International Journal of Africa Nursing Sciences 20 (2024) 100641

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Factors associated with uncontrolled blood pressure in adult hypertensive

patients on follow-up at Enat General Hospital, Amhara, Ethiopia, 2021
Melese Wagaye a, Prem Kumar a, Wondwossen Yimam b, Fatuma Seid a, Samuel Anteneh a,
Mitaw Girma b, Yemiamrew Getachew c, Yosef Zenebe c, Zelalem Debebe d, Mulugeta W/
Selassie e, *
a
Department of Adult Health Nursing, College of Medicine & Health Sciences, Wollo University, Dessie, Ethiopia
b
Department of Comprehensive Health Nursing, College of Medicine & Health Sciences, Wollo University, Dessie, Ethiopia
c
Department of Psychiatry, College of Medicine & Health Sciences, Wollo University, Dessie, Ethiopia
d
Center for Food Science and Nutrition, College of Natural and Computational Sciences, Addis Ababa University, Ethiopia
e
Department of Pediatrics and Child Health Nursing, College of Medicine & Health Sciences, Wollo University, Dessie, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Uncontrolled hypertension in hypertensive patients is a significant public health issue in both
Uncontrolled Blood Pressure developed and developing nations, and it can result in early death and disability on a global scale.
Associated factors Objective: To assess factors associated with uncontrolled BP among adult patients with hypertension attending
Hypertensive Patients
Enat General Hospital, Ethiopia.
Hospital
Method: An institutional-based cross-sectional study design was employed from May 1 to June 30, 2021. A
systematic random sampling technique was used to select 403 study participants. Epi-data version 4.6 and SPSS
version 25 was used to enter and analyze the data respectively. Variables with P-value < 0.25 in bi-variable
logistic regression analysis were imported to multivariate logistic regression analysis. Finally, variables with
p-value < 0.05 were declared for statistical significance.
Results: About 47.8% of participants had uncontrolled BP with a response rate of 95%. Abnormal waist
circumference (AOR: 3.703, 95% CI 1.690–8.133), moderate stress (AOR: 4.838, 95% CI 2.072–11.294), high
stress (AOR: 3.894, 95% CI 1.653–9.170), alcohol use (AOR: 3.097, 95% CI 1.665–5.763), high anxiety (AOR:
4.127, 95% CI 1.120–15.00), borderline anxiety (AOR: 6.560, 95 % CI 2.941–14.633), not eating fruit (AOR:
3.022, 95 % CI 1.430–6.386), medication non-adherence (AOR: 9.266, 95 % CI = 2.054–41.804), salt (AOR:
2.336, 95 % CI 1.269–4.302), and comorbidity (AOR: 3.204, 95 % CI 1.046–9.808) were factors associated with
uncontrolled BP.
Conclusions: Uncontrolled BP was strongly correlated with stress, alcohol use, anxiety, less fruit-eating habits, salt
intake, medication nonadherence, co-morbidities. Regular follow-up, early care seeking for co-morbidity and the
provision of health education regarding lifestyle changes are all recommended.

1. Introduction morbidity and mortality among patients with hypertension (Lancet:

Factors Associated with Uncontrolled Blood Pressure among Adult
Patients with Hypertension on Follow-Up at Enat General Hospital,
Amhara, Ethiopia, 2021 Introduction Hypertension (HTN) is a chroni­
cally increased blood pressure that increases the risk of cardiovascular,
chronic kidney disease, brain damage, diabetes, and cerebrovascular
illnesses, and it is the major cause of premature death worldwide. Car­
diovascular diseases (CVDs) are the most devastating contributors to
London, England, 2017) . Uncontrolled blood pressure (UBP) is defined
as BP > 130/80 mmHg in patients with proven comorbidity, BP > 150/
90 mmHg in patients with hypertension 60 years of age or older, and
systolic blood pressure (SBP) > 140 and/or DBP > 90 mmHg (Unger,
Borghi, Charchar, Khan, Poulter, Prabhakaran, 2020) . Globally, 1.4
billion people are suffering from HTN, and by 2025, that figure is ex­
pected to rise sharply to 1.6 billion and almost 9.4 million fatalities
every year (Ataklte, Erqou, Kaptoge, Taye, Echouffo-Tcheugui, Kengne,

* Corresponding author.
E-mail addresses: zelalem.debebe@aau.edu.et (Z. Debebe), alzunfa@yahoo.com (M. W/Selassie).

