Covariates of Knowledge, Attitude, Practice, and Burdens among the Caregivers of Hypertensive Patients

Caregivers of hypertensive patients play a significant role in ensuring adequate patient care and lowering the risk of hypertension-relatedcomplications. Caregivers are ideal study subjects for identifying gaps in hypertension management. Our study aimed to assess the knowledge, attitude, and practice (KAP) of hypertensive patients' caregivers, to identify their extent of involvement in patients' care, and to assess their care-related attributes. A descriptive cross-sectional study was conducted from August 2020 to February 2021 in the eight largest tertiary care medical college hospitals and all eight divisions of Bangladesh, with 949 caregivers enrolled. Data were collected using a pretested interviewer-administered questionnaire through snowball sampling and analyzed using a one-way ANOVA, independent-sample T-test, and chi-square test. Among the 949 interviewed caregivers, 541 (57.0%) were female, and 479 (50.5%) were aged 18 to 25 years. The percentage scores regarding overall knowledge, attitude, and practice of the caregivers were 54.83 ± 17.95, 47.95 ± 24.05, and 61.26 ± 17.50, respectively. Caregivers' education, history of hypertension, residence, age, relationship with the patient, occupation, and caregiving duration were significantly associated with the KAP scores. In addition, factors such as relationship with the patient, age, educational status, occupation, residence, and caregiving duration/day had significant correlations with all types of burden. Findings of this study suggest the necessity for awareness programs for the caregivers of hypertensive patients to diminish the gap in their KAP and improve their mental and physical health.


Introduction
Hypertension is one of the most common and challenging public health issues worldwide [1][2][3], contributing to the mounting global burden of disease and disability [2].Being a silent killer by damaging organs gradually and permanently, hypertension contributes to 9.4 million of the total cardiovascular annual deaths (17 million) [4,5].Although it was formerly considered a disease in developed countries, hypertension signifcantly afects low-and middle-income ones, with a prevalence rate of 31.5% of the population [6,7].Likewise, in 2017, the prevalence of hypertension among Bangladeshi adults was 40.7% [8].Hypertension is a chronic condition that imposes a colossal economic burden on the family and the health system.
In low-and middle-income countries, to minimize the burden of hypertension that mainly arises from a lack of knowledge and poor self-care practice, regular counselling of caregivers of hypertensive patients can be helpful [9].A caregiver is defned a relative/friend/neighbour assisting the patient without any compensation [10].Family members play a pivotal role in making the patient feel safe and supported during the disease period by conveying serenity, courage, and strength [11].It was also observed that family caregivers devote time and energy to the patients with their activities, fnancial and nutritional support, and medication [11].Moreover, they have good knowledge about the patients, so they can provide important information to the physicians and sometimes take vital decisions that may impact the patient's health and management [12,13].
Knowledge, attitude, and practice (KAP) surveys are the most commonly used technique in health-seeking behavior research [14].Moreover, a lack of knowledge of the disease risk factors contributes to the rising incidence of that disease [15][16][17].By exploring what is known and what is done concerning a healthcare-related objective, a KAP study can have a vast impact on the local community.So far, several studies have been conducted to evaluate patients' KAP toward hypertension in diverse populations worldwide.Tough in Bangladesh, a study conducted in 2018 focused on evaluating the KAP of hypertensive patients concerning hypertension [7], as far as we are aware, there has been no research conducted on the KAP of caregivers responsible for hypertensive patients.Considering the close relationship between patients and family caregivers in Bangladesh, we undertook this study to evaluate the levels of KAP of hypertensive patients' caregivers and try to identify related factors.
As many aged hypertensive patients require caregivers for their daily livelihood, the caregivers' quality of life might inversely relate to the caregiving burden.Caregivers' burden is defned as a multidimensional interaction of physical, emotional, and economic hardship experienced by the caregiver during caregiving [18].Caregiving responsibilities have shown challenging demands that may contribute to monetary burdens, erratic behavior, fuctuating emotions, and time defciency for social and personal enjoyment with motivation deprivation [18,19].Tis study particularly highlighted the level of burden and eforts in terms of physical, emotional, and economic challenges faced by the caregivers of hypertensive patients in Bangladesh to formally recognize their contribution.Tese specialized hospitals cover patients from all eight divisions as they manage the maximum patient infow of the country referred from primary and secondary hospitals.

