Knowledge on Hypertension and Self-Care Practice among Adult Hypertensive Patients at University of Gondar Comprehensive Specialized Hospital, Ethiopia, 2019

Background Patients with hypertension need to be aware of various aspects of hypertension and exercise self-care. But, there is limited information regarding this issue. Objective of the Study. This study was designed to assess knowledge on hypertension and self-care practice among adult hypertensive patients in the University of Gondar Comprehensive Specialized Hospital, Ethiopia. Materials and Methods Descriptive cross-sectional study was conducted among 384 hypertensive patients from April to May 2019. The study participants were selected using a systematic random sampling technique. Data were collected using a pretested interviewer-administered questionnaire. Descriptive statistics such as percentage and frequency of patients' knowledge on hypertension and their self-care practice were computed. Cross-tabulation was used to see the frequency and percentage of selected sociodemographic variables and knowledge level with self-care practice subscales. Finally, the results were summarized and presented in texts, figures, and tables. Results Among the study participants, 215 (56%) and 228 (59.4%) had good knowledge and self-care practice towards hypertension, respectively. The participants who had good knowledge had good self-care practice frequency. Conclusions In this study, knowledge on hypertension was low, while self-care practice was moderate on the self-care interventions. Hence, increasing patients' awareness and intervention on medication adherence, low salt diet consumption, physical activity, weight management, cigarette smoking cessation, and alcohol consumption reduction is important.


Background
More than 80% of the burden of hypertension in low-income and middle-income countries is because of the lack of information and poor self-care practice [1]. Lack of knowledge about hypertension is a major challenge in controlling hypertension. To reduce this burden, patients have to be counseled on lifestyle changes when they visit their health facility and take measures regarding self-care [2][3][4] . e selfcare involves medication adherence, eating low-fat diet, regular physical exercise, limiting alcohol consumption, not smoking, weight reduction, self-monitoring of blood pressure (BP), regular health care visit, and reducing stress [5][6][7][8][9][10].
In a study conducted in Saudi Arabia, around 68% of patients knew their target BP level [11], while around 70% of patients did not know their BP level in Asia [12]. In South India, 52.4% of hypertensive patients had average or good knowledge [13], and 14%-56% were aware of hypertension in Nepal [14]. On the other hand, 82% of patients did not know about hypertension and 92.2% had inadequate knowledge on hypertension in Canada and Sri Lanka, respectively [15,16]. In Botswana, more than 96% of patients responded as reducing smoking and stress can prevent hypertension, but almost equal proportion of participants were knowledgeable about alcohol restriction (65.2%), dietary restriction (66.3%), and physical exercise [17]. In Addis Ababa, Ethiopia, 43.6% hypertensive patients had good knowledge about hypertension [18], 9.2% knew the ideal BP, and 67.7% believed that exercise can reduce BP in a study conducted in Jimma University [19].
In India, 62.9% of the study participants had unfavorable self-care practice [20]. But, in Jeddah, Saudi Arabia, the selfcare practice ranged from 31.2% to 83.7% in each self-care subscales [11]. In a study conducted in Western Nepal, more than 55% of patients involved in their own care in each selfcare practice components (70% did not take alcohol/quit smoking, 80.6% took low fat and salt diet, 69.7% monitored their BP regularly, 58.2% reduced their stress, and 85% used medication regularly) [21]. In another study conducted in outreach clinic of South India indicated that 11.4%, 49.2%, and 39.2% hypertensive patients had good, average, and poor self-care practice, respectively [13]. A study conducted in Northwestern Nigeria showed that majority of the participants had inadequate self-care practice [22]. In studies conducted in Ethiopia, 51% of hypertension patients had poor self-care practice in Dessie town [23], and 51.5% of study participants had good self-care practice in Addis Ababa [18]. In addition, only 1.5% of participants smoked and 94.6% followed salt restrictions in Jimma University [19].
Nevertheless, limited studies have been conducted on this issue in Ethiopia, in the study area in particular. erefore, this study is designed to assess knowledge on hypertension and self-care practice among adult hypertensive patients.

