Adherence to lifestyle modifications and its associated factors among adult hypertensive patients attending their follow-up at public hospitals in West Shoa, Oromia, Ethiopia, 2023

Hypertension is the most common chronic disease in adults and a serious medical condition that is recognized as the leading risk factor for premature death, disability, and global disease burden [1]. Modifiable risk factors such as unhealthy diet, physical inactivity, tobacco and alcohol use, and being overweight or obese all increase the risk of developing hypertension and its complications [2]. Unhealthy diets, such as saturated fats, combined with low intake of fruits and vegetables, increase the risk of high blood pressure and cardiovascular disease [3].

Non-pharmacological interventions such as lifestyle modification, as well as pharmacological treatments, are required for hypertension management [4]. Lifestyle changes continue to be an effective alternative to drug therapy for the prevention, treatment, and control of high blood pressure, with very low costs and side effects [5]. It is also encouraged as adjunctive treatment for persons on drug therapy to enhance its effects [6].

Prevention and control of high blood pressure is one of the cornerstones in combating disease that cause cardiovascular complications. Adherence to significant lifestyle changes is one approach to such prevention [7]. Nearly 9.4 million deaths worldwide result from hypertension related complications [1]. Uncontrolled hypertension results in hypertension-mediated end organ damage such as brain, heart, kidneys, central and peripheral arteries and eyes [8]. In low and middle-income countries, the prevalence and absolute burden of hypertension are dramatically increasing [9]. It is also one of the most common health problems in Ethiopia [10].

Despite evidence of the usefulness and benefits of lifestyle modifications, non-adherence is a major clinical and public health challenge in the management of hypertension in low- and middle-income countries [11,12,13]. Non-adherence to lifestyle modifications, such as inability to modify their diet, consumption of excessive salt, harmful use of alcohol, smoking, and lack of regular physical activity, is very common in hypertensive patients worldwide [14, 15].

Identifying magnitude of lifestyle modification adherence and its associated factors can be used as a tool for advocacy by various stakeholders in sensitizing and influencing people with hypertension to change their lifestyle. It assists healthcare providers in developing appropriate management interventions to encourage lifestyle changes in hypertensive patients. It will also be used as input by hospital administrators in planning interventions to improve patients’ compliance with hypertension management in order to reduce the impact of hypertension and its complications on patients’ quality of life and the health-care cost burden. Therefore, this study aimed to assess adherence to lifestyle modifications and its associated factors among adult hypertensive patients attending follow up at Public Hospitals in West Shoa.

Study area, period

This study was conducted in public hospitals in the West Shoa Zone, Oromia Regional State, Ethiopia. According to information from the zonal health office, currently, the zone has eight public hospitals, 92 health centers, and 520 health posts. As stated by hospital’s chronic disease registration reports, the total number of hypertensive patients registered for follow-up in the total public hospitals was about 1212. The study was conducted from August 20 to September 20, 2023.

Study design

An institution based cross-sectional study design was used.

Population

All hypertensive patients who were attending follow-up at public hospitals in West Shoa Zone, Oromia Regional State, Ethiopia were a source population. All hypertensive patients who were visiting the selected public hospitals’ hypertension follow-up clinics in the West Shoa Zone during the time of data collection were included in the study population. Hypertensive patients who were critically ill and unable to provide the required information were excluded during the time of data collection.

Sample size determination and sampling technique

Sample size was determined for the magnitude of lifestyle modification adherence by using a single population proportion formula, considering the following assumptions: The magnitude of lifestyle modification adherence was 46.4% (P = 0.464) from a study conducted in Addis Ababa, Yekatit 12 Hospital Medical College [16], margin of error 5% (d = 0.05) and 95% confidence level(Zα/2 = 1.96). Then, the calculated sample size was 382.

Since the source population is below 10,000, finite population correction formula was used.

Where;

nf = the final sample size, ni = initial sample size = 382, and

N = total hypertensive patients in public hospitals in West Shoa

By considering a 10% non-response rate, the final sample size was 320.

