hypertensive cases in people with African origin in the United States of America such that, environmental and behavioral characteristics are likely to account for the increase prevalence of hypertension in Afro-Americans (Fuchs, 2011).

A study among adult shows that hypertension occurs more often in black than in white that is 32% and 23% respectively (Beers et al., 2006). Similar patterns were seen for prehypertension with incidence of 4.1% and 2.4% in African America and Caucasians (Din-Dzietham et al., 2007). Buckman & Westcott (2006) too mentioned that African-Caribbean, black Africans people who live in Europe and African-Americans have increased risk. This may be somehow linked to the way the body handles salt.

viii. Salt and Sedentary Lifestyle

Obese patients and African Americans are more vulnerable to the blood pressure - lowering influence of reducing salt intake. Relying on the baseline blood pressure and the extent of salt intake reduction, systolic blood pressure can be decreased by 4 to 8 mmHg. Prevention or delaying the incidence of antihypertensive therapy can be achieved when dietary salt is reduced, and it facilitate blood pressure reduction in hypertensive subjects on medication (Frisoli et al., 2012). High intake of salt raises blood pressure by fluid retention over a period (Forman et al., 2009). The increase sodium level in the blood the higher the blood volume rises. Sodium tends to bind unto water; therefore, the heart has to work harder to move the high volume of blood through the blood vessels, leading to high pressure on the arteries (Perry, 2002). Dietary Salt restriction is hence beneficial in the control of BP especially in blacks (Haddy and Pamnani, 1995).

Low educational attainment and sedentary life style have been associated to hypertension with low socio-economic status, age, less occupational stress; psycho-social factors such as time impatience and hostility, depression, job strain (Davidson et al., 2000). Desai and Kavishwar (2009) conducted a study from August, 2004 - September, 2005 which discovered that the prevalence was high in males as compared to females. The study was about the effects of lifestyle factors on the prevalence of hypertension involving 1493 participants using cross- sectional survey. Hypertension was low in non-smokers as compared to the smokers which were high; it was also high in those who consume alcohol when compared with non-alcoholic people. In that same study it was seen that the cases of hypertension were raised among those who were overweight, those that takes in mixed food compared with vegetarians.

2.1.8 Complications of Hypertension

Hypertension leads to severe vessel-related and organs complications if not controlled well. Some of the complications include stroke, arteriosclerosis, renal dysfunction, hypertensive retinopathy and sexual dysfunction (WHO, 2017).

i. Arteriosclerosis

This is a condition where fatty fibro plaques are accumulated, resulting in artery wall thickness (WHO, 2017). Throughout the arterial walls a plague is form, decreasing the size of the vessel and reducing flow of blood. Over a time period, atherosclerotic lesions can totally block the lumen by build-up of the lesion or plaque material and later contribute to the formation of thrombus (Nettina, 2006).

From Perry (2002) blood cells (that is platelet and monocytes) and fat deposits gather at the area of damaged, forming a hard plaque that further narrows the way through which blood can flow. When plaque narrows the coronary arteries, a blood clot (a thrombus) is forms over the narrowed artery, and heart attack will follow (Casey & Benson, 2006). The disease can lead to angina, cerebral ischemia, myocardial infarction, cerebral haemorrhage and vascular dementia (WHO, 2017).

ii. Stroke

In this condition, individuals may be in an unconscious state and it may cause paralysis. Cerebrovascular accident is a cardiovascular disease when the blood vessels are obstructed or spontaneous vascular bleeding (cerebral haemorrhage) occurring (WHO, 2017). The major cause of disability and death in hypertension is cerebrovascular accident. Although African is lacking wide range of surveillance data for stroke, the data available indicate that age-standardized mortality, occurrence and case fatality of disabling cerebrovascular accident in Africa are the same or increase than those measured in most region of high- income. In Africa more than half of the patient with ischaemic stroke and more than 90% of the patients with haemorrhagic stroke are found to be hypertensive (Mensah, 2008). Example, intracerebral or subarachnoid haemorrhage result from vascular rupture, 80% of stroke can be Ischaemic, resulting from haemorrhage or embolism or thrombosis 20% (Beers et al., 2006).

Various Signs and Symptoms of Cerebrovascular Accident (Stroke)

- Abrupt onset of weakness or numbness of the arms, legs, face and mostly half of the body
- Abrupt mental delusion or confusion
- Slurring of speech or difficulty to understand commands
- Difficulty in seeing with the eye
- Abnormal coordination, walking and dizziness
- Abrupt severe headache without possible cause (Perry, 2002).

iii. Myocardial Infarction (Heart Attack)

Heart failure and myocardial infarction are caused by hypertension. When the heart does not contract proper due to the blockage of blood vessels supplying the heart muscle, a condition called myocardial infarction occurs which is commonly known as heart attack. Heart failure simply means the amount of blood supplied to the body is not enough due to the deterioration of heart function (WHO, 2017; Tortora & Derrickson, 2006)).

Various Signs and Symptoms of Myocardial Infarction

- Pains that radiate to the neck, shoulder or arm.
- Chest pain with fever or nausea, dizziness and difficulty in breathing.
- Pressure in the chest or pains in the sternal area which last for several minutes, chest discomfort (WHO, 2017).

iv. Renal Failure

One of the complications of hypertension includes renal failure. When the renal vessels are exposed to high blood pressure over a long period of time, they are destroyed and become little efficient at waste filtering. At the initial stage, there is detection of protein in urine. Later on, anaemia and oedema also occur. At the worse stage of the renal function, kidney transplant or dialysis may be needed (WHO, 2017). Classification of renal failure is either chronic or acute. Acute renal failure is a fast reduction in renal activities over weeks or days, leading to accumulation of nitrogenous products in the blood (Beers et al., 2006).