https://doi.org/10.1016/j.ijans.2023.100641
Received 2 February 2023; Received in revised form 9 November 2023; Accepted 13 November 2023
Available online 29 November 2023
2214-1391/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
M. Wagaye et al.
2015) . A systematic review of 90 countries estimated that about 349
million people in high-income nations and 1.04 billion people in low-
income countries have hypertension, indicating a dramatic shift in the
distribution of the condition (Lancet: London, England, 2017) . In Sub-
Saharan Africa, it is estimated that there are 74.7 million patients
with hypertension; by 2025, that number is anticipated to increase by
68 % to 125.5 million (Guwatudde, Nankya-Mutyoba, Kalyesubula,
Laurence, Adebamowo, Ajayi, et al.) . The prevalence of hypertension in
Ethiopia ranges from 7 to 37 % (Legese, 2020) . The World Health Or­
ganization (WHO) estimates that non-communicable diseases (NCDs)
account for 39 % of all fatalities in Ethiopia, 16 % of which are linked to
cardiovascular diseases (CVDs) (World Health Organization, 2018) . The
average prevalence of hypertension was 13 % for urban people and 10 %
for rural residents in Amhara Regional State City and its surrounding
rural district administrations. However, nearly half of these individuals
(46.3 %) are people who were recently diagnosed with hypertension
(Tesfaye, Temesgen, Kasa, Yismaw, 2019) . Globally, hypertensives face
a high burden of uncontrolled blood pressure (UBP), with the US
experiencing 27.8 % and 35.2 % UBP from 2013 to 2018 and 48.3 %
from 2015 to 2016 (Fryar, Ostchega, Hales, Zhang, Kruszon-Moran,
2017) , while Thailand’s burden is 54.4 %. Africa has a varying
burden, with Congo and Nigeria having 77.5 % and 43.4 % UBP,
respectively. In Sub-Saharan Africa, UBP remains difficult, with 11 % of
those receiving treatment also having UBP. Meeting the WHO’s goal of a
25 % reduction by 2025 remains challenging (Ataklte, & Guwatudde,
2015, Ibrahim, 2020, Kika, 2016, Meelab, 2019, Muntner, 2020, &
Nansseu, 2016) .
The overall prevalence of UBP in Ethiopia is 48 % (Sarfo,Mobula,
Burnham,Ansong,Plange-Rhule,Sarfo-Kantanka,et al., 2018) and ranges
between 34.6 % and 52.5 % (Aberhe, & Fekadu, 2020, Gebremichael,
2019, Solomon, 2016) . The rising incidence of non-communicable
diseases (NCDs) and risk factors can hamper Ethiopia’s economic
progress, and UBP causes heart failure, chronic renal failure, and
strokes, putting financial strain on healthcare systems (Ethiopia MoH,
2017) . Age, sex, non-adherence to antihypertensive medications, non-
adherence to physical activity (Fekadu,Adamu,Gebre,Gamachu,Bekele,
Abadiga,et al., 2020) , non-adherence to low salt intake intake (Abegaz,
Abdela, Bhagavathula, Teni, 2018) , restricted access to health care
services, waist circumference, and non-enrollment in health insurance
are the main risk factors for uncontrolled blood pressure (Sarfo,Mobula,
Burnham,Ansong,Plange-Rhule,Sarfo-Kantanka,et al., 2018) .
Ethiopia faces high uncontrolled hypertension rates, causing car­
diovascular and cerebrovascular disorders. Despite advancements in
diagnostic and treatment techniques, the issue remains alarming. Prior
research in Ethiopia deserted to address imperative contributing factors
of uncontrolled blood pressure, specifically lifestyle advice, stress,
anxiety, depression, waist circumference, knowledge of participants on
hypertension, and enrollment status of health insurance. Moreover, the
current study provides a resolution to contradictory research findings
that uncontrolled blood pressure was more prevalent in males than fe­
males, and most importantly, there was no similar research conducted in
the study area. Hence, this study aimed to assess the proportion and
factors of uncontrolled blood pressure among adult patients with hy­
pertension attending Alem Ketema Enat General Hospital, North Shoa,
Ethiopia.
2. Methods and materials
2.1. Study area and period
Alem Ketema is 183 km from Addis Ababa. This town has Enat
General Hospital, which serves more than 6,000 patients every month,
and about 62,400 people do so annually. According to the hospital
report, it comprises 135 support staff members and 125 medical pro­
fessionals. This study was conducted from May 1 to June 30, 2021, at
Enat General Hospital.
2
International Journal of Africa Nursing Sciences 20 (2024) 100641
3. Study design
An institution based cross-sectional study design was used to choose
403 adult patients with hypertension who were receiving pharmacologic
therapy.
3.1. Source population
All adult patients with hypertensionon on follow-up attending Enat
General Hospital.
3.2. Study population
All adult patients with hypertensionon on follow-up attending Enat
General Hospital during the study period.
3.3. Inclusion criteria
Adult patients with hypertension who had on follow-up ≥ 6 months
and who were on pharmacologic therapy.
3.4. Exclusion criteria
All pregnant women and adult patients with hypertension, who were
unable to talk due to a major medical condition or impaired cognition, as
well as patients who had just been diagnosed and those whose medical
records were insufficient.
3.5. Sampling techniques and procedures
The study participants were chosen using a method of systematic
random sampling. By counting appointment lists in the registration
book, the total number of patients with hypertension who received on
follow-ups at various appointment dates during the study periods was
determined. The “K th” value was then computed as follows: N/n = 714/
403 = 2, where “N” was the total number of patients who visited during
the study period last year and “n” was the overall sample size. The first
person was then chosen using a random lottery process, and the subse­
quent participants were chosen at two intervals until the necessary
sample size was reached.
3.6. Sample size determination
The sample size (403) was determined using a single population
proportion calculation, assuming a 95 % confidence interval, a 5 %
margin of error, and a proportion of 48.6 % (Aberhe, Mariye, Bahrey,
Zereabruk, Hailay, Mebrahtom, et al, 2020) from a prior study carried
out in Northern Ethiopia. The final sample size with a 5 % non-response
rate was 403.
3.7. Data collection tools and procedures
Data were gathered using a semi-structured WHO questionnaire on
chronic disease risk factors and surveillance of NCDs. It consists of socio-
demography, behavioral analysis, and physical measurement. Eligible
patients’ medical records were reviewed, and a data abstraction form
was filled out to get their co-morbid conditions and the antihypertensive
medications they were taking. An eight-item, reliable medication
adherence scale was used to measure medication compliance (=0.83)
(Morisky, Ang, Krousel-Wood, Ward, 2008). The PSS with reliability
(=0.93) was used to assess the stress level (Baik,Fox,Mills,Roesch,
Sadler,Klonoff,et al., 2019) . Anxiety and depression were assessed by
the hospital anxiety and depression scale with reliability (=0.89)
(Spitzer, Kroenke, Williams, Löwe, 2006) . Anthropometric measure­
ments were accomplished using the Seca240 weight measuring equip­
ment, stadiometer height measuring tool, and measurement tape for
M. Wagaye et al. International Journal of Africa Nursing Sciences 20 (2024) 100641