Study Design, Area, and Period.
is hospital-based descriptive cross-sectional study design was conducted at the University of Gondar Comprehensive Specialized Hospital (UoGCSH) from April to May 2019. UoGCSH provides different specialized services in four major departments: the Pediatrics, Surgery, Gynecology and Obstetrics, and Internal Medicine. It also has its own chronic disease such as hypertensive patients follow-up service. Hypertensive patients are attending their follow-up monthly. On average, 450 adult hypertensive patients are attending their follow-up in the hospital per month [24].

Study Population.
All adult hypertensive patients on follow-up were the source population. Hypertensive patients available during data collection period were included. Participants who have attended their follow-up less than six months and could not to be interviewed were excluded.

Sample Size, Sample Technique,
and Procedure e sample size was calculated by using a single population proportion formula: where n � sample size, z � 1.96 at 95% confidence level, d � 5% margin of error, and p � 51.5%, proportion for selfcare practice among hypertensive patient, which was taken from a study conducted at Addis Ababa [18]. Accordingly, the sample size was 384. e study used systematic random sampling technique. Card numbers of the study participants were selected first from the log book according to their follow-up. Next, patients were selected using eligibility criteria. en, unique numbers were given for each participant.
e sampling frame was determined from the monthly patient flow, i.e., every two patients were used to select each study participants. e first person was selected by simple random sampling.

Operational Definitions
Participants were labeled as knowledgeable if they scored median and above and nonknowledgeable if they scored below the median. Twelve items were used to measure knowledge. e response of participants in each item was coded as "Yes" if they answered the items correctly, and "No" if they answered incorrectly. Median was calculated from items which were answered correctly.

Self-Care Practice.
Patients report on their engagement with any kind of recommended self-care activities. Participants were categorized as having good practice if they scored median and above and having poor practice if they scored below the median [25]. Self-care practice was measured by Hypertension Self-Care Activity Level Scale Effects (H-SCALE), which has six outcome domains: medication adherence (3 items): responses range from 0 to 21, and participants who reported that they followed the 3 recommendations on 7 out of 7 days were considered adherent (score � 21). Low-salt diet (12 items): scores of 6 out of 7 days were considered adherent. Physical activity (2 items): responses range from 0 to 14. Participants who scored 8 or better were considered adherent. Smoking (2 items): responses ranges from 0 to 14, and respondents who reported 0 days were considered a nonsmoker and all others were smokers. Weight management (10 items): responses range from 10 to 50. Participants who agreed or strongly agreed with all 10 items (score ≥40) were considered to be following good weight management practices. Alcohol (3 items): responses range from 0 to 21. Participants who did not take any alcohol in the last 7 days or who did not drink at all were considered abstainers. All others were nonadherent.

Data Collection Instrument/Tools and Procedure.
Semistructured interviewer-administered questionnaire was used to collect the data. e tool has three sections: Section I: sociodemographic information; Section II: knowledge-related questions; Section III: self-care-related questions. Knowledge on hypertension was assessed by a validated tool for hypertensive patients [26]. To measure self-care practice, Hypertension Self-Care Activity Level Effects (H-SCALE) which was used in a previous study in Jimma, Ethiopia, was used [27]. All questionnaires were prepared in English language and then translated to Amharic (local language), which has been used for data collection. To keep the quality of the data completeness of the questionnaire, it was checked before data entry, and EPI-data version 3.1 was used to minimize the data entry error.

Data
Processing and Analysis. Data were checked for completeness, edited, and entered to EPI-data version 3.1 and exported to SPSS version 21 for analysis. e data were explored to see missing values, the shape, and distribution of the data. On the basis of this information, there are no missing values, and the data were almost normally distributed. Descriptive statistics (frequencies, percentages, mean values, and standard deviations) were calculated for demographic characteristics. en, the percentage and frequency of patients' knowledge on hypertension and their self-care practice were computed. Cross-tabulation was used to check the frequency and percentage of selected sociodemographic variables and knowledge level with self-care practice subscales. Finally, the results were summarized and presented in texts, figures, and tables.

Sociodemographic Characteristics of Hypertensive
Patients.
e response rate of the study was 100%. e median age of the participants was 56 years (SD ± 13.6). Most of the respondents, 178 (46.4%), were within the age group of 41-60 years. Majority of the respondents, 139 (36.2%), 266 (69.3%), and 255 (66.4%), were housewife, lived in urban area, and married, respectively. A large proportion of the study participants, 303 (78.9%), had no family history of hypertension (Table 1).

