The Prevalence of Hypertension and Associated Risk Factors among Secondary School Teachers in Bahir Dar City Administration, Northwest Ethiopia

Background Hypertension is one of the noncommunicable cardiovascular diseases (CVDs), and its prevalence is rising in middle- and low-income countries. It is not given enough attention in the developing countries like Ethiopia. Not enough data and studies about hypertension are available in Ethiopia. This study aimed to determine the prevalence of hypertension and its associated risk factors among secondary school teachers in Bahir Dar city administration. Methods An institutional-based cross-sectional survey was conducted among secondary school teachers in Bahir Dar. Two hundred twenty-two randomly selected teachers were interviewed, and data related to the demographic, behavioral, health, and dietary characteristics of the individuals were recorded. Blood pressure data were taken. Logistic regression analysis had been used to assess independent risk factors for hypertension. p-values of less than 0.05 were considered statistically significant. Results The overall prevalence of hypertension in the study was 29.28%. Age 41 to 50 (AOR: 2.506; 95% CI: 1.103–5.694; and p=0.028), having self-reported diabetes mellitus (AOR: 8.595; 95% CI: 2.795–26.424; and p < 0.0001), having a family history of hypertension (AOR: 3.387; 95% CI: 1.579–7.285; and p=0.002), khat chewing (AOR: 5.426; 95% CI: 1.811–16.256; and p=0.003), physical inactivity (AOR: 5.212; 95% CI: 1.974–13.763; and p=0.001), and presence of self-reported repeated stress (AOR: 3.027; 95% CI: 1.404–6.527; and p=0.005) were the risk factors associated with hypertension. Conclusions Different intervention measures with a particular emphasis on prevention by introducing lifestyle modifications are highly recommended to mitigate and control hypertension.


Introduction
Blood pressure (BP) is the force of circulating blood on the walls of the arteries [1]. It has two components, namely, systolic BP (SBP) and diastolic BP (DBP) [2]. SBP is the maximum blood pressure during contraction of the ventricles, and DBP is the minimum pressure recorded before the next contraction [3]. BP is written with the SBP first, followed by the DBP (e.g., 120/80) [1]. Based on SBP/DBP, BP in adults is classified as normal (<120/<80), prehypertension (120-139/80-89), stage one hypertension (140-159/90-99), and stage two hypertension (≥160/≥100) [4]. Hypertension brings about the damage of the heart, damage of blood vessels in the brain and the kidneys, enlargement of the heart, heart failure, stroke, kidney failure, blindness, and cognitive impairment [5].
Globally, an estimated 17.9 million people died from cardiovascular diseases in 2016, representing 31% of all global deaths. Of these deaths, 85% are due to heart attack and stroke [6]. Hypertension is the leading risk factor for mortality and the main cause of global disability-adjusted life years (DALYs). In 2015, SBP attributed to 10.7 million deaths and nearly 212 million DALYs [7]. e prevalence of hypertension increase after 2000 may be due to lifestyle changes, and the highest global hypertension prevalence has shifted from highand medium-income countries (HMIC) to low-and mediumincome countries (LMIC) [8]. For example, in 2010, 28.5% of adult hypertension was in high-income countries and 31.5% in low-and middle-income countries [9]. Because of weak health systems, the number of people with hypertension who were undiagnosed, untreated, and uncontrolled is also higher in low-and middle-income countries compared to the highincome countries [10]. By 2025, the projected number of people with hypertension is expected to rise by 60% and reach 1.56 billion people globally [11].
Hypertension is a widespread problem in sub-Saharan Africa (SSA), and in some communities, it has been reported to be as high as 38% [12]. In 2015, the prevalence of hypertension among the Ethiopian population was estimated to be 19.6% (23.7% among urban population and 14.7% among the rural and urban combined population) (20.6% among males and 19.2% among females) [13].
ere is no single precise cause of hypertension [19]. However, there are known risk factors that increase the possibility of hypertension. e risk factors of hypertension can be classified as modifiable and nonmodifiable [20]. Modifiable risk factors are risk factors of hypertension that many people can reduce their blood pressure by changing their diet and lifestyle [10]. ey include unhealthy diets (excessive salt consumption, a diet high in saturated fat and trans fats, and low intake of fruits and vegetables), physical inactivity, consumption of tobacco and alcohol, and being overweight or obese, whereas the nonmodifiable risk factors of hypertension are a family history of hypertension, age over 65 years, gender, genetics, and coexisting diseases such as diabetes or kidney disease [21].
Many studies in Ethiopia have identified risk factors associated with hypertension, for example, the male gender, overweight, and sleep duration of ≤5 hours [22]; age, having ever smoked cigarette, the number of hours spent walking/ cycling per day, the number of hours spent watching TV per day, history of diabetes, adding salt to food in addition to the normal amount that is added to the food during cooking, and body mass index [15]; having ever been told hypertensive, using animal product butter, physical inactivity, and BMI 25.0 to 29.9 and greater than 30 [23]; age, cigarette smoking, alcohol drinking, and khat chewing [14]; and tobacco use, alcohol abuse, overweight and physical inactivity together with poor access and utilization of health services, absence of health insurance schemes, and rapid urbanization [24].
Generally, different literatures showed that the prevalence of hypertension is increasing radically especially in developing countries like Ethiopia and particularly in urban settings. Its prevalence is associated with socioeconomic, demographic, lifestyle, and dietary factors. e present study thus aimed to evaluate the prevalence of hypertension and associated risk factors among secondary school teachers in Bahir Dar city administration.