From eight public hospitals in West Shoa that give hypertension follow-up services, four were selected using a lottery method for simple random sampling. The total number of hypertensive patients registered for follow up in the selected hospitals during the data collection period was 653. The sample size was proportionally allocated to each of the selected hospitals. The study subjects were selected by a systematic sampling technique.

Study variables

Adherence to lifestyle modifications is a dependent variable. Independent variables include socio-demographic characteristics (age, sex, religion, educational level, occupational status, residence, and marital status); disease-related characteristics (co-morbidity, duration of hypertension treatment, family history of hypertension, number and frequency of drug intake per day), attitude toward lifestyle modifications, perceived social support, and self-efficacy.

Operational definitions

Lifestyle modifications adherence are respondents who reported that they were adherent to the all recommended healthy lifestyles (regular physical activity, smoking cessation, following a healthy diet for hypertension and moderated alcohol drinking). Lifestyle modifications non-adherence are respondents who reported that they were not adherent to one or more of the recommended healthy lifestyle modifications [14, 17].

Physical activity adherence

respondents who reported that they performed moderate physical activities such as brisk walking, jogging, cycling or household chores for at least 30 min per day for 5–7 days per week [18].

Attitude toward lifestyle modifications

Based on the total score of a 6-items of the attitude questions with 5-point Likert scale, respondents who scored median value and above were considered to have “favorable attitude”, while those who scored below median score were considered as having “unfavorable attitude” toward lifestyle modifications [19].

Perceived social support

Perceived social support was measured by the respondents’ score on the ENRICHD social support instrument (ESSI). The scoring criterion is based on the participant’s score on 5 of 7 items (items 1, 2, 3, 5, and 6) which were summed to create a total score ranging from 5–25, with higher scores (>18) indicating high perceived social support [20].

Self-efficacy

Self-efficacy was measured by the respondents’ score on Hypertension Self efficacy Scale. A score of self-efficacy greater than or equal to the mean score was classified as having good self-efficacy while the score of self-efficacy lower than the mean score was considered as poor self-efficacy [21].

Data collection tool and techniques

Data was collected by using face-to-face interview guided questionnaires. Questionaries’ related to demographic characteristics, disease related characteristics, attitude toward lifestyle modifications and all components of lifestyle modifications were adapted from review of different literatures [14,15,16, 19, 22,23,24].

A set of six items were used to measure attitude toward lifestyle modifications among hypertensive patients. Each items contains a five-point Likert scale to be coded as ‘1’ for strongly disagree, ‘2’for disagree, ‘3’ for neutral, ‘4’ for agree and ‘5’ for strongly agree.

Its internal consistency (Cronbach’s alpha) was checked and it became 0.87. The ENRICHD social support instrument (ESSI) was used to measure perceived social support and 5-items Hypertension Self-Efficacy Scale was used to measure self-efficacy. Its reported that internal consistency (Cronbach’s alpha) was 0.88 [25]. It contains first 6 items with a 5-point Likert scale ranging from 1 = none of the time to 5 = all the time. The 7th item is a Yes/No question. Its internal consistency (Cronbach’s alpha) was rechecked and it became 0.84.

The 5-items Hypertension Self-Efficacy Scale was used to measure self-efficacy. Its reported that internal consistency (Cronbach’s alpha) was 0.81. It was revised for hypertension self-efficacy from the six items Chronic Diseases Self-Efficacy Scale by replacing the word ‘illness’ with ‘high blood pressure’. Originally, each item contains a 10-point scale ranging from ‘1’ for totally unconfident to ‘10’ for totally confident. The alternatives was modified to 5-point scale and coded as ‘1’ for completely unconfident ‘2’ for unconfident, ‘3’ for not sure, ‘4’ for confident and ‘5’ for totally confident [21]. Its internal consistency (Cronbach’s alpha) was rechecked and it became 0.86.

Data quality control and management

Two weeks prior to the actual data collection, the questionnaire was pre-tested on 5% of the sample size among hypertensive patients who had hypertension follow up at Guder Primary Hospital. Data collectors and supervisors were trained for one day on the study tools and data collection procedure before the actual data collection time. The collected data was checked for its completeness on daily basis.