waist circumference. Body weight (kg)/height (m2) was used to 4. Results

compute BMI, and participants were categorized based on the WHO BMI
cut-off point, i.e. Underweight < 18.50, normal weight range 18.5–24.9,
overweight 25–29.9, and obese > 30 s An international physical activity
questionnaire (IPAQ) with a reliability score of α = 0.91 (Van der Ploeg,
Tudor-Locke, Marshall, Craig, Hagströmer, Sjöström, & Bauman, 2010)
was used to evaluate the physical activity, which was categorized as
vigorous, moderate, and sedentary according to WHO physical activity
recommendations. The respondents’ knowledge of hypertension was
assessed by the 14-item hypertension evaluation of lifestyle and man­
agement (HELM) scale (Schapira, Fletcher, Hayes, Eastwood, Patterson,
Ertl, et al., 2012) . Using a modified Bloom’s cut-off point, participants’
general knowledge was classified as adequate if it was over 80 % (score:
8 points) and inadequate if it was below 80 % (score: 8 points). The data
were collected by two trained BSc nurses. The information is gathered
from both interviews and patient chart reviews. Before the data collec­
tion, the objective of the study was explained clearly to the participants.
After reading the information sheet to the participants, their willingness
to participate was asked, and written consent was obtained from each
respondent because it was their right to participate or not. The patients
were interviewed at Enat General Hospital in private rooms to ensure
their privacy and confidentiality and, of course, to facilitate their
participation. The allocated time for each patient interview was one
hour excluding the document review. The study and data collection
period was from May 1 to June 30, 2021 and June 1 to June 30, 2021 at
Enat General Hospital respectively.
4.1. Socio-demographic characteristics of the study participants
The total number of participants in this study was about 403, with a
response rate of 383 (95 %). 224 (58.5 %) of the 383 study participants
were female, and 239 (62.4 %) were city inhabitants. The respondents
were 53.11 years old on average (SD = 9.833), 325 (84.90 %) were
married, 184 (48 %) were illiterate, and 148 (38.6 %) were farmers
(Table 1).
4.2. Magnitude of uncontrolled blood pressure among the study
participants
A total of 200 (52.2 %) of the 383 study participants who were
receiving follow-up and treatment had controlled blood pressure, while
183 (47.8 %) had uncontrolled blood pressure (Fig. 1) (see Table 2).
4.3. Behavioral-related factors of the study participants
Out of all study participants, 130 (33.9 %) had consumed alcohol in
the previous 30 days. 118 (30.8 %) consumed fruit, 195 (50.9 %)
consumed vegetables, 264 (68.9 %) had minimal stress, and 136 (35.5
%) added extra salt to their meals (Table 3).
4.4. Clinical characteristics of the study participants

3.8. Data analysis 362 (94.5 %) of the 383 study participants had received advice about
cutting back on salt, 19 (5 %), about eating more fruits and vegetables,
The collected data were entered into Epi-Data version 4.6 and 107 (27.9 %), about getting more exercise, and 53 (13.8 %) had been
analyzed by SPSS version 25. Bi-variable and multivariable logistic identified as having diabetes mellitus (Table 4).
regression with a 95 % confidence level were used to evaluate the data.
Upon bi-variable analysis, the variable with a p-value < 0.25 was 4.5. Drug and anthropometric measurements of the study participants
transferred to multivariable logistic regression, and the variable with a P
value < 0.05 was deemed statistically significant. The Hosmer- 235 (61.4 %) of the 383 study participants had received hydro­
Lemeshow test was employed to assess the model’s fitness. To chlorothiazide, 137 (35.8 %) enalapril, 165 (43.1 %) nifedipine, and 62
examine the relationship between sex and blood pressure control rate,
the chi-square test was performed. The proportion of uncontrolled blood Table 1
pressure was determined using descriptive statistics, and the data were Socio-demographic characteristics of adult patients with hypertensionon on
arranged, processed, evaluated, and presented using words, tables, and follow-up attending Enat General Hospital, Amhara, Ethiopia, 2021 (n = 383).
graphs. Variables Frequency Percent
(%)
3.9. Data quality control
Sex Male 159 41.5
Female 224 58.5
A data extraction tool was developed in both English and Amharic Residence Urban 239 62.4
using terms and variables from many studies. The Cronbach alpha test Rural 144 37.6
Age 25–34 16 4.2
(stress = 0.84, anxiety = -0.80, and depression = 0.87) was used to
35–44 50 13.1
assess reliability for the outgoing variables, which were measured using 45–54 115 30
a reliability checklist. A senior cardiologist and internist also checked ≥55 202 52.7
the validity of the checklist. The tool was pretested on 20 patients in Marital status Married 325 84.9
Mida Primary Hospital patient reviews to ensure consistency. Finally, Widowed 28 7.3
Other* 30 7.8
there was no changes required to the questionnaire after the pre-test and
Educational status Unable to read and write 184 48
expert review. Read and write 77 20.1
Primary school (1–8) 38 9.9
3.10. Ethical consideration High school/preparatory 23 6
school (9–12)
College/University 61 15.9
The Department of Adult Health Nursing in the College of Medicine Occupational status Government employee 57 14.9
and Health Sciences at Wollo University granted ethical clearance. The Retired 27 7
Enat General Hospital’s relevant authorities granted permission. Par­ Housewife 68 17.8
ticipants’ confidentiality and privacy were preserved, and the study was Merchant 53 13.8
Farmer 148 38.6
carried out under the Helsinki Declaration.
Other* 30 7.8
Average monthly Above poverty line 271 70.8
income Below poverty line 112 29.2
Health insurance Yes 307 80.5
enrolment No 76 19.8

