Knowledge, attitude and practice towards hypertension among patients receiving care in a Nigerian Hospital

In Nigeria, hypertension has become an important health problem. The burden of hypertension has been on the increase because of the increasing adult population and change in lifestyles of Nigerians [1]. During the last two decades, there has been a rise in the number of prevalence studies regarding hypertension and other non-communicable diseases [2]. In 2011, the prevalence of hypertension was reported to range from 6.2% to 48.9% in males and 10% to 47.3% in females using a BP benchmark of 140/90 mmHg [3]. The overall crude prevalence was reported to be 2.1% to 47.2% (95%CI) Abstract


Introduction
In Nigeria, hypertension has become an important health problem. The burden of hypertension has been on the increase because of the increasing adult population and change in lifestyles of Nigerians [1]. During the last two decades, there has been a rise in the number of prevalence studies regarding hypertension and other non-communicable diseases [2]. In 2011, the prevalence of hypertension was reported to range from 6.2% to 48.9% in males and 10% to 47.3% in females using a BP benchmark of 140/90 mmHg [3]. The overall crude prevalence was reported to be 2.1% to 47.2% (95%CI) in Nigerian adults aged 18 years and above 4. Studies also have shown a higher prevalence in urban areas (17.5% to 51.6%) compared to rural areas (4.6% to 43%) [4]. There has been a continuous and steady increase in the incidence and prevalence of hypertension around the world [5]. Presently, over 1.5 billion people are affected with high blood pressure worldwide [6].
Poor knowledge about hypertension can lead to poor attitude towards the disease which may directly affect patients self-care practices towards hypertension [7] There is a direct relationship between a patient's knowledge and the management of their illnesses. A good knowledge and attitude towards hypertension have been associated with controlled blood pressure, reduced cardiovascular risks, improved medication compliance, reduced morbidity and mortality [8].

Objective
This study aimed to assess the Knowledge, attitude and practice towards hypertension among hypertensive patients receiving care in a Nigerian hospital.

Study design
This was a cross sectional study conducted among Hypertensive patients receiving care in the Kogi State Specialist Hospital in Lokoja, Kogi state. The study was carried over a period of one month (July 3, 2019-August 3, 2019) to ascertain the patients Knowledge about hypertension Outcome measures were Blood pressure, Body mass Index and Knowledge about hypertension.

Study setting
The Kogi state specialist hospital is the one of secondary health institution in Kogi State and it is located in the heart of the state capital, Lokoja. The hospital serves as a referral centre for all the primary health facilities in the state, as well as neighbouring states. It is a 150 bedded hospital. Kogi State is the 24 th largest State in Nigeria with a population of 3,314,043 as at 2006 national census and a projected population in 2017 estimated to be 4,252,665. It is among the six North Central States of Nigeria. It has 21 local government areas. Lokoja is located at a geographic coordinates of latitude 7.8 0 N, 6.74 0 E and 55 meters above sea level. It has a maximum temperature of 39.6 o C between the months of October to May with a relative humidity of 60% and annual rainfall of about 1000meters. Lokoja has a total population of 196,643 people as at the last 2006 national census. The main ethnic groups are Igala, Ebira and Yoruba.
Ethical Clearance: Ethical clearance was obtained from the Health and research ethics committee of the hospital. Also, written and oral consent were obtained from the patients before participating in the study. Data collection: A profoma was designed to collect the socio-demographic and clinical characteristics like the blood pressure, weight (in Kilograms) and height (in meters).

Data collection instruments
A well designed demographic questionnaire: This was carefully designed by the researchers. It consists of 16 questions. 10 questions were on the demographic characteristics of the patients like gender, weight, marital status, education, employment, religion, income per month, religion, smoking status and alcohol consumption while 6 questions were on the health status of the patient like duration of illness (months), Number of medical condition, present medical conditions, number of antihypertensives, emergency hospitalisation in the past four week and selfrated health. Knowledge about hypertension was assessed using an 8-item question with questions about hypertension, risk factors, treatment, symptoms and complications. Attitude and practice towards hypertension was assessed using three and four questions respectively with questions on regular measurement of blood pro ile, health eating, exercise, compliance to treatment and maintain normal body weight.

Data analysis
The data cleaning was conducted in Microsoft excel after which information were exported and analyzed using the Statistical Package for Social Sciences (SPSS for windows, Version 16.0. SPSS Inc. 2007. Chicago, USA) software. Continuous data were presented as mean ± standard deviation while categorical data were presented as percentages and frequencies. Chi square and t-test was also used to examine association between the variables in the data collected.