Inclusion and Exclusion Criteria.
Te eligibility criteria for the participants were as follows: (1) the person who was identifed by the hypertensive patient with systolic blood pressure (BP) ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg with or without antihypertensive/s or normal BP due to taking antihypertensive/s having the most caregiving interaction, (2) age ≥18 years, and (3) the study considered one caregiver who provided day-to-day services to a hypertensive patient; if more than one caregivers were available, the one who gave the most eforts was interviewed.Te exclusion criteria were as follows: (1) respondents moderately/ severely sufering from any psychiatric illness, and (2) caregivers of pregnant women with hypertension.

Sample Size and Sampling.
Te Cochran formula was used to calculate the sample size [20].Te sample size was calculated using the following formula: where N � population Size, P � probability, level of signifcance (0.05), e � margin of error (5%), z � z-score (95%-1.96),and SS � sample size.
In our study, the collected sample size (n = 949) was larger than the calculated sample size because a larger sample size detects outliers that might skew the data and provide a reduced margin of error.

Development and Validation of the Survey Questionnaire.
Following an extensive literature search, a face-to-face interviewer-administered questionnaire with 60 questions that included rank order scaling, a Likert-like scale, and both open-and closed-ended questions was prepared in English to evaluate KAP and the burdens of hypertensive patients' caregivers [21].Later, it was translated into Bangla (the local language) for data collection.Te questionnaire was checked and validated by a public health specialist, fve cardiologists, and medicine specialists.Te study questionnaire was 2 International Journal of Hypertension piloted with 40 participants not included in the fnal study.Te fnal questionnaire was upgraded with 54 questions taken from feedback from the pilot test.Other than baseline information, ten knowledge assessment questions, six attitude-related questions, and ten practice-associated questions were included in the fnal questionnaire.In addition, the extent of caregiving and caregivers' QoL were also assessed.

Data Collection.
In this study, most of our participants were reached out through face-to-face interviews.However, a portion of the participants were interviewed through phone calls because of their unavailability at hospital sites.
To ensure data quality and minimize potential bias, all collectors underwent comprehensive training to equip them with the necessary skills and knowledge to conduct interviews efectively and uniformly.Te data collection team consisted of three physicians supervising three male and four female data collectors for convenient dealing with the participants of both genders.To avoid the infuence of the peers, the interviews were carried out in private.Te objectives and procedures of the study were explained to the participants in their native language (Bengali).Local translators assisted both collectors and participants in interpreting the local languages.All participants' information was kept confdential.
2.6.Variables and the Method of Verifcation.Te knowledge part consisted of multiple-choice questions with 0-1 and 0-5 scores based on the number of correct responses.Responses to the attitude section had a Likert-like scale of −2 to +2 and +1 to −1 (strongly agree/+2, agree/+1, no idea/0, disagree/ −1, and strongly disagree/−2).Caregivers attained 1 point for each correct practice and 0 for each incorrect one.Te score latitudes were from 0 to 14, −12 to +12, and 0 to 10 for the knowledge, attitude, and practice portion, accordingly.Te knowledge, attitude, and practice scores were transformed into percentages by dividing the total score of each part of each respondent by the maximum score of the identical portion and then multiplied by 100 (

Overall Scores of the Caregivers.
Te total level of patients' knowledge was 54.83 ± 17.95, the total level of patients' attitude was 47.95 ± 24.05, and the total level of patients' practice was 61.26 ± 17.50 (Table 2).

Supporting Roles of Caregivers.
Upon asking about the defnite role they play regarding caregiving, a scale of 0-4 was implemented, and the scores were 0-not at all, 1somewhat, 2-fairly, 3-strongly, and 4-always.Most of the participants (>300 respondents in both cases) mentioned that they were always associated (scale 4) with advocacy and providing emotional support to the patient (Figure 1(a)).
Rendering physical support was the least demanding role that the caregivers mentioned.

Burdens Associated with Caregiving.
While assessing caregivers' perceived level of burden, a scale of 0-4 was applied as an assessment tool.Te measurement scale signifed the level of burden as 0, implying not at all, 1-very little, 2-somewhat, 3-much, and 4-extreme.In Figure 1(b), most caregivers (above 50%) did not report any fnancial, physical, or mental burden (scale 0).About 200 caregivers described their facing difculties as very little (scale 1), whereas only a few caregivers (<100) expressed an extreme level of burden stemming from their liability of caregiving (scale 4).