Knowledge of Hypertensive Patients about
Hypertension.
e majority, 365 (92.4%) and 379 (98.7%), reported that hypertension is a serious disease and regular check-ups are important, respectively. But, 144 (37.5%) of the respondents were not aware about the normal BP level. Most of the respondents, 305 (79.4%) and 339 (88.3%), were aware of about the negative impact of smoking of cigarette and alcohol drinking, respectively. Around half of the respondents, 188 (49%), knew diets that consist of low-fat milk and whole wheat bread ( Table 2).

Self-
In the cross-tabulation of self-care practice with knowledge level, a higher frequency of good self-care practice was observed among those who had good hypertension knowledge.

Discussion.
is study was intended to determine knowledge on hypertension and its self-care practice among adult hypertensive patients at the University of Gondar Comprehensive Specialized Hospital. Based on this aim, 56% and 59.4% had good knowledge and overall self-care practice, respectively. More than half of hypertensive patients had good knowledge of hypertension in this study.
is finding is similar to the study finding in South India (52.4%) [13]. On the other hand, it is higher than studies conducted in Nepal (14%) [14], Ethiopia (43.6%) [18], and Canada (18.2%) [15]. e possible reasons for the difference might be due to the study setting, sample size, and study period variation between the current study and previous studies.
In this study, almost sixty percent hypertensive patients had good self-care practice towards hypertension. is finding is higher than the studies conducted in Addis Ababa, Ethiopia (51.5%) [18] and south India (14%) [13]. ese differences could be due to variation in residence and study period as majority of the participants were from urban in this study, which might help them to get information easily. In addition, it is the government's current agenda to work on noncommunicable diseases.
Similarly, in this study, majority of the participants had good medication adherence, which is lower than studies conducted in Saudi Arabia (83.7%) [11] and Western Nepal (85%) [21]. is variation might be due to the reason that majority of the participants in the current study were not knowledgeable about hypertension. In the current study, almost quadruple times of the respondents had low-salt diet adherence. is finding is lower than studies conducted in Saudi Arabia (79.3%) [11] and Ethiopia (94.6%) [19]. But, it is higher than the study conducted in Nigeria (18.5%) [22]. is might be due to the variation in the study setting, sample size, and study period variation. is study also revealed that below one-third of the participants had adhered with physical activity recommendations, which is lower than the study conducted in Saudi Arabia (57.3%) [11], but higher than study conducted in Nigeria (9.3%) [22]. e difference could be that participants were not well educated about self-care practice towards lowsalt diet and physical activities in the current study. e current study pointed out that majority of the participants had quit smoking, which is an important aspect of self-care practice. is finding is in line with the study conducted in western Nepal (70%), and it is lower than the study conducted in Jimma, Ethiopia (98.5%) [19]. But, it is higher than the study conducted in Saudi Arabia (31%) [11]. is difference could be due to majority of the participants who were from urban in the International Journal of Hypertension current study, but the reverse is true in Saudi Arabia where life style and urbanization affect smoking condition. is study also ascertained that more than half of the study participants had good weight management practice, which is comparable to the study conducted in Saudi Arabia (59.9%) [11].

Clinical Relevance of the Study
As shown above and mentioned by different literatures, understanding the level of patients knowledge on hypertension and its self-care measures are an important topic to be addressed to fill treatment gaps. e current study points out that the patient's involvement in their own care can bring good clinical outcome. is will have an impact to avert hypertension-related complication and mortality.

Conclusions
e level of knowledge and self-care practice among hypertensive patients were relatively low, and almost 80% of participants had poor self-care practice in the physical activity domain. Hence, giving focus on awareness of hypertension and self-management of hypertensive patients are important. Furthermore, a large follow-up study is recommended.
Data Availability e datasets generated and/or analyzed during the current study are not publicly available due to some privacy reasons, but part of the raw dataset will be available from the corresponding author upon reasonable request.  International Journal of Hypertension

Additional Points
Since the study assessed the perceived patient's report, it might underestimate or overestimate the result.

Ethical Approval
Ethica clearance was obtained from the ethical review committee of the School of Nursing, College of Medicine and Health Sciences, University of Gondar. Official permission was obtained from the study site.

Consent
Oral informed consent was obtained from study participants.

Conflicts of Interest
e authors declare that they have no conflicts of interest.