Results
From table 1, a majority of the patients were aged 46-55 years 89 (27.5%), while almost half of the patients were males 161 (54.6%). about half of the patients 141 (43.5%) were self-employed while a majority of the patients had at least a tertiary education 173 (53.4%). Only 4 (1.2%) of the patients reported that they had no formal education. About 60% of the patients reported to have had hypertension for 6-10 years while only 170 (57.4%) of the patients reported not to have any family history of hypertension. Also, only half of the patients 164 (50.6%) had their blood pressure controlled with the remaining half having an uncontrolled blood pressure. A majority of the patients 287 (88.6%) were obese having a body mass index >30 kg/m 2 (Table 1).
From table 2, less than half of the patients 121 (37.3%) were able to answer correctly the de inition of hypertension. A good number of the patients 212 (65.4%) knew that uncontrolled blood pressure was dangerous to their health but only 53 (16.4%) knew that lowering high blood pressure could improve someone's health. Less than half of the patients 98 (30.2%) neither knew what the two numbers reported for blood pressure were nor what be the normal blood pressure levels ( Table 2).
From table 3, only one quarter of the patients had good knowledge and attitude towards hypertension. Also, only 4 (1.3%) patients had a good practice towards hypertension.
From table 4, there is a signi icant positive correlation between knowledge and attitude (r = 0.287, p < 0.001). Also, there is a fair positive correlation between Knowledge and practice (r = 0.254, p < 0.05). Meanwhile, there is no correlation between attitude and practice ( Table 5).
There were signi icant differences in the knowledge scores and practice scores among the different age groups while there was no signi icant difference in the attitude scores among the age group. There were no statistical difference in the knowledge, attitude and practice scores among the males and females. However, there were signi icant differences in the knowledge and attitude scores between those that had a formal education and those that had no formal education. There was a signi icant difference in the knowledge scores     between those that have had hypertension for less than 10 years and those that have had hypertension for more than 10 years. Those that had a family history of hypertension had a signi icant difference in their knowledge, attitude and practice scores when compared with those that do not have a family history of hypertension.

Discussion
In this study, there were more males than females. This is consistent with several studies that have shown that more men use the health care facilities as their female counterparts could be busy with home keeping and house chores [9]. Only half of the population had their blood pressure controlled while the other half had uncontrolled blood pressure. This is similar to a study by Dickson et al were more than half of the patient under study had their blood pressure uncontrolled [10]. Majority of the patients where knowledgeable about the meaning of hypertension but only few knew the importance of improving their systolic blood pressure. Majority of the patients did not know that SBP is important in blood pressure control. Increased recognition of the SBP has been identi ied as one of the major public health and medical challenges in the management of hypertension. Only a few of the patients in this study knew that poorly treated hypertension could lead to complications like stroke, kidney failure, brain damage and/ or even blindness. There was a strong positive correlation between knowledge and attitude scores and also Knowledge and practice scores. A recent study also showed that there is a strong positive correlation between patients knowledge about hypertension and their attitude towards the disease state [3]. Studies have also shown that poor knowledge about hypertension can lead to poor lifestyle practices that may hinder blood pressure control From the study, younger patients had a better knowledge and attitude scores when compared to the older patients and this was statistically signi icant. However, the older patients had a better mean attitude score than the younger patients. This also explains why mean knowledge scores increased with an increase in the duration a patient had been hypertensive.
Patients who had obtained a tertiary education had better mean knowledge scores than patient who had only a primary school education. This is expected as tertiary education can increase the level of exposure and learning of these patients.
Interestingly, patients who had a family history of hypertension had better mean knowledge, attitude and practice scores that those who do not have a family history of hypertension. This could be because having a relative or close family member with an illness increases one's curiosity towards that same illness. In this study, there was a strong association between duration of hypertension and mean knowledge scores. This could be as a result of constant counselling over the years as they visit a health care facility.
Uncontrolled high blood pressure among Nigerians has been attributed to increased consumption of salty foods and fat, reduced intake of fruits and vegetables and lack of physical activity [11].

Conclusion
There was an acceptable level of knowledge and attitude towards hypertension among the study participants. However, practice of hypertension self care activities seems to be poor. There is a need for an educational intervention to improve practice of self care activities as this will help improve blood pressure control.
Source of funding: this research was solely sponsored by the authors.