Factors Afecting KAP.
Data analysis revealed that all KAP percentage scores were signifcantly higher (P � 0.004, a � 0.002, <0.001) in caregivers living in the same home with hypertensive patients.Caregivers' relationships with the patient were also signifcantly correlated with their level of knowledge and attitude (P < 0.001, <0.001).While the older age had a negative impact on knowledge (P < 0.001), the highest score was obtained by the youngest age group (18-26) signifcantly (Table 3).KAP scores were signifcantly higher in caregivers with above secondary-level education, P value < 0.001, a � 0.001, and <0.001, respectively.However, the knowledge and practice scores were signifcantly better in the group that did not have hypertension.Among the occupations, healthcare professionals scored the highest in knowledge and attitude (P < 0.001, <0.001).Te inhabitants of urban areas had better KAP towards hypertension than those from rural or suburban areas (P < 0.001, <0.001, a � 0.001).A signifcant association was noted between the level of attitude and caregiving duration/day (P < 0.001), and International Journal of Hypertension

Factors Associated with the Burden of Caregiving.
Table 4 presents the relationship between caregivers' sociodemographic information and burden (Figure 4).More than 65% of them live always/sometimes with patients confronted with no/little burden during caregiving (P = 0.026, 0.049, 0.005).Te relationship with the patient was statistically signifcant correlating with all difculties (P < 0.001, <0.001, <0.001, <0.001).Percentages of not having any tiredness (65.4%) and an economic burden (56.6%) were higher in male caregivers, P value = 0.003, a = 0.020, respectively.However, the rates of feeling that burdens were high among those aged 26 years or more (P value = 0.006, <0.001, = 0.001, <0.001).Tose who had a secondary-level education or less faced burdens at a higher level (P < 0.001 in all four cases).Percentages of encountering severe trouble among homemakers were exclusively high in all four cases (P < 0.001).Another variable showing a signifcant infuence on all burdens was the residence of the caregivers.Besides, 55.1% of the caregivers who spent more than ten years complained of being at a minimum level of tiredness (P = 0.001).Signifcant associations were noted between the burden and spent time/day for caregiving (P < 0.001 in every case).Tose who are not hypertensive themselves found not/less afected regarding their mood (75.8%) (P = 0.003), tiredness (79.1%) (P = 0.001), and restlessness (81.4%) (P < 0.001) (Table 4).

Discussion
Tis study aimed to explore the status of knowledge and mental burden of the caregivers of hypertensive patients in Bangladesh, attributing it to the presence of other sociodemographic correlates.A study from Uzbekistan showed that 64.6% of the primarily diagnosed hypertensive patients had adequate knowledge about hypertension.However, patients acquire more knowledge about their own diseases over time.But the majority of the caregivers in this study also presented fair general knowledge (54.83%) about hypertension [15].Since more than half of our respondents were from urban areas, this high depth of knowledge about this chronic disease was quite expected.For instance, most respondents could successfully identify hypertension as a risk factor for stroke.Similar results were reported in a study from Sweden where 90% of the patients who already sufered from stroke could mention hypertension as one of the contributing factors [16].Te knowledge score on knowing the names of antihypertensive medicines taken by their patients was higher than the awareness score about the side efects of the medications.Tis might be explainable since the adverse efects of antihypertensive drugs are generally not that common [22].Overall, most of the participants had good knowledge about the age group at risk of hypertension, the danger signs of hypertension, and could identify hypertension as a risk factor for stroke.In the current study, age was negatively correlated with knowledge level.Te younger participants (age 18-25) scored the highest, whereas the middle-aged caregivers (36-40 years) scored the least.Tis may be explained because young caregivers are more adept at seeking health knowledge.Moreover, the daughter/son of the caregivers, the highly educated, those who stayed in the same house as the patients, the healthcare professionals, those who lived in urban areas, and those who had more than three hypertensive patients at home showed better knowledge scores than others.Te total attitude score was 47.95 ± 24.05, which was the lowest compared to the knowledge and practice scores.Only a few caregivers showed a positive attitude regarding lifestyle measures that help maintain normal blood pressure.However, the participants were well aware of the importance of avoiding extra salt, which is indeed a good sign, as a high intake of dietary salt is a risk factor for hypertension and other noncommunicable diseases.A study on rural Latino caregivers' revealed a similar fnding as the caregivers attempted multiple strategies to limit the consumption of excess salts by their children to reduce the risk of high blood pressure at a young age [22].A great number of participants supported discontinuing medication when blood pressure remained normal, proving their incognizance of the pathology of hypertension.Moreover, good attitudes were shown by the caregivers when it came to medication adherence during high blood pressure and regular exercise.In Bangladesh, it is commonly seen that there is a wide acceptance of herbal medicine mostly among the rural habitats and to some extent among the urban inhabitants.In this study, some participants thought that herbal medicine could control hypertension.
Regarding the practice, the respondents showed a fair level of it (61.26± 17.50).However, those who are hypertensive patients themselves may get exhausted due to their own disease history and a long course of treatment and, therefore, show less compliance.More than half of the caregivers answered that they encourage their patients to exercise regularly, which aligns with the recommendation of 30 minutes of physical activity by the World Health Organization (WHO) [23].Participants exhibited good practice in being conscious of the danger signs of hypertension, reminding the patients about taking medications correctly, and helping to avoid stress and forbidden foods.Besides, participants who shared the same house with their patients exhibited a higher impact on the practice level.
Our study shows that spouses, daughter/son, and sister/ brother carried out responsibilities at a higher percentage.Moreover, a Nigerian study on caregivers of hypertensive patients found that 46% were patients' spouses [24].Education is found to be a positive factor that afects our participants' KAP levels.Tis was expected as higher education increases awareness regarding health issues and provides access to the required information.Hence, focusing on arranging educational programs, primarily targeting older populations and   International Journal of Hypertension rural dwellers may help raise the KAP level.Te positive family history of hypertension also showed a signifcant relationship with the caregivers' knowledge and practice.Te higher the number of hypertensive patients in the family, the higher the knowledge level was.Te sufering of multiple members of the family may infuence them to learn more about the disease.On the contrary, the practice level was the lowest for the caregivers if there had been >3 hypertensive patients in the family, portraying caregivers' exhaustion.

