CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Hypertension is a common and major public health problem associated with a high

level cardiovascular morbidity and mortality worldwide (Lim et al., 2022). It

remains the major risk factor for heart failure, stroke, coronary artery disease, and

chronic renal failure in Nigeria (Ogah et al., 2022). Hypertension which was

initially considered rare in sub-Saharan Africa is now a major noncommunicable

disease threatening sub-Saharan Africa. Previous studies in sub-Saharan Africa had

shown a higher prevalence of hypertension in urban centers than in rural

communities, but recent studies show a growing trend in prevalence of

hypertension in rural communities compared to that of the urban communities

(Onwubere et al., 2021). This may be attributed to a growing increase in the age

and lifestyle changes in the rural communities. Prevalence of hypertension in

Nigeria has progressively increased from 10.1–13.3% and 8.9% in the late sixties

to between 38.8 to 44.5% and 34.8% recently in rural and urban communities,

respectively (Ogah et al., 2022).

Hypertension or high blood pressure is a common and serious condition that can

lead to or complicate many health problems. The risk of cardiovascular morbidity

and mortality directly correlated with blood pressure also are risk of stroke,
1
myocardial infarction (MI), angina, heart failure, kidney failure or early death from

a cardiovascular origin. Blood pressure generally rises with age and hypertension

has also a variety of causes, which can be as a result of side effects of certain

medications such as over-the-counter cold medications and oral contraceptives and

other hormonal drugs. Obesity, heredity and lifestyle also play a role in the

development of hypertension. When symptoms of hypertension do occur, they can

differ between individuals depending on factors such as the level of blood pressure,

age, underlying cause, medical history, the presence of complications and general

health, (Siyad, 2017).

Most of these studies were done either in the South-West or the South-East Nigeria

and very few were done in South-South, Nigeria. As a result of these identified

changes in the epidemiologic trend of hypertension and its complications, there is

therefore the need to regularly conduct a survey on the prevalence of hypertension.

This study therefore will be conducted to find the recent prevalence of

hypertension among artisans in Owerri West, Imo State and also identify other risk

factors associated with hypertension.

1.2 Statement of the Problem

Hypertension is not uncommon in young adults; the incidence among young adults

is increasing with the years. It is progressively becoming a common health

2
problem worldwide because of the cumulative longevity and prevalence of

contributing factors such as obesity, physical inactivity and also unhealthy diets.

Regrettably, most adults due to ignorance of risk factors and preventive measures

of hypertension engage in unhealthy lifestyles such as excessive consumption of

alcohol, sedentary lifestyle, excess consumption of sodium intake, tobacco and

cigarette smoking, obesity, reduced intake of fruits and vegetables, stress and

consumption of foods rich in cholesterol. These unhealthy lifestyle practices have

increased the prevalence of hypertension in the world including Nigeria, which

culminates into high cases of deaths. Hypertension is one of the problems affecting

especially a great portion of the adult population and currently causes one in every

eight deaths worldwide, making it the third leading killer disease in the world.

Ejike, Ezeanyika and Ugwu (2010) estimated that about one billion adults had

hypertension in the year 2010, and the number is expected to rise to 1.56 billion in

the year 2025. In addition, hypertension is the commonest non-communicable

disease in Nigeria with over 4.3 million Nigerians classified as being hypertensive.

In Nigeria, many people lose their lives to hypertension. This is not an acceptable

situation, considering the fact that hypertension is preventable and manageable to

reduce its impact on the health and lives of people in Nigeria.

According to Merwe and Merwe (2015), general practitioners may be reluctant to

make a diagnosis of hypertension in a young person, and may also lack confidence
3
about how to investigate and treat the condition. Also, there is evidence that

hypertension in young adults is less likely to be diagnosed or treated even when

they have good access to primary health care.

1.3 Objective of the Study

1.3.1 General Objective of the Study

This general objective of this study is to determine the prevalence of hypertension

among artisans in Owerri West, Imo State, Nigeria.

1.3.2 Specific Objectives of the study

i. To determine the prevalence of hypertension, among artisans in Owerri

West, Imo State, Nigeria

ii. To investigate the relationship between tobacco smoking and hypertension

among artisans in Owerri West, Imo State, Nigeria

iii. To determine the relationship between family history and hypertension

among artisans in Owerri West, Imo State, Nigeria

iv. To identify the relationship between dietary habits and hypertension among

artisans in Owerri West, Imo State, Nigeria

1.4Research Questions

i. What is the prevalence of hypertension among artisans in Owerri West, Imo

State, Nigeria?

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 ii. What is the relationship between tobacco smoking and hypertension among

artisans in Owerri West, Imo State, Nigeria?

iii. What is the relationship between family history and hypertension among

artisans in Owerri West, Imo State, Nigeria?

iv. What is the relationship between dietary habits and hypertension among

artisans in Owerri West, Imo State, Nigeria?

1.5Research Hypothesis

H01: There is no prevalence of hypertension among artisans in Owerri West,

Imo State

HA1: There is prevalence of hypertension among artisans in Owerri West, Imo

State

H02: Tobacco smoking has no significant relationship with hypertension among

artisans in Owerri West, Imo State, Nigeria

HA2: Tobacco smoking has significant relationship with hypertension among

artisans in Owerri West, Imo State, Nigeria

H03: Family history has no significant relationship with hypertension among

artisans in Owerri West, Imo State, Nigeria

HA3: Dietary habits has significant relationship with hypertension among

artisans in Owerri West, Imo State, Nigeria

5
 H04: Family history has no significant relationship with hypertension among

artisans in Owerri West, Imo State, Nigeria

HA4: Family history has significant relationship with hypertension among

artisans in Owerri West, Imo State, Nigeria

1.6 Significance of the Study

Hypertension is not common only with the elderly but affects individuals of all age

groups. According to Packard, (2016) risk factors of hypertension in adults and

possibly in children and adolescents includes the following: high blood cholesterol

levels, being overweight, inactivity, smoking, kidney and heart disease, and use of

prescription medications (such as steroid medications and birth control pills) or

illegal leisure drugs (such as cocaine).