Description of the Study Area.
Bahir Dar is a town located in northwest Ethiopia at the southern extreme of Lake Tana where the Blue Nile starts its long journey to the Sudan and Egypt. It is situated at an altitude of about 1820 meters above sea level, at the geographic coordinates 11°36′ N and 37°25′ E [25]. e town is 567 and 465 km northwest away from Addis Ababa through Debre Markos-Bure and Dejen-Motta roads, respectively [26]. Based on the 2017/18 budget annual statistical bulletin of Amhara National Regional State Plan Commission, the city administration has a projected population of 341,608 (161,758 males and 179,850 females). From this population, 281,886 (82.5%) are urban inhabitants and the rest 59,720 (17.5%) rural inhabitants. e town has a total area of 361.74 square kilometers or 36,174.36 hectares. According to the information gathered from the city mayor office, the city administration is currently divided into six subcities, three satellite towns, and 26 urban and 14 rural "Kebeles" for administrative purposes (Kebele is the smallest administrative unit in Ethiopia). e three satellite towns/suburban areas are Zegie, Meshenti, and Tis Abay. e satellite towns have their municipalities, which are under the jurisdiction of the main city mayor. In the city administration, there are ten privately owned, ten government-owned, and one prison-owned secondary schools.

Study Design and Period.
e researcher used an institutional-based cross-sectional descriptive survey to assess the prevalence and associated risk factors of hypertension among secondary school teachers in Bahir Dar city administration, northwest Ethiopia. All government-owned secondary schools were included. e secondary schools selected for the study had a total number of 710 teachers (492 males and 218 females). Interviews and physical measurements were conducted from December 2019 to February 2020. e gathered data were tabulated and statistically analyzed using SPSS software version 21.

Study Participants and Sampling
Techniques. Ten government secondary schools of Bahir Dar city administration were included in the study. e complete name lists of teachers were collected from these schools. e collected lists of all teachers from these ten secondary schools were alphabetically ordered. Participants were selected by a computer-based systematic random sampling method. e required sample size was determined by Cochran's formula [27]: where n is the sample size, p is the estimated proportion, z is the confidence level (usually 1.96 for 95% confidence level), and e is the desired level of precision. e prevalence of raised blood pressure among the adult population according to the study done by Ayele Simachew and Abdurehman To compensate for a nonresponse rate, 5% of the calculated sample had been added and the result was (211 × 0.05) + 211 � 222. e proportional sample size taken from each secondary school is indicated in S_1.

Inclusion and Exclusion
Criteria. Secondary school teachers in the city administration except for pregnant women and those teachers who were severely sick during the time of data collection were included in the study.

Study Variables.
Hypertension status was the outcome (dependent) variable, and the independent (predictor) variables were sociodemographic characteristics (sex, age, marital status, religion, educational status, and income); behavioral factors (alcohol consumption, smoking, khat chewing, physical activity, feeding styles, and stress); and other factors (body mass index, waist circumference, selfreported family history of hypertension, and self-reported diabetes mellitus).