International Journal of Hypertension
We also asked our participants about how much caregiving stress afects their overall QoL.Homemakers, rural residents, and caregivers with low literacy levels perceived more burden in the process of caregiving.Tese groups of caregivers also had lower KAP scores.Terefore, it seems that their increased stress might be infuenced negatively by their KAP level or vice versa.In addition, this study found that female caregivers were feeling more tired and fnancially loaded.Another possible contributor to the caregiver's burden is the duration of caregiving.A study conducted on stroke patient's caregivers in Gilan province of Iran showed that the duration of caregiving was <5 years for 84.4% of family caregivers [25].However, the caregiving period was more extensive in the case of hypertensive patients, which might extend to >10 years as it is a long-term illness.Our study demonstrated the association of 1-5 years of caregiving with a higher percentage of tiredness.Tis might be associated with new-onset lifestyle changes with reduced sleep time, high levels of stress, and anxiety, leading to the point of an individual's burnout syndrome.Because of the cost and amount of antihypertensive drugs for a long period, it was observed that more than 10 years of caregiving fnancially burdened the caregivers to the highest extent.Our study also found that caregivers who were hypertensive (51%) faced more exhaustion than the nonhypertensive ones.Tis can be explained as the additional burden of responsibilities from caring for a chronically ill patient that leads to increased stress and physical, mental, and emotional exhaustion that eventually results in neglecting their own health condition.

Conclusion
Tis study showed a fair level of knowledge and fair practice among the caregivers.However, the relatively poor attitude score of the caregivers raises a crucial concern that needs to be addressed.Our data indicate that specifc attention is needed if they are less educated, unemployed, hypertensive patients themselves, and caring for patients for a more extended period which can afect their KAP score and stress level, and eventually they may feel vulnerable.So, our fndings support the call for specifc learning programs for caregivers, to reduce the gap in their knowledge and avoid emergency conditions by improving their awareness and practice.Moreover, further attention to the mental and physical health of the caregivers may help to improve their QoL which will ultimately enhance their caregiving role.

Figure 1 :
Figure 1: Caregivers' roles and burdens.X-axes signify the number of caregivers, and Y-axes denote the roles (a) and burdens (b).
Site.A descriptive cross-sectional study was conducted from August 2020 to February 2021 in out-patient and in-patient departments at eight government hospitals (Chittagong Medical College Hospital, Mymensingh Medical College Hospital, Sir Salimullah Medical College and Mitford Hospital, Dhaka Medical College Hospital, Khulna Medical College, Sylhet MAG Osmani medical College, Rangamati Medical College Hospital, and Comilla Medical College Hospital) in Bangladesh.

Table 1 :
Baseline sociodemographic characteristics of the caregivers.

Table 3 :
Correlations between factors and KAP percent score.

Table 4 :
Correlations between factors and burdens.