Data processing and analysis

Data was checked, coded and entered in to Epi-Data version 3.1 and then it was exported to Statistical Package for the Social Sciences (SPSS) version 25.0 for statistical analysis. Descriptive statistics was used to describe the study participants. Bivariate analysis was done to see the association of each independent variable with the outcome variable. Variables with a p-value < 0.25 during bivariable analysis were entered into a multivariable binary logistic regression analysis. Odds ratio with its 95% CI was estimated to identify the factors associated with the outcome variable where the level of statistical significance was stated at p-value < 0.05.

Socio-demographic characteristics of the hypertensive patients

Out of the total hypertensive patients attending the chronic follow up units of public hospitals during the study period, 316 eligible patients were included in the study, with response rate of 98.8%. One hundred seventy (53.8%) of them were males. The mean (standard deviation) age was 55.23( ± 12.95) years. Concerning educational status, 125 (39.6%) of them had no formal education at all and 79(25.0%) had diploma and above (Table 1).

The disease related characteristics of the hypertensive patients

In this study, 194 (61.4%) of respondents had no family history of hypertension. More than half of the respondents, 163(51.6%) were on hypertension treatment for five years or more. Of the total respondents, 190(60.1%) had no co-morbidities. More than three-fifth of the respondents, 197(62.3%) took two or more drugs per day and 189(59.8%) respondents took drug more than once daily.

Attitude toward lifestyle modifications adherence

About half, 161(50.9%) of the participants had favorable attitude, whereas 155(49.1%) unfavorable attitude toward lifestyle modifications to control hypertension (Table 2).

Of the total participants, 103(32.6%) had high perceived social support while 213(76.4%) had low perceived social support. Regarding self-efficacy, about 165(52.2%) had good self-efficacy whereas 151(47.8%) had poor self-efficacy.

Adherence to recommended lifestyle modifications

This study found that 97(31%) of the participants were found to be adherent to lifestyle modification. In contrast to this, 213(69%) of hypertensive patients were found to be non- adherent to the recommended life style modification (Fig. 1).

Blue section as indicated represents the proportion of patients who adhered to lifestyle modification, while the orange section indicates those who were non-adherent. Of the total participants, 103(32.6%) had high perceived social support while 213(76.4%) had low perceived social support. Regarding self-efficacy, about 165(52.2%) had good self-efficacy whereas 151(47.8%) had poor self-efficacy.

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Factors associated with lifestyle modifications adherence

The association of dependent and independent variables was done using bivariate and multivariable binary logistic regression analysis. Hypertensive patients who aged 25–44years were 2.71 times more likely to be adhere with recommended lifestyle modifications (AOR = 2.71, 95% CI: 1.19–6.19, p = 0.018) than those aged 65–84years. On the other hand, patients who living in urban area had 81% less likely to be adherent to lifestyle modifications (AOR = 0.19, 95%CI: 0.09–0.39, p = 0.001) when compared with patients who living in rural areas.

Similarly, hypertensive patients who had less than five years of treatment durations were 2.17 times more likely to be adherent to recommended lifestyle modifications (AOR = 2.17, 95%CI: 1.14–4.13, p = 0.018) when compared with patients who had more than five years of hypertension treatment durations.

Patients who had favorable attitude toward lifestyle modifications were 2.14 times more likely to be adherent to recommended lifestyle modifications (AOR = 2.14, 95%CI: 1.06–4.30, p = 0.033) than patients who had unfavorable attitude toward lifestyle modifications. Similarly, patients who had high perceived social support were 6.23 times more likely to be adherent to recommended lifestyle modifications (AOR = 6.23, 95%CI: 3.18–12.22, p = 0.001) than patients who had low perceived social support. In addition, patients who had good self-efficacy were 2.66 times more likely to be adherent to recommended lifestyle modifications (AOR = 2.66, 95%CI: 1.25–5.69, p = 0.011) when compared to patients who had poor self-efficacy (Table 3).