The young nowadays engage in activities that render them prone to the

development of hypertension and other related health complications such as

alcoholism and smoking; and they engage in little or no physical activities. This

study will help promote the awareness that hypertension is real among young

adults so as to encourage the putting in place of policies and measures to sensitise

and mobilise our communities towards mitigating the disease among this group of

people.

6
1.7 Scope of the Study

The study will be limited to artisans in Owerri West, Imo State, Nigeria.

1.8 Operational Definition of Terms

Hypertension: abnormally high blood pressure, a state of great psychological

stress.

Hypertension Management: Hypertension is managed using lifestyle

modification and antihypertensive medications. Hypertension is usually treated to

achieve a blood pressure of below 140/90 mmHg to 160/100 mmHg.

Knowledge: facts, information, and skills acquired through experience or

education; the theoretical or practical understanding of a subject.

Perception: Perception is the organization, identification, and interpretation of

sensory information in order to represent and understand the presented

information, or the environment.

Body mass index: a weight to height ratio is a record of how much weight you

have in relation to how tall you are (kg/m2). The World Health Organization

(WHO) definitions were used to describe it: the reference (which is normal Body

mass index) was set at 18.5 to 24.9 kilogram per meter squared, overweight was

defined as 25 to 29.9 kilogram per meter squared, and obesity defined as 30

kilograms per metersquared and above.

7
Obesity: a buildup of fat in the body that is excessive. Obesity was considered as

having a BMI of thirty or higher

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 CHAPTER TWO

LITERATURE REVIEW

2.1 Conceptual Review

2.1.1 Hypertension

Hypertension can be defined in two ways; first hypertension can be defined as high

blood pressure at or above 130mm Hg in systolic and diastolic at or above 80 mm

Hg. Second definition defines hypertension as blood pressure at or above 140 mm

Hg in systolic and 90mm Hg in diastolic (WHO, 2021). Non-communicable

diseases (NCDs) are estimated to cause 41 million deaths every year, equivalent to

71% of all deaths worldwide. The most affected age group is 30-69 years, where

15 million of them die from NCDs every year. Cardiovascular disease accounts for

17.9 million deaths, Cancer accounts for 9.3 million deaths, respiratory diseases

accounting for 4.1 million deaths and diabetes 1.5 million deaths annually (WHO,

2021). The proportion of the global burden of disease attributable to hypertension,

increased from about 4.5 percent (nearly1 billion adults) in 2000 to 7 percent in

2010 (Bromfield et al., 2013). This makes hypertension the single most important

cause of morbidity and mortality globally and highlights the urgent need of action

to address the problem. Eighty percent (80%) of global cardiovascular disease

(CVD) mortality occurs in Lowand-Middle Income Countries (LMIC) (Adeloye et

al., 2015). Currently, hypertension is emerging as an important public health

9
problem in sub-Saharan Africa (SSA) (Mills et al., 2016); Approximately 80

million adults had hypertension in sub-Saharan Africa in 2000. Projections based

on current epidemiological data suggest that this figure will rise to one hundred

and fifty (150) million by 2025 (Mills et al., 2016). Risk factors for hypertension

are increasing among African urban as well as rural populations (Mathenge et al.,

2010)

2.1.2 Awareness of Hypertension Status

The World Health Organization has identified hypertension, or high blood

pressure, as the leading cause of cardiovascular mortality. The World Hypertension

League (WHL), an umbrella organization of 85 national hypertension societies and

leagues, recognized that more than 50% of the hypertensive populations worldwide

were unaware of their condition (Chockalingam, 2007). In economically developed

countries like USA, Canada and England, awareness of hypertension status was at

81%, 83% and 65% respectively (Joffres et al., 2013). This could be due to

massive health campaigns and community sensitization about hypertension

through mass media in these developed countries.

Across East Africa, awareness of hypertension status varies from country to

country. For instance, in a study done in adults of urban Ilala district and Rural

Shari village of Kilimanjaro Tanzania by Edwards et al., (2000), just fewer than

20% of the hypertensive participants were aware of their diagnosis. This was a two
10
linked cross-sectional population base survey done. The awareness between the

urban and the rural participants was not differentiated and may be it could have

been higher in the urban residents due to easy access to information in the urban

than in the rural areas. Comparably, a community-based cross-sectional study

among 842 adult residents aged 20 years or older of the rural district of Rukungiri

in Uganda between January and February 2006, awareness status of hypertension

was very low, with nine out of ten unaware of their condition (Wamala et al.,

2009). However, in both studies hypertension awareness was not categorized with

respect to age and sex.

In a systematic review and meta-analysis to assess the recent burden of

hypertension in subSaharan Africa, Ataklte et al., (2014), found awareness of

hypertension status between 7% and 56%. This was based on studies published

between 2000 and 2013. In Southwest Ethiopia, a hospital-based cross-sectional

survey conducted on 734 participants aged 15 years or older, only 35.1% of them

were aware of their hypertension status (Gudina et al., 2013). In Angola, though

community based survey of 1,464 adults aged 18 to 64 years conducted in Bengo

province, amongst the hypertensive individuals, only 21.6% were aware of their

status (Pires et al. 2013). Awareness of hypertension status was more in the

females than the males, and increase with advance in age. This low awareness of

hypertension status reported in this study could have been attributed to the lower
11
cut off for the upper age limit of the study participants and since awareness

increases with advance age (Mathenge et al., 2010), the study could have included

more of the elderly participants. In terms of sex distribution of awareness of

hypertension status, it is true females were more aware of their status because

generally females tend to be more concerned about their health than their male

counterparts (Vlassoff, 2007).

However, the awareness of hypertension status was much higher than that found in

South Eastern Nigeria which was at 2.8% (Andy et al., 2012). This was a cross-

sectional study involving 3869 participants 15 years and above in three rural

communities in the Cross River and Akwa Ibom states of Nigeria. The difference

could be due to inclusion of more of the elderly in the Angola study than the

Nigeria study and also the Angola study had a smaller sample size. The Nigeria

study had a limitation in that there was no age and sex categorization of

hypertension awareness status.