Blood Pressure Measurement.
e prevalence of hypertension in this study was determined using the systolic and diastolic blood pressure measurements taken during the data collection time and those teachers who were under hypertension medication during the survey time. e prevalence of hypertension in this study refers to the number of respondents whose average value of SBP was above or equal to 140 mmHg and/or DBP was greater than or equal to 90 mmHg during screening time. Teachers whose average BP was less than or equal to 140/90 mmHg and under hypertension medication (taking antihypertensive drugs) during the time of data collection were considered hypertensive.
BP measurement was conducted based on the WHO guidelines for the management of hypertension [28]. Blood pressure was measured in a sitting position using a digital BP measuring device (Omron M3-Automatic Upper Arm Blood Pressure Monitor). e purpose of the measuring device was to determine the proportion of the study population with raised blood pressure. Two consecutive BP measurements were taken from the 222 respondents. BP was measured while both arms were placed on the table with the palm facing upwards. e subjects of the study remained resting for at least five minutes before the first measurement at the data collection center, and it had been made sure that they should not take caffeine and alcohol and should not do physical activity/exercise for at least 30 minutes before the BP measurement. e second BP measurement had been taken after five and more minutes' interval from the first measurement. e averages of the two readings of PB were used for analysis. e measurements were taken from 8:00 AM to 2:00 PM in schools in a private class.

Anthropometric Measurement.
Anthropometric physical measurements such as weight, height, and waist circumference (S_2) were conducted for the 222 teachers to estimate the prevalence of overweight and obesity in the study population by excluding pregnant women. e weight and height data were used to compute BMI (S_3). e measurement values of weight and height were calculated using the BMI formula. BMI and WC were calculated to determine the obesity and overweight of the respondents. A digital personal weighing scale for weight measurement and standardized height and waist circumference measuring devices were used. Weight was measured to the nearest 0.1 kg and height to the nearest 0.1 cm in the standing position using a portable height meter. e weight measuring scale was checked and adjusted at zero levels between each measurement. e BMI of respondents was calculated as weight in kg divided by height in meters squared. Waist circumference was measured by using a nonstretching tape meter by placing a tape measure around the abdomen at the midpoint between the lower margin of the last palpable rib and the top of the iliac crest of the hipbone.

Questionnaire
Survey. Data were collected by a structured questionnaire consisting of close-ended questions and physical measurements. e purpose of the questionnaire was to gather selected sociodemographic and behavioral characteristics of secondary school teachers from a representative sample (S_4). Anthropometric measurement spaces that were filled by a health officer were included in the questionnaire. e questionnaire was prepared in English language, and translation into Amharic was not needed since all the respondents were able to read and write the English language.
Private measurement areas or classes were prepared in the schools by school administers for BP, BMI, and WC measurements. e questionnaires were handed directly to the participants with clear instructions on how to complete the questionnaires. Finally, the filled questionnaires were collected by the investigator and other persons assigned by the investigator. e confidentiality of the findings was strictly maintained on all collected data.

Data Analysis.
e collected data were edited, checked, and cleared manually. e edited, checked, and cleared data were coded and encoded into a computer and analyzed using SPSS Windows Version 21. Descriptive analysis like percentages, frequencies, proportions, and measures of dispersions with 95% confidence intervals for the prevalence estimates was employed to describe sociodemographic, behavioral, and other variables included in the study. e presence or absence of a significant association between independent and dependent/outcome variables was determined in the study by different statistical methods. e authors determined the association between hypertension and the sociodemographic, behavioral, dietary, and other factors by the Chi-square test of association (S_5). en, we used the independent variables significant at 25% in the final multivariate logistic regression analysis. e presence of a statistical association between dependent and independent variables was also assessed using univariate and multivariate logistic regression analysis. p-values of <0.05 were considered statistically significant. Results were summarized and presented in tables.