The objective of this study was to determine the magnitude of adherence to lifestyle modifications and identify factors that associate with lifestyle modifications adherence among hypertensive patients attending chronic follow up units of public hospitals in West Shoa.

In this study, the magnitude of adherence to the recommended lifestyle modifications was found to be 31% (95% CI: 25.7–36.1%). The result of this study was higher compared to study done in Kenya, Jordan, Nepal and Ethiopia, Dessie [11, 16, 22, 26]. On the other hand, the finding of this study is lower than the studies done in Ghana [25], Eritrea [26] and Ethiopia [23, 25, 27, 28]. This inconsistency might be due to health care system level variation, cultural belief and practice disparity, low economic status, environmental influences, low educational status and awareness created variance, and religious influences. However, the result of the current study is comparable with the study conducted in Harari, Ethiopia [29].

In this study, young adults were more likely to be adherent to recommended lifestyle modifications than the older adults. This finding is in line with the studies done in Nepal and Addis Ababa [23, 26]. This is may be due to the fact that young adults have more energy and better physical capacity to engage in physical exercise and made dietary adjustments. In addition to this, they are more likely exposed to health information through social media, education system, and public health campaign. Hypertensive patients who were urban residents less likely to be adherent to the recommended life style when compared with patients who were rural residents. In reality, urban residents were less adherent to the recommended life style change due sedentary life style and lack of physical activities, poor dietary habit and more availability of processed foods, time constraint because of urban residents often work longer hours, leaving less time for physical activities and meal adjustments. In opposite, this finding is inconsistent with the studies done in China and South Korea where rural residents were less adherent to lifestyle changes recommendations [30, 31].

Respondents who had favorable attitude toward lifestyle modifications were more likely to be adherent than respondents who had unfavorable attitude. In accordance to this, studies in Jordan and Mizan Tepi, Ethiopia showed that patients with positive attitude about hypertension management were found to be more adherent compared to the patients with negative attitude [15, 22]. It’s known that peoples who have favorable attitude are more motivated, open to change, and perceived health improvement as achievable and valuable. Respondents who had high-perceived social support were more likely to be adherent when compared with those who had low perceived social support. Consistent to this finding, a study conducted in Dessie town, Ethiopia found out that high-perceived social support was associated with better adherence [32]. A patient may feel more assured about their comprehension of their treatment and the significance of adherence if they see that their friends or family are supporting them.

In addition, this study found out adherence to lifestyle modifications was higher among hypertensive patients with good self-efficacy than those with poor self-efficacy which is supported by studies done in Thailand, Punakha and Dessie, Ethiopia [16, 33, 34]. This might be due to patients with good self-efficacy have more confidence to care for their high blood pressure that may result in better self-care adherence. This explanation is partly supported by the fact that self-efficacy is one’s belief in the ability to perform a behavior necessitated to produce a desired outcome that patients with good self-efficacy perceived themselves to be more capable of performing self-care and thus made greater efforts to practice recommended lifestyle modifications [34, 35].

This study has some limitations. First, there might be social desirability bias since the adherence of the healthy lifestyle behaviors of the study participants were based on self-reports which may affect measurement precision. Second, this study was conducted only in public hospitals. This study did not include hypertensive patients who were attending follow up in private health facilities. In spite of these limitations, the study tried to assess exhaustively the magnitude of lifestyle modifications adherence and its associated factors, so that it can be used as input for the responsible body who working on this area for interventions.

In this study, the magnitude of adherence to recommended lifestyle modifications found to be low. Older age patients, urban residents, have been receiving treatment for hypertension longer, having favorable attitude toward lifestyle modifications, perceived social support and poor self-efficacy are factors identified for this low adherence to lifestyle modifications. Therefore, to overcome low adherence to lifestyle modification, both governmental and non-governmental organization intervention is needed. A combination of education, behavioral and social support, and environmental change is very important. Providing health education about the benefits of lifestyle change, encouraging self-monitoring, and engaging social support from family, friends, and support groups further enhance adherence to the recommended lifestyle modification.