2.1.3 Lifestyle and Environmental risk factors of hypertension

Several studies done have showed that environmental and lifestyle risk factors

operate interactively rather than independently to promote hypertension among

individuals in the society. There exist long term and short-term impact of

numerous environmental factors reported to affect blood pressure, and they keep

on changing such as exposure to loud noise, high altitude, cold ambient

12
temperature, air pollution, specific organic pollutants and heavy metals. Other

proposed environmental factors include obesity, alcohol, salt consumption,

physical inactivity and exposure to chronic stress (Pickering, 2017).

Study conducted in Canada on 13,407 respondents indicated that engaging in less

than 150 minutes per week on physical activities, eating less fruit and vegetables

fewer than five times per day, being obese, having diabetes and having chronic

disease were all associated with increased risk of elevated blood pressure. The

reported prevalence of hypertension for those respondent with those six factors was

55% in women and 44% in men aged 20-39 years (Leung et al., 2019).

Study conducted among 11,517 respondent aged 35-79 years in China on urban

and rural respondents reported overweight, abnormal obesity and

hypertriglyceridemia positively related to hypertension, while physical activity was

negatively related to high blood pressure. The prevalence rate of hypertension

among urban residents aged 35-79 was high (Huang et al., 2019). Another study

done in South Africa among 451 participants, from 2017 to 2019 reported

nutritious foods, recreational physical activity and accessing of health care the risk

factors to high blood pressure (Jongen et al., 2019). Study done in India from 2015

to 2016 among 811,917 people aged 15-49 years, concluded that obesity and

consumption of alcohol are the major predictors of hypertension (Ghosh et al.,

2019).
13
A study carried out in the South Africa in 2019 among 329 participants reported

obesity, physical activity and dyslipidemia as significant and independent

determinants of uncontrolled hypertension (Masilela et al., 2020). Adequate

physical activity has many health-promoting effects and, independent role in

reducing hypertension (Diaz et al., 2013). Genetics contributes to primary

hypertension, persons whose parents had hypertension are more likely to be

hypertensive themselves (Doris, 2011).

Study done in University of North Carolina at Chapel Hill, found the association of

drugs use with the rising incidences of hypertension (Viera et al., 2010). Young

adults who use drugs that cause vasoconstriction, a narrowing of the blood vessels,

often suffer from high blood pressure (Van Amsterdam et al., 2012). Cocaine is the

most common drug that causes high blood pressure. Some legal medications such

as steroids, cold-relief medicines and birth control pills also can cause

hypertension. This study, however, concentrated in specific population where drug

use is prevalent among that age group (Han et al., 2017).

Changes in individual and societal lifestyle is a risk to hypertension in young

adults, such as an increase in tobacco use, excessive alcohol consumption, reduced

physical activity and adoption of "Western" diets that are high in salt, refined sugar

and unhealthy fats and oils (Okwuonu et al., 2014). There is a direct effect between

high levels and specific patterns of alcohol consumption (such as binge drinking)
14
and rising risk of hypertension (Van Vijver et al., 2013). Fruit and vegetable

consumption is one element of a healthy diet and varies considerably among

countries, reflecting economic, cultural and agricultural production environments.

Most of the benefits of fruits and vegetables come from reduction in CVD and risk

factors, particularly hypertension (Alissa et al., 2017). In addition to a high salt

intake, many people in Africa often consume too much salt per day or twice the

recommended maximum level. The core benefits of reducing salt intake

correspond to reduction in high blood pressure (WHO, 2020). Reduction in salt

intake and an increase in potassium improve the blood pressure in African

populations. A low sodium diet leading to a low urinary excretion level of 52

mmols per day, reduces blood pressure in normotensive people significantly within

four to five days (Oladapo et al., 2013). Stress has been associated with

hypertension. Severe stress can lead to a temporary but dramatic spike in blood

pressure, over time this might contribute to high blood pressure, although not

conclusively proved. In addition, some people cope with stress by overeating,

drinking too much, or smoking, which may themselves be independent risk factors

(Osuala, 2017).

Hypertensive disease is increasing in developing countries due to daily high

alcohol consumption, frequent smoking, frequent red meat consumption and

inadequate fruits and vegetables intake (Osuala, 2017). Fruit and vegetable
15
consumption is one element of a healthy diet and varies considerably among

countries, reflecting economic, cultural and agricultural production environments.

Most of the benefits of fruits and vegetables come from reduction in CVD and its

risk factors, particularly hypertension (Kai et al, 2013). Findings from a cross-

sectional study conducted in Kenya in 2015 among participants aged 18-69 years

revealed higher body mass index and alcohol consumption as the risk factors of

hypertension (Mohamed et al., 2018).

2.1.4 Prevalence of Hypertension in Nigeria

Understanding the prevalence of hypertension has attracted much attention among

researchers. Many earlier researchers focused on general prevalence, while

subsequent studies focused on understanding the prevalence in different strata of

the society, which includes hospital clients, age groups, gender, urban and rural

settings and among the working class (Samuel, 2017). Most of the studies

reviewed adopted a cross-sectional design method with the smallest sample size at

77. Participants were often recruited through hypertension screening at medical

outreaches. The prevalence of hypertension varied broadly between researches,

ranging from a minimum of 3.2% to a maximum of 10.1% for children and

adolescents, and a minimum of 21.5% to a maximum of 78.5% for adults. In

studies that compared hypertension in (semi) urban and rural settings, prevalence

was higher among urban dwellers with the exception of Okpechi et al (2013). The
16
semi-urban and rural setting prevalence in the study of Ulasi, Ijoma & Onodugo