Other*= single and divorced, students, daily laborers, and no job.

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M. Wagaye et al. International Journal of Africa Nursing Sciences 20 (2024) 100641

Table 3
Behavioral factors of adult patients with hypertension on follow-up attending
Enat General Hospital, Amhara, Ethiopia from May to June 2021.
Variables Frequency Percent
(%)

Hypertension knowledge Adequate 3 0.2

Inadequate 380 99.8
Stress Low 264 68.9
Moderate 57 14.9
High 62 16.2
Anxiety Normal 187 74.9
Borderline 65 17
High 31 8.1
Depression Normal 347 90.6
Borderline 7 1.8
High 29 7.6
Diet Meat Yes 227 59.3
used No 156 40.7
Fruit Yes 118 30.85
Fig. 1. Uncontrolled blood pressure among adult patients with hypertension
No 265 69.2
attending Enat General Hospital, Amhara, Ethiopia, 2021 (n = 383). Vegetables Yes 195 50.9
No 188 49.1
Cereal products Yes 100 26.1
Table 2 No 283 73.9
Sex and blood pressure control rate of adult patients with hypertension on Other* Yes 368 96.1
follow-up attending Enat General Hospital, Amhara, Ethiopia, 2021(n = 383). No 15 3.9
Oil used Saturated 32 8.4
Variable Controlled Uncontrolled Total P-value Unsaturated 343 89.6
Sex Male Observed 72 87 159 0.022 Other 2 2.1
Expected 83 76 Salt Additional salt added to Yes 136 35.5
Female Observed 128 96 224 food preparation No 247 64.5
Expected 117 107 Salt added per day >1teaspoon 99 72.8
Total 200 183 383 <1 teaspoon 37 27.2
Alcohol use Yes 130 33.9
No 253 66.1
Antihypertensive medication Non- 22 5.7
(16.2 %) amlodipine drugs. In addition, 161 (42 %) and 222 (58 %) of
adherence adherent
the study participants had monotonous and dichotomous drug orders, Adherent 361 94.3
respectively. Regarding the anthropometric measurements, 261 (68.1 Physical activity Sedentary 124 32.4
%) and 122 (31.9 %) had normal and abnormal waist circumference, Moderate 153 39.9
respectively. Concerning the BMI of the study participants, 270 (70.5 Vigorous 106 27.7