Ethical Considerations.
Ethical clearance was obtained from the ethical review committee of Science College of Bahir Dar University (S_6). Depending on this clearance paper, permission was obtained from the Bahir Dar city administration education department. e city administration education office wrote a permission letter for the secondary schools to get permission to conduct the study. e secondary schools' administration and teachers got an explanation about the objective of the study. Before collecting the data, informed written consent was obtained from all the study participants. Finally, the prevalence of hypertension on secondary school teachers of Bahir Dar city administration was reported to the city education and health offices to take future control and intervention measures.

Operational Definitions.
For this study, the following definitions were given for terms and clauses.
2.11.1. Physically Active. Respondents who did at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or did at least 75 minutes of vigorousintensity aerobic physical activity throughout the week or an equivalent combination of moderate-and vigorous-intensity activity were considered as physically active [29].

Abdominal Obesity.
It is the waist circumference (WC) ≥ 90 cm for men and ≥80 cm for women [32].

Family History of Hypertension.
It is defined as either parent indicating on the submitted questionnaire that they were hypertensive (diagnosed by a physician and/or on antihypertensive drugs) or had a family history of hypertension [33].

Alcohol
Use. It is defined as a self-reported intake of at least one dose in the previous 30 days; alcohol abuse was defined as four or more doses on at least one occasion during the same period [34].
2.11.6. Khat Chewing. It is the practice of chewing khat leaves by the worker at least once per week [35].

Cigarette Smoking.
It is the regular inhalation of the gases and hydrocarbon vapors generated by slowly burning cigarettes [35].

Current Smoker.
A current smoker is an adult who has smoked 100 cigarettes in his or her lifetime and who currently smokes cigarettes [36].
2.11.9. Nonsmoker. Someone who has not smoked greater than 100 cigarettes in a lifetime and does not currently smoke [36].

Sociodemographic Characteristics of the Study
Participants. Data were collected from 222 secondary school teachers who were randomly selected from the ten government-owned secondary schools in Bahir Dar city administration. All sample teachers voluntarily responded to the structured questionnaires and to participate in the anthropometric and blood pressure physical measurements. Due to this, the overall response rate was 100%. One hundred and forty-nine (67.1%) of the study participants were men and the rest 73 (32.9%) women with a male-tofemale ratio of 2.04:1. e majority of the study participants, 139 (62.6%), were in the age category of 41 to 60 years. About 83 (37.4%) of the study participants were in the age category of 20-40 years. e majority of the teachers (52.3%) were in the middle-income category earning between 6001 to 10,000 Ethiopian Birr ($160.52-$267.49) per month.
All the respondents of the study had completed a tertiary level of education. About 142 (64%) were first-degree and the rest 80 (36%) were second-degree holders. In terms of religion, the majority of the study participants, 199 (89.6%), were Orthodox Christians, 13 (5.9%) were protestants, and the rest 10 (4.5%) were Muslims. One hundred and sixtyfour (73.9%) of the study participants were married. e majority (83%) of the study participants were urban inhabitants whereas about 17% were semiurban/suburban dwellers. ere were no rural residents among the subjects of the study. e detailed sociodemographic characteristics of the study participants are presented in Table 1.

e Prevalence of Hypertension in the Study Population.
According to the data obtained from the study, the average SBP and DBP were 122. 23

e prevalence of Hypertension in the Study Schools.
As displayed in Table 3, the prevalence of hypertension in the city administration government-owned secondary schools differs from school to school. e overall prevalence of hypertension in the study population was 65 (29.28%). It ranged from 6.7% in Zeghie secondary school to 42.9% in Diaspora secondary school. Diaspora (42.9%), Bahir Dar preparatory (37.5%), Ghion (35.7%), Fasilo (34.5%), Tana Haik (29.4%), Meshenti (27.8%), and Shum Abo (25%) had greater than the average prevalence whereas Ethio-Japanese, Shum Abo, Meshenti, and Tis Abay secondary schools had less than the average hypertension prevalence in the city.