(2010) was 35.4% to 32.0% among the 1458 adults in the semiurban community of

Emene-Nike and the rural community of Mbulu-Ujodo in Enugu State. The

prevalence of hypertension among the study population is associated with their

socio-culture nomenclature whereby they believe in gods, chief priests and native

doctors for healing before seeking medical care. Abegunde & Owoaje’s (2013)

cross-sectional study in Iseyin (urban) and Ilua (rural) Oyo state tested

hypertension among adults of age 60 years and above. Consumption of dietary fat

and lack of exercise are the lifestyle behaviours that are considered effects of

urbanisation, which contributed to the higher prevalence of hypertension among

the 316 urban populations in the study. With an. exceptional result, Okpechi et al

(2013) found out that the prevalence of hypertension among their urban

respondents (30.7%) is lower than that of the rural respondents (32.0%). OkpechI

et al (2013) acknowledge that among their 2893 respondents, findings show a

reversal of the urban-rural hypertension prevalence trend. On the one hand, the

result was attributed to the disparity in the education, income and tobacco use in

the urban and rural settings. On the other hand, the difference in the age might

have influenced the results, as the participants from the rural community were

older than those in the urban setting. In the University of Ibadan, Ige, Owoaje &

Adebiyi (2013) conducted a cross-sectional survey of staff members with the aim
17
of documenting the prevalence of self-reported Non-Communicable Diseases and

risk behaviours among university workers who are considered to be a high-risk

group in urban South-West Nigeria. University workers are referred to as high risk

because of the white and blue collar jobs they engage in within the university

community where ready access to transportation and fast food are available, hence

they are less likely to adhere to regular exercise and healthy diet which will reduce

the prevalence of hypertension. Among the 547 academic and non-academic

samples, the hypertension prevalence was found out to be 21.5%. Though all the

respondents reported at least one risk factor of hypertension, especially unhealthy

diet (96%), hypertension prevalence was significantly higher among participants

above the age of 40. The high prevalence of hypertension among this group

according to Ige, Owoaje & Adebiyi (2013) may be a function of respondents'

limited perceived risk of contracting the disease, which affects their choice and

disposition to hypertension prevention lifestyle behaviours. In a cross-sectional

study consisting of 5,733 children and adults ages 3 to 78 years, Ajayi et al (2017)

investigated the blood pressure pattern and hypertension risk factors among

dwellers of Mokola, Ibadan, Oyo State. The respondents who were selected

through the multistage cluster sampling are mostly traders and public service

workers. Though hypertension was discovered to be prevalent among the adult

participants (27.3%), the study also reports that 12.8% of the children participants
18
who are below the ages of 18 are hypertensive. The major contributory factor of

hypertension in this study is obesity among the children and middle age (35-55

years) among adults. Similarly, the study of Emmanuel et al (2017) found out that

hypertension is no longer a rare phenomenon among young people as 10.1%

hypertension prevalence was recorded among secondary school adolescents in

Ekiti, Nigeria. The 416 students aged 10-19 years recorded a higher prevalence of

hypertension in females, which the authors opine might be as a result of the greater

delay in pubertal growth among males. They also discovered that high Body Mass

Index (BMI) just as seen in Ajayi et al (2017) is a predictor of hypertension among

adolescents.

The prevalence of hypertension in all the studies reviewed is considered high and

certain lifestyle behaviours adopted by the respondents were mostly responsible for

the continuous increase of hypertensive patients. Lack of exercise, obesity, poor

diet and occupational stress top the chart of the contributing factors of

hypertension. This is even more prevalent among workers who seem to go through

occupational stress, hardly have time to exercise and consume an unhealthy diet,

making them obese. Perhaps, people are not knowledgeable about lifestyle

behaviours that would help them prevent hypertension. Therefore, all the studies

made a call for a constant community screening and increased awareness of

hypertension and its risk factors across the different populations in Nigeria.
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2.1.5 Knowledge, Attitude and Practice concerning Hypertension in Nigeria

With the high prevalence of hypertension in Nigeria, it has become important to

assess the knowledge of the etiology, risk factors and prevention of hypertension

among Nigerians. This is germane for understanding knowledge-based reasons for

prevalence and strategies for better health education. Akindele & Ayankogbe’s

(2013) study focused on examining the knowledge and awareness of hypertension

among the people of Ifako-Ijaye in Lagos state. The study recorded that 79.2% of

the 250 respondents have heard of high blood pressure. Though the participants

recorded a high rate of being aware of the illness hypertension, only 21.6% were

aware that they were hypertensive at the beginning of the study, while a greater

percentage of 37.2% was discovered to be hypertensive during the study. The

knowledge of the participants on the symptoms of hypertension were discovered to

be limited as 34% did not know any, while others associated it to difficulty in

breathing (25.6%), continuous dizziness (18.8 %), persistent headaches (17.6),

disturbance of vision (2.4%) vomiting (0.8%) and others (0.8 %).

In a hospital-based study consisting of 252 hypertension patients, Okwuonu,

Ojimadu, Okaka & Akemokwe (2014) reported that only 23.4% had the knowledge

of the consequences of having hypertension while 64% of these participants who

were not aware of the cause of hypertension, hoped to be cured of it. According to

the authors, inadequate knowledge among hypertension patients also creates

20
barriers to hypertension control and knowledge of others. The result of this study is

worrisome, as people who are already hypertensive do not have the knowledge of

their condition.

In the Atlantic Coastline of rural Lagos state, Afolabi, Ajibade, Ganiyu & Abu

(2015) discovered that 43% of their 77 female-focused study did not know what

hypertension is. Others associated high blood pressure to fear (14%), excessive

thinking (18%), "when blood overflows” or “ejeriru” (17%) and 5% thinks it

means fast breathing, shock and fatigue. Health-enhancing behaviour such as blood

pressure measurement is important for knowing one’s blood pressure, early

detection and prevention of hypertension. This practice according to this study has

been reported to be uncommon among Nigerians. It was discovered that 23% of

their study sample had never measured their blood pressure before while only 29%

had measured their blood pressure within the last 6 months prior to the study. The

study also revealed that participants had their blood pressure measured because of

illnesses, pregnancy and during a general check-up. Sadly, 71% of them were not

aware of why they had their blood pressure measured.