%), 94 (24.5 %), and 19 (5 %) were normal, overweight, and obese
(Table 5).
4.6. Factors associated with uncontrolled blood pressure among the study
participants
Using a bi-variable logistic regression analysis, variables with a p-
value of 0.25 were shown to be associated with uncontrolled blood
pressure, and those variables were then included in a multivariable lo­
gistic regression. At a p-value of less than 0.25, fifteen variables were
linked to uncontrolled blood pressure. These factors were included in
the multivariable logistic regression along with sex, educational level,
health insurance, alcohol, fruit, salt, stress, anxiety, depression, co­
morbidity, renal disease, diabetic nephropathy, adherence, BMI, and
waist circumference (see Table 6).
After adjusting for potential confounders, alcohol use was signifi­
cantly associated with uncontrolled blood pressure. Other significant
factors included comorbidity, bad waist circumference, high and mod­
erate stress, high and borderline anxiety, and non-adherence to medi­
cation. In multivariable logistic regression, the other factors, however,
did not reach their statistical significance. When compared to study
participants with normal waist circumference, low stress, alcohol use,
and normal anxiety, those with abnormal waist circumference were 3.7
times (AOR = 3.703; 95 % CI = 1.690 to 8.113), moderate stress was 4.8
times (AOR = 4.838; 95 % CI 2.072 to 11.294), and borderline anxiety
was 6.6 times (AOR = 6.560; 95 % CI 2.941 to 14.633) more likely to
have uncontrolled blood pressure. High stress was 3.9 times (AOR 3.894,
95 % CI 1.653–9.170), participants who didn’t eat fruit were 3 times
(AOR = 3.022, 95 % CI 1.430–6.386), participants who added addi­
tional salt to food preparation were 2 times (AOR = 2.336, 95 % CI
*Other, Injera and butter.
1.269–4.302), and medication non-adherence was 9 times (AOR 9266,
95 % CI 2.054––41.804) more likely to have uncontrolled blood pressure
at P < 0.01 than those with consume fruit, did not add additional salt to
food preparation, low stress, and medication adherence. Participants
with high anxiety were 4 times (AOR = 4.127, 95 % CI 1.120–15.00),
and those with co-morbidity were 3 times (AOR 3.204, 95 %CI
1.046–9.808) more likely to have an uncontrolled blood pressure than
those with low anxiety and no co-morbidity, respectively, at P < 0.05.
Health insurance, body mass index, sex, level of education, depression,
diabetes mellitus, and renal disease were not significantly linked with
uncontrolled blood pressure (Table 6).
5. Discussion
The purpose of the study was to assess the prevalence of uncontrolled
blood pressure and associated factors among adult patients with
hypertensionfollow-up. The prevalence of uncontrolled blood pressure
was found to be 47.8 % (95 % CI 43.1–53.1). This study’s findings were
consistent with those of a systematic review conducted in Ethiopia (48
%) (Amare, Hagos, Sisay, Molla, 2020) , a cross-sectional study con­
ducted at Jimma University in Ethiopia (52.7 %) (Tesfaye, Temesgen,
Kasa, Yismaw, 2019) and (49.7 %) (Solomon, Tigestu, 2016) , Mekelle
public hospitals in Tigray, Ethiopia (48.6 %) (Aberhe, Mariye, Bahrey,
Zereabruk, Hailay, Mebrahtom, et al, 2020) , and Nigeria (43.4 %)
(Ibrahim, Agbesanwa, Muftau, Omosanya, Olalekan, Olamide, 2020) .
However, this study’s findings were greater than those from Nekemte,
Ethiopia (34.6 %) and the Third National Health and Nutrition Evalu­
ation Survey (27.1 %) (Fekadu,Adamu,Gebre,Gamachu,Bekele,Abadiga,

4
M. Wagaye et al. International Journal of Africa Nursing Sciences 20 (2024) 100641

Table 4
Clinical characteristics of adult patients with hypertension on follow-up attending Enat General Hospital, Amhara, 2021 (n = 383).
Variables Controlled Percent (%) Uncontrolled Percent (%)

Tobacco advice Yes 3 1.5 5 2.7

No 197 98.5 178 97.3
Salt advice Yes 189 94.5 173 94.5
No 11 5.5 10 5.5
Fruit and vegetable advice Yes 10 5.0 9 4.9
No 190 95.0 174 94.1
Reduce fat advice Yes 100 50 96 52.5
No 100 50.0 87 47.5
Physical activity advice Yes 52 26.0 55 30.1
No 148 74.0 128 69.9
Maintaining healthy weight advice Yes 51 25.5 55 30.1
No 149 74.5 128 69.9
Co-morbidity Cardiovascular disease Yes 3 1.5 4 2.2
No 197 98.5 179 97.8
Diabetic Mellitus Yes 10 5.0 43 23.5
No 190 95.0 140 76.5
Chronic renal disease Yes 5 2.5 9 4.9
No 195 97.5 174 95.1
Asthma Yes 7 3.5 11 6.0
No 193 96.5 172 94.0
Family history of hypertension Yes 18 9.0 11 6.0
No 182 91.0 172 94.0
Comorbidity Yes 23 11.5 60 32.8
No 177 88.5 123 67.2