Factors Associated with the Development of Hypertension in the Study Population.
After adjusting for possible confounders in the multivariate logistic regression analysis, study participants who were from age categories 41 to 60 years were 2.51 times (AOR: 2.506; 95% CI: 1.103, 5.694; and p � 0.028) more at risk of developing hypertension  Khat chewers were five times more likely to be hypertensive than non-khat chewers (AOR: 5.426; 95% CI: 1.811, 16.256; and p � 0.003). Participants who did not undertake physical activities of 150 minutes or more per week had five times more likely to develop hypertension as compared to those who participated in such amount of physical activities (AOR: 5.212; 95% CI: 1.974-13.763; and p � 0.001). ose study participants who had repeated stress in their lifestyles were three times more likely to be hypertensive compared to those who were not stressed (AOR: 3.027; 95% CI: 1.404, 6.527; and p � 0.005) ( Table 4). Even though not statistically significant after adjusted for confounders in the adjusted odds ratio, individuals with BMI ≥25 kg/m 2 were almost two times more likely to become hypertensive as compared to those with BMI <25 kg/m 2 (AOR: 1.810; 95% CI: 0.829, 3.951; and p � 0.136).
Variations in the prevalence of this study and other studies might be attributed to the differences in sociodemographic characteristics, sample size differences, lifestyle, feeding habits, differences of study settings, and other variations of the study subjects. For example, in the Zambian study mentioned above, 22% of the study subjects were cigarette smokers and 63% were alcohol consumers, which is very high compared to the subjects of the present study (8.56% smokers and 52.25% alcohol consumers). Furthermore, the subjects of this study were secondary school teachers who were educated. However, subjects of other studies were from the general adult population. In addition, other studies may be conducted both in urban and rural settings compared to the present study which was conducted among urban dwellers. e prevalence of hypertension in the present study was higher among male participants than female participants. e higher occurrence of hypertension among men may be attributed to the large number of men engaged in risky behaviors such as alcohol consumption, smoking, and khat chewing than women. e level of hypertension is raised with the rise of age. Teachers aged 41 to 60 years were two and half times more hypertensive than teachers aged 20 to 40 years.
is finding is in line with the community-based studies conducted in Gondar [38], in Bedele [56], and in Durame town [54] in Ethiopia. Aging leads to less physical activity, increases peripheral resistance, and results in hormonal changes. ese situations in turn cause high blood pressure [57]. Older persons have a four times higher risk of hypertension than younger persons. In 2008, hypertension in adults older than 25 years of age was 40% and accounted for 12.8% of the global deaths [18].
Self-reported diabetes mellitus was also another factor for the higher prevalence of hypertension in the present  [43]. e high risk of hypertension among diabetic individuals could be due to increased peripheral vascular resistance and the fact that both diseases share common risk factors. Both diabetes and hypertension may cause each other. People with DM are more likely to develop hypertension due to the hardening of the arteries [58].
In this study, individuals with a positive family history of hypertension were more likely to be hypertensive. ose who had a family history of hypertension were 3.387 times (AOR: 3.387; 95% CI: 1.579-7.281; and p � 0.002) more likely to be hypertensive than those who did not have. e finding was in line with the studies conducted in Gondar, northwest Ethiopia (AOR: 2.71; 95% CI: 1.37-5.36) [38], and in Debre Markos town (AOR: 4.38; 95% CI: 1.985-12.015; and p < 0.01) [59]. is may be because family members may share similar lifestyles and genetic factors since participants with a family history of hypertension have the same genetic component and families tend to share the same lifestyle choice and behavior [60].
Physical inactivity was identified as another factor associated with hypertension in this study. Physically inactive teachers were 5.212 times (AOR: 5.212; 95% CI: 1.974-13.763; and p � 0.001) more likely to be hypertensive than physically active teachers. is result was similar to that of the studies done in Bedele town, southwest Ethiopia (AOR: 3.10; 95% CI: 0.97-9.97) [56], and Gondar, northwest Ethiopia (AOR: 2.86; 95% CI: 1.5-7.12) [38]. Regular exercise reduces the risk of many diseases including hypertension [65]. In a study conducted in India, sedentary people were 20 to 50% at a high risk of hypertension than physically active people [66]. A report from northwest Ethiopia also showed that people who did not walk for at least 10 minutes daily were about three times more likely to be hypertensive than their counterparts [38]. e stress level of the study participants was another most important factor of hypertension in this study. Secondary school teachers with stressful conditions were 3.027 times at higher risk of hypertension than those who were not repeatedly stressed (AOR: 3.027; 95% CI: 1.404-6.527; and p � 0.005). is result was in line with a similar study done in Arba Minch town, Southern Ethiopia (AOR: 12.3; 95% CI: 4.9-30.0; and p < 0.001) [44]. Stress increases the heart rate and can raise blood pressure over a while. Consequently, it precipitates in heart attack and stroke [67]. Stress can cause hypertension through frequent blood pressure elevations as well as by stimulation of the nervous system to produce large International Journal of Hypertension amounts of vasoconstriction hormones that increase blood pressure. Overall, studies show that stress does not directly cause hypertension, but can have an effect on its development [68]. From the researcher's own experience, the teaching profession is a highly stressful occupation. e major sources of stress for secondary school teachers may be the curriculum, pupils, school authority, society, teaching environment, less income, and high living costs.
Higher BMI was evidenced as another risk factor for hypertension.
ose secondary school teachers who were categorized as overweight and obese (≥25 kg/m 2 ) were almost two times (AOR: 2.161; 95% CI: 0.916-5.099; and p � 0.078) more likely to be hypertensive compared to those whose BMIs were <25 kg/m 2 even if the association was not statistically significant in the multivariate logistic regression analysis. is result is consistent with studies conducted in Durame town, Southern Ethiopia (AOR: 15.7; 95% CI: 7.89-31.21) [54] and Debre Markos town in northwest Ethiopia (AOR: 4.70; 95% CI: 1.99-11.065; and p < 0.001) [59]. e observed relationship between overweight, obesity, and hypertension could be due to the differences in dietary habits and physical inactivity of the study participants. As BMI level increases the risk of chronic diseases increases and an increased level of BMI indicates the accumulation of fat tissue in the human body, this might be because excess weight increases blood cholesterol and triglyceride levels and lowers high-density lipoprotein levels [59].