Among the students and staff of Benue State University, Okpara, Utoo & Bako

(2015) conducted a study to examine the awareness of hypertension and its

relationship with socio-demographic factors in a tertiary institution. Out of the 417

participants, 78.4% were not aware of their blood pressure and were incidentally
21
diagnosed of hypertension during this study. About 69.9% of those discovered to

be hypertensive had also not measured their blood pressure in more than 6 months

prior to the study. Such low level of awareness and practice in an academic

environment is alarming. All public secondary school teachers in Ekiti State, as

studied by Ajewole, Fasoro & Agbana (2017) have heard about hypertension

before. The study is a descriptive cross-sectional study conducted to examine the

awareness level of private and public secondary school teachers in Gbonyin Local

Government Area of Ekiti State, on hypertension. This was born out of the

problem that prevention of hypertension will be hindered when there is low

awareness. All of the randomly selected 203 respondents whose returned copies of

questionnaire were considered valid have all heard about hypertension. However,

78.4% of the teachers in the study were hypertensive, but were unaware of their

status. In addition to this finding on awareness, their low knowledge rate about the

risk factors of hypertension brought the authors to the conclusion that there is a

difference between hearing and being knowledgeable about hypertension.

Raji, Abiona & Gureje (2017) conducted a longitudinal community-based cohort

study, which had been conducted in multiple waves from 2003/2004 to 2009. The

1469 sample of Raji et al (2017) consist of adults who are 60 years and above.

With the help of 24 trained interviewers, this study assessed its participants

through a face-to-face interview. The prevalence of hypertension among this group

22
was recorded at 62.2%. They further found out that the low awareness rate of the

78% newly diagnosed hypertensive patients was significantly associated with low

socio-economic class and Body Mass Index.

2.1.6 Factors associated with hypertension among adults

2.1.6.1 Tobacco smoking

Tobacco smoking is a modifiable risk factor to hypertension. Scholars have

proposed the best and most efficient ways to control chronic diseases such as

hypertension with tobacco smoking cessation being the most urgent intervention

needed for the control (Fu et al., 2017). Various researchers have sought to

determine the prevalence of hypertension among various cohorts some of them

being patients with various conditions. There have been associations determined

between tobacco smoking and hypertension while others have found no association

between tobacco smoking and hypertension.

Smoking was shown to be widespread in 30.2% of adult patients with severe and

persistent mental disorders (Hamadeh et al., 2016). This research was done in

Bahrain.

Adeloye et al. (2019) undertook research to determine prevalence of tobacco

smoking in Nigeria. It was determined that in Nigeria, current smokers accounted

for 10.4% (9.0–11.7) of the population, whereas ever smokers accounted for

17.7%. In both categories, this was higher among males than among women. It was
23
seen that In Nigeria in 2015, The average daily cigarette use for each individual

was 10.1 (6.1-14.2), equating to one hundred and ten million cigarettes daily and

approximately forty billion cigarettes smoked.

The association between cigarette smoking with blood pressure in males was

investigated in research. When contrasted to never smokers, former smokers

exhibited higher odds of high blood pressure while current smokers did not.

Current smokers had lower adjusted blood pressure than nonsmokers as well as

previous smokers, according to the data (Li et al., 2017). Health literacy and

counselling should be considered when coming up with tobacco control strategies

(Fu et al., 2017).

2.1.6.2 Family history

Family history is a modifiable risk factor of hypertension meaning it cannot be

changed. However, the effect of this risk factor can be reduced by making lifestyle

changes. Studies have been done among different cohorts to determine the

association between family history and hypertension. Some of the studies have

been reviewed below.

Research by Ranasinghe et al. (2015) established that the prevalence as seen in

family history of high blood pressure to be 43%. This was a survey that was

crosssectional done among 5,000 adultsfrom Sri Lanka. Ranasinghe et al. (2015)

carried out research to find out the impact of the history of the family to the
24
prevalence of hypertension as well as related metabolic risk variables. The study

sample was drawn from a sample that was representative of nationality in Sri

Lanka. Patients having history in the family in high blood pressure had a

substantially greater high blood pressure prevalence (29.3%, n = 572 over 1951) as

compared to those without (24.4%, n = 616 over 2530). The existence of history of

high blood pressure in the family in parents (odds ratio: 1.28), grandparents (odds

ratio: 1.34), as well as siblings (odds ratio: 1.27) was linked to an increased risk of

acquiring high blood pressure for all individuals. It was concluded that high blood

pressure prevalence was increase when having a family history with high blood

pressure, according to the finding. There was a significant relationship between

family history and hypertension as shown in research by Peng (2019). With

increase in family history of hypertension the risk of hypertension also increased.

2.1.6.3 Dietary habits

Dietary habits have been shown to be associated with hypertension. The dietary

habits include excessive salt intake, consumption of fruits and vegetables,

consumption on fatty foods among other habits. Some studies are discussed below.

In a study by Safdar et al. (2015) dietary patterns had; fruit and vegetable, sweet

and fat, and seafood and patterns of yogurt were obtained by the use of factor

analysis principal component. Seafood together with patterns of yogurt showed

lower likelihood of being associated to high blood pressure, while no substantial

25
association showed for remaining two diet patterns. The results suggested, some

patterns of diet could be associated with high blood pressure for urban adults in