likely to raise the chance of having high blood pressure. Previous

Table 5
research conducted in other locations, including Ghana (Modey, Esinam,
Drug and anthropometric measurement of adult patients with hypertension on
Manu, Laar, Akamah, Torpey, 2020) , Ayder comprehensive specialized
follow-up attending Enat General Hospital, Amhara, Ethiopia, 2021 (n = 383).
hospital in Tigray, Ethiopia, and Jimma University in Ethiopia (Tesfaye,
Variables Frequency Percent (%)
Temesgen, Kasa, Yismaw, 2019) , had comparable results (WHO, 2018) .
Drugs HCT Yes 235 61.4 This might be because alcohol influences the production of UBP in
No 148 38.6 several different ways. Possible mechanisms include an imbalance in the
Enalapril Yes 137 35.8
No 246 64.2
central nervous system, dysfunction of baroreceptors, increased sym­
Nifidipine Yes 165 43.1 pathetic activity, stimulation of the renin-angiotensin-aldosterone sys­
No 218 56.9 tem, elevated cortisol levels, increased vascular reactivity brought on by
Amlodipine Yes 62 16.2 elevated intracellular calcium levels, stimulation of the endothelium to
No 321 83.9
release vasoconstrictors, and loss of relaxation brought on by inflam­
Number of drugs Monotony 161 42
Dichotomous 222 58 mation and endothelium injury leading to endothelium inhibition
Waist circumference Normal 261 68.1 (Husain, Ansari, Ferder, 2014) . Alcohol use has been demonstrated to
Abnormal 122 31.9 decrease urinary potassium excretion while increasing urinary magne­
BMI Normal 270 70.5 sium and calcium excretion. Alcohol use may alter these minerals, which
Overweight 94 24.5
could raise blood pressure (Kawano, 2010) . Accordingly, if a person
Obese 19 5
continues to consume alcohol, the arterial wall loses its capacity to relax
HCT: Hydrochlorothiazide; BMI: Body Mass Index. as a result of inflammation and oxidative stress to the endothelium
brought on by angiotensin II, which is one of the main contributors and
et al., 2020, Zhou, Xi, Zhao, Wang, Veeranki, 2018) . This could be inhibits endothelium-dependent nitric oxide generation. Alcohol con­
explained by the fact that more people in this study than in the Third sumption and hypertension have a close association and are most likely
National Health and Nutrition Evaluation Survey (Zhou, Xi, Zhao, Wang, causally related. Lower blood pressure and improved adherence to
Veeranki, 2018) and Nekemte, Ethiopia studies had abnormal waist doctor-recommended medication and lifestyle changes have both been
circumference, consumed alcohol, didn’t eat fruit, and reported feeling associated to reduce consumption. Therefore, raising patients with hy­
stressed and anxious (Zhou, Xi, Zhao, Wang, Veeranki. 2018) . The pertension awareness of how alcohol usage affects blood pressure con­
discrepancy in study findings may stem from variations in how uncon­ trol during routine follow-up sessions can help to reduce the severity of
trolled blood pressure was defined in the various investigations. Addi­ UBP. There was a higher likelihood of uncontrolled blood pressure in
tionally, this might be connected to variations in population participants who did not include fruit in their diet. Similar results were
sociocultural and behavioral traits as well as variations in healthcare obtained in research conducted in Ghana (Kawano, 2010) . Fruits are a
services provided in research locations (Zhou, Xi, Zhao, Wang, Veeranki, good source of potassium, magnesium, vitamin C, and folic acid, all of
2018) . However, compared to studies conducted in the Democratic which are believed to lower blood pressure by enhancing endothelial
Republic of the Congo (77.5 %) (Solomon, Tigestu, 2016) , Morocco (77 function, controlling baroreflex sensitivity, causing vasodilation, and
%) (Essayagh, Essayagh, El Rhaffouli, Khouchoua, Bukassa, Khattabi, boosting antioxidant activity. Increased fruit consumption may also
et al., 2019) , and Thailand (54.4 %), the magnitude of uncontrolled affect how your diet is structured, especially if you consume more di­
blood pressure in our study was lower (Meelab, Bunupuradah, Suttir­ etary fiber and less fat (Li, Li, Wang, Zhang, 2016) . High fat intake has
uang, Sakulrojanawong, Thongkua, Chantawiboonchai, et al., 2019) . been associated with a higher chance of having uncontrolled blood
The difference could be explained by the older age of the study partic­ pressure. As a result, patients with hypertension should learn about the
ipants, the lower percentage of co-morbidity, and the higher number of advantages of having fruit in their diet during their follow-up visit.
patients with hypertension receiving antihypertensive drugs. The results Uncontrolled blood pressure was substantially associated with the
of the current investigation showed that drinking alcohol was more addition of additional salt during food preparation. The result was

5
M. Wagaye et al. International Journal of Africa Nursing Sciences 20 (2024) 100641

Table 6
Bi-variable and multivariable analysis on factors associated with uncontrolled blood pressure among adult patients with hypertensionon on follow-up attending Enat
General Hospital, Amhara, Ethiopia 2021 (n = 383).
Variables Category BP COR(95 % CI) AOR(95 % CI) P-Value

UBP CBP

Sex Male 72 128 1.00

Female 87 96 0.621(0.412–0.935) 0.646(0.346––1.209) 0.172
Educational status Not read and write 83 101 0.969(0.542–1.732) 0.820(0.300–2.238) 0.698
Read and write 39 38 1.210(0.617–2.371) 1.187(0.413–3.414) 0.751
Primary 18 20 1.061(0.477–2.389) 0.962(0.283–3.266) 0.950
Secondary (9–12) 15 8 2.210(0.817–5.977) 1.606(0.397–6.495) 0.507
College/university 28 33 1.00
CBHI Enrolled 25 175 1.00
Not enrolled 51 132 2.705(1.593––4.591) 2.928(0.840–4.429) 0.122
Alcohol use Yes 86 44 3.143(2.019–4.895) 3.097(1.665–5.763) 0.0001***
No 97 156 1.00
Fruit consumption Yes 48 70 1.00
No 135 130 1.514(0.976–2.350) 3.022(1.430–6.386) 0.004**
Additional salt added to food Yes 90 46 3.240(2.089–5.024) 2.336(1.269–4.302) 0.006**
No 93 154 1.00
Comorbidity Yes 60 23 3.754(2.203–6.396) 3.204(1.046–9.808) 0.041*
No 123 177 1.00
Waist circumference Normal 99 162 1.00
Abnormal 84 38 3.617(2.289–5.716) 3.703(1.690–8.113) 0.001**
BMI Normal 116 154 1.00
Overweight 51 43 1.575(0.982–2.524) 0.754(0.337–1.689) 0.492
Obese 16 3 7.080(2.016–24.873) 3.159(0.605–16.493) 0.173
Stress Low 90 174 1.00
Moderate 43 14 5.938(3.086–11.427) 4.838(2.072–11.294) 0.0001***
High 50 12 8.056(4.083–15.893) 3.894(1.653–9.170) 0.002***
Anxiety Normal 108 179 1.00
Borderline 50 15 5.525(2.959–10.316) 6.560(2.941–14.633) 0.0001***
High 25 6 6.906(2.745–17.371) 4.127(1.120–15.00) 0.033*
Depression Normal 156 191 1.00
Borderline 4 3 1.632(0.360–7.403) 0.616(0.082–4.619) 0.637
High 23 6 4.693(1.865–11.813) 1.765(0.437–7.128) 0.425
Medication Adherence Non-adherent 19 3 7.608(2.212–26.162) 9.266(2.054–41.804) 0.004**
Adherent 164 197 1.00
Renal failure Yes 9 5 5.836(2.836–12.012) 0.633(0.121–3.309) 0.588
No 174 195 1.00
DM Yes 43 10 5.835(2.835–12.012) 2.128(0.585–7.741) 0.252
No 140 190 1.00