Conclusion
e overall prevalence of hypertension among the study participants in this study was 29.28%. Seventy-eight (35.1%) of the study participants were in the prehypertension stage, which increases the overall future risk of hypertension. Among the hypertensive teachers, 39 (60%) did not know their hypertension status before this study. Seventeen (26.15%) of the hypertensive teachers were under hypertension medication (taking antihypertensive drugs), and six of these have controlled their elevated blood pressure. Aging, self-reported diabetes mellitus, family history of hypertension, khat chewing, physical inactivity, and stressful conditions were the risk factor associated with hypertension among the secondary school teachers of Bahir Dar city administration. Modification of lifestyles like controlling diabetes mellitus, healthy feeding, avoiding khat chewing, doing physical exercise, avoiding stressful conditions, controlling body mass index, and making regular checkups are highly recommended to control and prevent hypertension.

Significance of the Study
e findings of this study will add to the literature about the prevalence of hypertension and associated risk factors among secondary school teachers. Data on the prevalence of hypertension can guide policymakers to design proactive and workable programs for managing and controlling the condition. e findings of the study will also contribute to academic knowledge and add to ongoing research efforts on hypertension. Valuable information about the prevalence of hypertension and associated risk factors will be generated in the study area. It will also serve as a source of relevant information for those who want to carry out further investigation on hypertension. Baseline information about hypertension will be provided to the local health centers or other concerned agencies to develop appropriate prevention methods to control hypertension in the study area.

Limitations of the Study
e findings from this study may not apply to the general population of the city administration because the secondary school teachers are not representatives of the various aspects of the population including age, sex distribution, occupation, educational level, social status, and location of residence.
e study may not be free from recall and social desirability biases from self-reported variables like self-reported DM and family history of hypertension.

Data Availability
All the data sets generated and analyzed during the study are included the text.

Conflicts of Interest
e authors declare that they have no competing interests regarding the publication of this paper. S_4: behavioral, dietary, and other characteristics of the study subjects, Bahir Dar, northwest Ethiopia, January 2020 (n � 222). S_5: chi-square association between sociodemographic, behavioral, dietary, and other factors and hypertension among Bahir Dar secondary school teachers, northwest Ethiopia, January 2020 (n � 222). S_6: ethical clearance. S_7: awareness, diagnosis, treatment, and checkup practice of hypertension in the study population, Bahir Dar, northwest Ethiopia, January 2020 (n � 222). (Supplementary Materials)