Pakistani who earn low income. The studied show that there is an association

between body mass index and hypertension despite some studies showing no

association between and individuals body mass index and hypertension

2.1.7 Strategies and interventions for prevention and control hypertension

Within the context of limited resources, in most of Africa, the greatest gains in

controlling the hypertension epidemic lie in its prevention, or at least early

detection and adequate control (Beaglehole et al., 2011). For most African

communities the major obstacle to the control of blood pressure is the absence of

appropriate services at the primary health care levels of the health service delivery

system (Van Vijver et al., 2013). The commonality of many risk factors for

hypertension justifies an integrated approach to prevention and control

hypertension. Levels of approaches are as follows; Primordial prevention- refers to

reduction of the risk factors of hypertension in the general population and

decreasing the risk of developing hypertension in future. Primary prevention-

refers to prevention of the condition in those who have prehypertension. Secondary

prevention- refers to prevention of complications in those already developed

hypertension. Tertiary Prevention- refers to preventing progression to end stage

complications in those already developed some associated complication. Several

26
studies have suggested that medications now used to control blood pressure, such

as angiotensin receptor blockers or angiotensin converting enzyme inhibitors, may

also be helpful in the reduction of stress and anxiety (Marvar et al., 2014). There

are also a number of drugs that can treat high blood pressure, including beta-

blockers, calcium channel blockers and angiotensin-converting enzyme inhibitors

(Johannes, 2017). Thus, anti-hypertensive therapy should be tailored and

personalized based on an individual's health profile (Turner et al., 2007). For

instance, in patients with hypertension associated with unusual features such as

early onset of severe hypertension or clinical features such as palpitations and

diaphoresis, further evaluation for secondary hypertension is recommended as

these conditions are potentially curable. On the other hand, patients with severely

elevated hypertension and with evidence of target organ dysfunction or damage

need to be triaged early and started on antihypertensive therapy to lower

cardiovascular and renal morbidity and mortality (Schmieder, 2010).

2.2 Theoretical framework

2.2.1 The health belief model

Health Belief Model is a psychological model that analyzes as well as predicts

health behaviors by focusing on individual attitudes and beliefs. In reaction to

failed free tuberculosis (TB) program for health screening, social psychologists

Kegels and Hochbaum, Rosenstock, of the United States Public Health Service
27
established the Health Belief Model in 1950s. Health Belief Model now has been

altered when investigating wide range of short-term and long-term health

behaviors. This model has eight main integrated constructs pertaining to

hypertension prevention interventions.

Perceived susceptibility: This is a person's belief, or perception, that they are at

risk of a significant health problem. The thought that one can develop hypertension

or maybe knowing those at risk can aid improve the health behavior of those who

are at risk of developing hypertension, therefore lowering the probability of getting

the condition.

Perceived seriousness or severity: It’s when someone realizes how terrible

hypertension is. It’s feasible having a positive attitude toward improved health-

practices that help prevent hypertension if properly talked about impact or effects

of hypertension for one's life.

Cues to Action: Are things serving as reminders or persuade people to perform a

recommended health action. They include: a family member's illness or death from

hypertension, information from electronic and print media (television, books,

radio, journals, magazines, as well as newspapers), together with advice from

influential individuals regarding seriousness, the cause, as well as prevention of

hypertension.

28
Perceived threat: A person's belief or view that hypertension can lead to death or

even cause negative health impacts may lead them believing there to be a reason

for concern about hypertension. Perceived benefit: Value attached to efforts

towards mitigating threat. Knowing one’s blood pressure by getting tested and

behavior change can have benefits that help in hypertension prevention.

Perceived barriers: Environmental, socioeconomic, cultural, literacy level, and

religious variables can all prevent people from implementing suggested health

actions. Lack of knowledge on hypertension may be a barrier in prevention of the

disease.

Likelihood of taking recommended preventive action: Based on the knowledge

available on hypertension, one might assess the risks of hypertension against the

benefits and drawbacks of avoiding risk factors and having blood pressure checked

as preventive strategies

2.3 Empirical Review

A study done in Brazil to estimate the prevalence and the risk factors associated

with hypertension concluded that obese, overweight or former smokers were the

risks to hypertension, (Wenzel, Souza, & Souza, 2009). This cross-sectional study

was done among 380 male military personnel with ages ranging from 19-35years

and used multiple regressions to analyse association with 90% confidence interval.

This model resulted to a higher (52%) prevalence among past smokers in

29
comparison to never smokers (90% CI: 1.13; 2.50). The authors considered the

association of weight gain to ex-smokers would have been the probable factors that

affected the results as prevalence set of overweight and obesity was 36%.

A South African study on risk of smokeless tobacco use on hypertension, used

cross sectional data on 4092 of age 25-70 years black women, the data was

analysed using ANOVA and multiple logistic regression, (Ayo & Omole, 2008).

The daily eight times smokeless tobacco users, resulted in high systolic and

diastolic mean (131mmHg and 84mmHg) as compared to never users (121mmHg

and 77mmHg). Even though the authors found hypertension prevalence to be high

(23.9%) among snuff users than non-users (17%), the association lacked to indicate

significance as a risk factor having adjusted for other confounders. In conclusion

the authors pointed out that the amounts of snuff consumed have a detrimental risk

to hypertension thus highlighted need of cession.

Cross-sectional descriptive study was conducted by Wada, 2016 in which 520

respondents were recruited using multi-stage sampling technique. Modified WHO-

STEPS semi-structured interviewer administered questionnaire was adapted for the

study. Data was collected on Knowledge, sociodemographics, Behavioural,

Physical (Anthropometric measurements) and biochemical variables. Blood

pressure was measured and 5mls of blood was collected to determine the blood

sugar and lipid profile. The prevalence of Systolic and Diastolic hypertension were
30
138(26.5%) and 183(35.2%), diabetes mellitus 30(5.8%), Obesity 48(9.2%) and

overweight 142(27.3%). Multivariate analysis revealed being older than 40 years

(AOR: 4.10; 95% CI: 2.44 - 7.11), having BMI >30(AOR: 2.47; 95% CI: 1.57 -

3.66), lack of physical activity (AOR: 2.31; 95% CI: 1.24 - 5.04), high serum uric

acid (AOR: 3.21; 95% CI: 1.55- 6.59) as independent risk factors of hypertension.

The study revealed low level of knowledge on hypertension which is a major

cardiovascular risk factor among study participants. A BMI greater than

30(obesity), lack of vigorous physical activity were the major modifiable risk

factor while age greater than 40 years was found to be the non-modifiable risk

factor of hypertension among the civil servants of Kano State. It is recommended

that Sensitization Campaigns of civil servants to embark on regular medical

checkups and exercises.