Note: * P < 0.05, ** P < 0.01, ***p < 0.001, CI: Confidence Interval; AOR: Adjusted Odds Ratio; COR: Crude Odds Ratio; BP: Blood Pressure; UBP: Uncontrolled Blood
Pressure; CBP: Controlled Blood Pressure; DM: Diabetes Mellitus; CBHI: Community Based Health Insurance and 1:00 – Reference.

consistent with research published by Ethiopia’s Mekelle Public Hospi­
tals (Aberhe, Mariye, Bahrey, Zereabruk, Hailay, Mebrahtom, et al.,
2020) , Jimma University Specialized Hospital (Solomon, Tigestu, 2016)
, University of Gondar Hospital (Animut, Assefa, Lemma, 2018) , and
The WHO STEPwise approach to surveillance (STEPs) report of Ethiopia
(Institute EPH, 2016) . This might be a result of how high-salt diets affect
the renin-angiotensin system, which causes fluid retention, raises car­
diac burden, and uncontrolled blood pressure. As a major extracellular
ion, sodium is a key regulator of extracellular fluid volume. The vascular
volume increases and the heart rate initially rise when salt intake ex­
ceeds the kidney’s capacity to eliminate sodium. Contrarily, many
vascular beds can self-regulate blood flow, and to maintain constant
blood flow in the face of elevated arterial pressure, the bed’s internal
resistance needs to increase (Kasper, FAS, & Hauser, & Longo, &
Jameson, & Loscalzo, 2016) . The relevance of keeping salt consumption
to within 1 teaspoon per day should be discussed with patients with
hypertension during follow-up visits. The likelihood of participants
having uncontrolled blood pressure was almost three times higher in co-
morbidity participants. Additionally, this result was similar to the data
from Ayder Comprehensive Specialized Hospital, Ethiopia (Gebre­
michael, Berhe, Zemichael, 2019) . Co-morbid conditions like diabetes,
heart failure, and CKD frequently appeared in HTN patients. The ma­
jority of presentations are categorized as primary because these co-
morbidities have been shown to advance HTN by taking part in its
pathogenesis, even though no clear mechanism for the development of
HTN from these co-morbidities has been identified. For HTN
management, these illnesses must receive the proper care. Experts have
created a lower cut-off point for diabetes, chronic kidney disease, and
coronary artery disease to satisfy blood pressure goals (CAD). For
instance, careful glycemic control and CKD’s gradual course prevent or
at least lessen vascular damage and fluid retention (Chobanian, Bakris,
Black, Cushman, Green, Izzo, et al.) . The results suggest that treatment
selection should be dependent on the presence of co-morbidities, often
known as “compelling indications,” and that the lower cut point should
be targeted while managing HTN. Uncontrolled blood pressure and
abnormal waist circumference were found to be strongly associated. It
was comparable to research findings from a cross-sectional survey
conducted in Southern Uganda and Northwestern Tanzania (Almas,
Patel, Ghori, Ali, Edhi, Khan, 2014) . This could be a result of the fact
that centrally placed body fat affects blood pressure elevation more so
than peripheral body fat. According to recent research, adipose tissue
activation of the renin-angiotensin system makes central obesity a risk
factor for hypertension (RAS). Researchers assert that insulin resistance
and the renin-angiotensin system are related and that either condition
can be brought on by the other. The remodeling of the resistant vascu­
lature and the development of target organ damage may be significantly
influenced by regional renin-angiotensin systems and alternative
angiotensin II production routes(Hall, Arthur, 2006) . This could be
caused by a big and aging population, as well as problems like rising
urbanization and undesirable lifestyle changes (including low physical
activity, unhealthy diet, and high levels of alcohol). Additionally, cen­
tral obesity decreases the effectiveness of anti-hypertension drugs