Various Sign and Symptoms of Renal failure

- Proteinuria
- Oedema,
- Anaemia
- Increase in blood pressure
- Deterioration to hypertensive nephropathy
- Frequency in micturition, mostly at night
- Dysuria
- Facial puffiness with oedema of feet and hand
- Lower back pain
- An unpleasant taste and odour in the mouth

v. Retinopathy

Hypertensive retinopathy can occur from extreme high blood pressure that leads to blindness and blurry of vision (Buckman & Westcott, 2006). Tortora & Derrickson (2006) unfolded that surface of the retina is the only area in the body where blood vessels can be examined and directly seen for pathological alterations, such as other illnesses and hypertension. Most researches have shown a relationship between retinopathy and hypertension (Defronzo, Ferrannini, Keen & Zimmet, 2004).

2.1.9 Hypertension Management

The management of hypertension can be group into two that is pharmacological and non- pharmacological treatment. According to the standard treatment guideline (2017), the non- pharmacological factors include:

- Reduction of salt intake
- Animal fat intake should be reduced
- Regular consumption of vegetable and fruits
- Reduction of weight in obese and overweight
- Increase physical activity e.g. Brisk walking for 30minutes 3times a week
- Avoidance or reduce in alcohol consumption
- Avoid or quit smoking

Pharmacological treatment, numerous classes of anti-hypertensive medications are readily available for the control and management of hypertension. These consist of endothelin receptor blockers, calcium channel blockers (CCB), diuretics, aldosterone receptor antagonist, renin inhibitors, a-2 adrenergic receptor agonist, vasodilators, angiotensin II receptor blocker (ARBs), and angiotensin­converting enzyme (ACE). The first line management of hypertension include the following antihypertensive medications, calcium channel blockers, ACE inhibitors, thiazide- diuretics and angiotensin II receptor blockers (James et al., 2014). Drugs from the diverse classes are used as single or in combination, but the vast cases demand more than a single medicine in the management of hypertension. The angiotensin-converting enzyme inhibitors prevent the action of the angiotensin converting enzyme and the angiotensin II receptor blockers work by antagonising the activation of angiotensin receptors. The diuretics raise the secretion of excess water and salt by the kidneys out of the body whilst the calcium channel blockers obstruct the incoming of calcium into the muscle cells of the wall of the artery (Go et al., 2014).

2.2 Prevalence and burden of hypertension

There is increase prevalence of hypertension in the low and middle income countries, the most prevalent region of hypertension is African, which the prevalence of tend to be he in the urban centers as compare to the rural areas (Manus et al., 2018). The report of hypertension in India between 2011 and 2013 depicts that, the hypertension prevalence in India after assessing the regional population size turns to be 29.8%. After using the Freeman-Turkey transformations to stabilize the regional-wise data, the total hypertension prevalence in India was (29.2%). Taking the rural and urban comparison into contemplation it was bare that in the North India, the huge prevalence of hypertension 14.5% and 28.8% in the rural and urban population respectively. Also East India prevalence of hypertension among the rural and urban was 31.7% and 34.5% in that order, again in the West India the same rural and urban comparison outcome was 18.1% and 35.8% for rural and urban respectively and lastly the South India prevalence of hypertension too was rural (21.1%) and urban (31.8%) of the population (Anchala et al., 2014).

Hypertension in Palestine occupies the eighth position as the chief cause of death in their country, with 13deaths per 100,000 people with rate of 5% of all death (Palestine Ministry of Health, 2012). Similarly, a research which of done in Enugu, South Eastern Nigeria, and the prevalence of hypertension was projected to be 5.4%, 6.9% in females and 3.8% in males (Ujunwa et al., 2013). Among Chinese, the hypertension prevalence from 1991-2011 was analyzed which indicated the prevalence of hypertension in males aged 50years raises from 9.81% in during 1991 to 36.6% in 2011, which shows the periodic of age-specific hypertension prevalence over a time frame thus from 1991-2011(Qi et al., 2019). In Northern Angola the approximated prevalence of hypertension was 23.0% and pre-hypertension was 44.8% with the highest portion of the people being men and in older age group as compared to the younger ones (Pires et al., 2013).

Europe is considered as a high-prevalence hypertension region with countries like Poland (70.7%), Germany (55.3%) and Spain (45.1%) having the highest world prevalence (Kearney et al., 2004). This high prevalence is attributed to excessive intake of nutrient, genetic susceptibility, physical inactivity, obesity, excessive consumption of alcohol, smoking, psychosocial stressors, and environmental toxins (Wolf-Maier et al., 2003). Germany has a prevalence of 55.3% that is about twice that of the United States of America 28.7% and Canada 22.0% (Prugger et.al., 2006). The prevalence of hypertension at Chingau in China from 2000 to 2010 reported to increase approximately 2% over the past 10years, which men has the higher prevalence rate as compare to women thus 30.2% and 23.4% in 2000 respectively and 31.0% and 27.8% in 2010 respectively. The isolated systolic hypertension in 2010 was double of what was recorded in 2000 in terms of prevalence (Huang et al., 2017).

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