Damaris, 2021 conducted a research on determination on the risk factors of

hypertension among young adults aged 18-35 years attending Tenwek Mission

Hospital. Purposive sampling was used to select the cases whereas the controls

were selected using simple random sampling after they had received their

medication. Semi-structured interviewer administered patient questionnaire was

used during data collection. Data collected were entered into MS excel then later

transferred to STATA version 14.1 for cleaning and analysis. Level of awareness

on knowledge about signs and symptoms was found to be below 36%.

31
Multivariable logistic regression was fitted to find out factors associated with

hypertension, where all covariates with p-value ≤ 0.1 were included in the adjusted

model. Descriptive statistics indicated that majority of the respondents were

females {n=100 (62.5%)}. Multivariate logistic regression analysis found sex to be

statistically significant risk factor of hypertension where females were found to be

2.5 times likely to suffer from hypertension compared to their males counterpart

{AOR=2.5, 95%CI [0.48-5.69], p-value=0.034. It was recommended that

Government should make available provision on blood pressure check to members

of public for early tracking and tracing of young adults with hypertension to plan

on a tailored intervention in prevention and control of hypertension.

Jennifer et al., 2020 carried out a research to assess levels of awareness,

knowledge, attitude and practices relating to hypertension and diabetes among

adults aged 35 years resident in selected communities in Imo and Kaduna states,

Nigeria. A descriptive cross-sectional study. The study assessed the level of

hypertension and diabetes knowledge among the participants. Regular blood

pressure (BP) and glucose screening practices were also examined as outcome

measures. Statistically significant associations were observed between age and

regular BP and BG level checks. Despite the high awareness rate of hypertension

and diabetes observed in this study and a relatively good knowledge about the two

conditions, unhealthy lifestyle practices and non-regular routine screening abounds

32
among the respondents. Thus, there is a need to improve access to quality

information about hypertension and diabetes aimed at motivating adoption of

healthy behaviours.

Mbah et al., 2013 determined the prevalence and the risk factors of hypertension

among middle - aged persons in Ahiazu Mbaise Local Government Area, Imo

State. A total of 200 subjects aged 40-60 years were selected and used for the

study. Anthropometric measurements (weight and height) were taken. Body Mass

Index (BMI) of the subjects was also calculated. The blood pressure measurements

of the subjects were also collected using a sphygmomanometer and then classified

using standard methods. A structured interviewer administered questionnaires were

used to obtain information on the socio-economic characteristics, personal data and

risk factors associated with hypertension among the subjects. The Statistical

Package for social sciences was used for data analyses. The prevalence of

hypertension (32.5%) was found among the subjects with a higher proportion in

female subjects (20.0%) than males (12.5%). A quarter of the subjects (25.0%)

were either overweight or obese. Less than half (30.0%) of the subjects had a

frequent consumption of alcoholic beverages and 23.0% had a frequent intake of

salty foods. These were all implicated as the risk factors of high blood pressure.

There is need for preventive strategies on hypertension control and enlightening

33
the public on the risk factors of hypertension especially high BMI and wrong

eating habit and lifestyle should be encouraged.

Ozims et al., 2017 carried out a research to investigate the prevalence of

hypertension among adults aged 30-69 years who used Imo State Specialist

Hospital, Owerri (IMSSHO), from 2009-2013. The study adopted the Ex-Post

Facto Design to ascertain the prevalence of hypertension in the population of

study. The instrument for data collection was Self-Developed Data Collection

Schedule Sheet and the hospital's Medical Records. The data collection schedule

sheet was approved by the thesis supervisor and validated by three lecturers. Facts

collected were tallied and recorded in the data collection schedule sheet in figures

and were analyzed using descriptive statistics of frequency table and percentage

and inferential statistics like chi-square (^ 2) at 0.05 level of significance. The

results of the analyses revealed that there were 556 adults aged 30-69 years living

with hypertension from 2009-2013. It revealed that age and gender influenced

prevalence of hypertension among these adults. The prevalence of hypertension

was highest among ages 60-64 years-150 (26.98%) and lowest among ages 30-34

years-8 (1.44%); and by gender, it was higher among women-306 (55.04%) than

men-250 (44.96%). It also revealed that there were 33 deaths due to hypertension,

out of which, 12 (36.6%) were men and 21 (63.66%) were women. It further

revealed that both age and gender did not significantly influence the prevalence of
34
hypertension mortality among these adults. In view of the results, some

recommendations were made which included provision of hypertension centers for

free blood pressure checking and 72 multi-sectional approaches among others to

ensure early detection and diagnosis, prompt treatment, prevention and control of

hypertension.

2.4 Summary of Literature Review

The prevalence of hypertension is quite high at 40% globally (Alwan, 2011). More

research is needed to understand why there is a high occurrence of hypertension in

the population and especially health workers who are considered to be the leading

team in motivation and control of blood pressure. Occupational stress is one of the

factors believed to cause hypertension, but convincing evidence for such an

association is difficult to find among hospital practitioners especially in Kenya.

Excess alcohol use and smoking are associated with hypertension, though the link

between these is not clear. Several risk factors for hypertension have been

identified including age, gender, lifestyle among others in western countries.

However, the effect of dietary habits, physical activity, nutritional status and how

they affect blood pressure has not been ascertained among artisans in Owerri West.

This study is aimed at assess the prevalence of hypertension among artisans in

Owerri West, Imo State, Nigeria.

35
 CHAPTER THREE

MATERIAL AND METHOD

3.1 Study design

The researcher will employ the descriptive survey method. A cross-sectional study

design will be employed in this study to assess the prevalence of hypertension

among artisans in Owerri West, Imo State, Nigeria.