6
M. Wagaye et al.
(Chudek, Owczarek, Ficek, Olszanecka-Glinianowicz, Wieczorowska-
Tobis, Walencka, et al., 2021) . When recommending antihypertensive
drugs, this tendency should be taken into account. Additionally, it was
discovered that uncontrolled blood pressure was strongly connected
with both moderate and high levels of stress. This conclusion is sup­
ported by an Indian study report (Norris, 2016) . This may be due to the
spike in sympathetic outflow brought on by stress, as well as repeated
stress-induced vasoconstriction that results in vascular hypertrophy and
ultimately raises peripheral resistance and blood pressure (Kasper, FAS,
& Hauser, & Longo, & Jameson, & Loscalzo, 2016) . As a result of poor
adherence to pharmacological and non-pharmacological therapy (such
as food, sodium, and alcohol restrictions), stress also contributes to
uncontrolled blood pressure (Kang, Dulin, Nadimpalli, Risica, 2018) .
Recognizing and successfully managing stress, anxiety, depression, and
other psychiatric conditions including panic attacks is essential for
maintaining healthy blood pressure. Uncontrolled blood pressure
revealed a strong correlation with both high and borderline anxiety.
This conclusion is supported by an Indian study report (Anantha,
Gopalakrishnan, Umadevi , 2017) . Anxiety is closely related to RAAS
and SNS. By increasing renal water and sodium retention, boosting heart
rate, and harming endothelial cells, SNS causes endothelial dysfunction
and raises the risk of atherosclerosis. SNS activation can lead to
abnormal lipid metabolisms and hemodynamic changes, such as a drop
in high-density lipoprotein cholesterol and an increase in low-density
lipoprotein cholesterol, which both have an impact on endothelial
function (Mancia G, Grassi G., 2014) . The body’s primary system for
responding to stress is the hypothalamic–pituitary–adrenal (HPA) axis
(Kudielka, Wüst, 2010) . When this axis is malfunctioning, increased
steroid hormone secretion results in sodium and water retention, which
raises blood pressure (Pan, Cai, Cheng, Dong, An T, Yan, 2015) . To put it
another way, stress and worry enhance a person’s propensity for
harmful behaviors including increased eating, drinking, and smoking as
well as decreased activity (Bonnet, Irving, Terra, Nony, Berthezène,
Moulin ,2005) . One of the obstacles to adherence to hypertension
treatment is anxiety (Bautista, Vera-Cala, Colombo, Smith, 2012) . Stress
and worry are the most frequently mentioned impediments to lifestyle
improvement, according to Khatib et al (Khatib, Schwalm, Yusuf, Hay­
nes, McKee, Khan, et al., 2014) . For some people, traditional antihy­
pertensive therapy is necessary, along with psychosocial support and
anti-anxiety medicine. This study also found a strong correlation be­
tween uncontrolled blood pressure and medication non-adherence.
Similar investigations were conducted in Morocco (Essayagh T,
Essayagh M, El Rhaffouli, Khouchoua, Bukassa, Khattabi, et al., 2019) ,
Mekelle public hospitals in Tigray (Aberhe, Mariye, Bahrey, Zereabruk,
Hailay, Mebrahtom, et al., 2020 , Tigray (Gebremichael, Berhe, Zemi­
chael, 2019) , and the central zone’s public hospitals in Morocco
(Negash, Siyoum, Hailemariam, Kidanu, Gebremeskel, Weldesamuel,
et al., 2018) . Patients with newly treated hypertension, coronary artery
disease, and ischemic stroke have all demonstrated deleterious effects of
non-adherence to antihypertensive medication (Kim, Bushnell, Lee,
Han, 2018). According to behavioral models, even the most successful
treatment administered by the most meticulous clinician won’t be able
to control hypertension unless the patient is driven to take the medi­
cation as directed and to create and maintain a healthy lifestyle. When
patients have positive interactions with their physicians and have con­
fidence in them, their motivation increases. Better communication
produces better outcomes, and empathy encourages trust and acts as a
strong motivator. As a result, it is wise for medical professionals to think
of non-adherence as a factor in blood pressure failure to target, resistant
hypertension, and rapid loss of control. According to our analysis, there
is a statistically significant relationship between gender and blood
pressure control rate (p-value = 0.022). In comparison to men (47.5 %),
it was higher among women (52.5 %). This might be a result of women
living more sedentary lifestyles than men (Chi-square p-value = 0.015)
and them being more susceptible to stress.
7
International Journal of Africa Nursing Sciences 20 (2024) 100641
6. Limitations of the study
The study was carried out by a cross-sectional quantitative study
approach, which might be inadequate to find all potential factors asso­
ciated with UBP and the effect relationship cannot be confirmed based
on the nature by itself. Moreover, this was a single institutional-based
study.
7. Conclusion and recommendations
Uncontrolled blood pressure was a high percentage, and it was more
prevalent in women. Uncontrolled blood pressure was strongly corre­
lated with stress, alcohol use, anxiety, less fruit-eating habits, salt
intake, medication nonadherence, and co-morbidities. Regular follow-
up, early care seeking for co-morbidity, and the provision of health
education regarding lifestyle changes are all recommended. Further
research can be performed by using cohort research methods with a
multicenter approach with a large population.
8. Ethics approval and consent to participate
Ethical approval was obtained from the Ethical Review Committee of
Wollo University, College of Medicine and Health Sciences with
approval number MED2430/21. Permission letter was received from
Enat General Hospital. The aim and/or purpose of the study were
explained to all study participants. The confidentiality and privacy of
participants were secured by avoiding any personal identifier. Written
consent was obtained from each family and significant others before
study commencement and this study were conducted as per the Decla­
ration of Helsinki. Children’s families and significant others were
informed of their full right to withdraw from the study at any time they
wish.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
We would like to thank Wollo University for its technical support. We
would also like to thank Enat General Hospital as well as data collectors
and supervisors for their unreserved contribution.
Author contribution
All authors contributed equally from the concept to the analysis of
the study. All authors read and approved the final manuscript.
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