3.2 Area of study

The study will be conducted in Owerri West Local Government Area of Imo State,

Nigeria. Imo State has a total population of two million four hundred and eighty

five thousand six hundred and thirty five people (2,485, 635) according to National

population Census (NPC, 1991). There are fifteen (15) autonomous communities

in Owerri West Local Government Area. Owerri – West Local Government is

located South– West of Owerri which is the State Capital and it is about 3 km off

Owerri–Elele– Port –Harcourt Road. Three (3) communities namely, Nekede,

Obinze, Ihiagwa will be selected

36
Fig 3.1: Map of Owerri West (Aubuike, 2019)

3.3 Study Population

The population chosen for this study will comprise of all artisans living in selected

communities in Owerri West, Imo at the time of study.

3.4 Sampling Method

Convenience sampling is a method of collecting samples by taking samples that

are conveniently located around a location or Internet service. The convenience

37
sampling method will be used because this study was largely exploratory. Artisans

that met the selection criteria will be recruited and assessed during the study

period. Participants will be recruited consecutively for the in-depth interview until

a saturation point was reached.

3.5 Sample size determination

The sample size will be determined using the Taro Yamen formula (1967) for

sample size determination.

n= N_

1+Ne2

Where:

n is the desired sample size

N is the population size (25000)

e is margin of error (0.05)

Therefore,

25000_

1+25000(0.05)2

25000

63.5

n = 393.700……………… 394

38
Furthermore, to adjust for a 10% rate of non-response and invalid response (i.e.,

90% expected response rate =0.9).

n= n/expected response rate

n =394/0.90= 437.7777

n= 438.

3.6 Instrument for Data collection

A validated open-ended and close questionnaire will be used as a survey tool. The

structured based questionnaire will be prepared for the study to collect data from

artisans. The questionnaire consists of 4 sections. Section A consists of information

on socio demographic characteristics. Section B family history. Section C consists

tobacco smoking history of the respondents. Section D consist Dietary habits. A

Sphygmomanometer will be used to check blood pressure of the respondents. Two

separate readings will be taken and the average will be used.

3.7 Validity

Validity is defined as how much any measuring instrument measures what it is

intended to measure. Bryman and Bell (2007) also suggested that the important

issue of measurement validity relates to whether measures of concepts really

measure the concept. Validity refers to the issue of whether an indicator (or set of

indicators) that is devised to gauge a concept really measures that concept. In this

thesis, construct validity has been used.

39
3.8 Reliability

Reliability is defined as be fundamentally concerned with issues of consistency of

measures (Bryman and Bell, 2007). There are three prominent factors related to

considering whether a measure is reliability: stability, internal reliability and inter-

observer consistency. In this study, internal reliability will be considered. Bryman

and Bell suggested that a multiple-item measure in which each answers to each

questions are aggregated to form an overall score, we need to be sure that all our

indicators are related to each other.

3.9 Method of Data Collection

Data will be collected using interviewer-administered questionnaires and will be

done during the weeks which are Mondays to Friday. The respondents will be

checked with Sphygromamometer

3.10 Method of Data Analysis

The response to the item on the questionnaires will be analyzed using frequencies

and percentages, with the use of Statistical Package for Social Science (SPSS)

Version 21.0. To ensure consistency, the responses in the questionnaires will be

edited and coded. The response for the open-ended questions will be grouped

based on common ideas that the respondents expressed. The data will be collected

and analyzed using tables and simple percentages, mean score and standard

deviations.
40
3.10 Ethical consideration

An introductory letter will be collected from the Department of Public health,

Federal University of Technology, Owerri and this will enable me to have a good

rapport with the respondents selected for the study.

41
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45
 INTRODUCTORY LETTER

Dear Respondents

I am Unegbu Olachi Lynda from Federal University of Technology, Owerri

pursuing a Bachelor of Science (BSC) in Public Health. I’m interested in learning

more about prevalence of hypertension among artisans in Owerri West, Imo State,

Nigeria. I will ask you several questions. The data you give will be utilized to

foster better wellbeing training programs for youngsters such as yourself. Try not

to compose your name on this poll. The appropriate responses you give will be

kept rigorously secret; they might be utilized for factual investigation. No one will

know what you write. Answer the questions based on what you really do and to the

best of your ability. Completing the survey is voluntary. If you don’t want to

answer a question, just leave it blank.

46
 Questionnaire

Thank you for accepting to participate in this study. Below is a list of questions we
would like you to respond to. They will take about 15 minutes to complete, Tick
the provided according to what applies to you. Please do not write your name on
this paper. Thank you.

Section A: Demographic Data

1. Gender

Male

Female

2. Age

Less than 20 years

20-29 years

30-39 years

40-49 years

50-59 years

60-70 years

3. Marital status Single

Married

Divorced

Widowed

4. Highest Level of education Primary

Secondary

College/university

47
None

Section B: Family history of hypertension

5. Does any of your family suffers from hypertension?

Yes

No

6. If yes, is the person your immediate or extended family?

7. What is the gender of the person with hypertension?

Male

Female

8. Have you ever had your blood pressure measured by a doctor or other health
worker?

Yes

No

9. Have you ever been told by a doctor or other health worker that you have
raised blood pressure or hypertension?

Yes

No

Section C: Tobacco smoking history

10.Do you currently smoke any tobacco products e.g. cigarette, cigar

Yes

No

48
 11.If yes, how often do you smoke

Daily

2-4 times a week

More than 4 times a week

12.During the past 12 months, have you tried to stop smoking?

Yes

No

13.During any visit to a doctor or other health worker in the past 12 months,
were you advised to quit smoking tobacco?

Yes

No

14.During the past 12 months have you ever smoked any tobacco

Yes

No

Section D: DIETARY HABITS

15.In a typical week, on how many days do you eat fruit?

Number of days

Don’t know

16.How many portions of fruit do you eat on one of those days?

Number of servings

Don’t know

17.In a typical week, on how many days do you eat vegetables?

49
Number of days

Don’t know

18.How often do you add salt right before you eat food or as you are eating it?

Always

Often

Sometimes

Rarely

Never

Don’t know

19.What quality of salts is added in cooking or preparing foods in your

household?

About 1 tablespoon

Less than 1 tablespoon

50