Cardiovascular disease prevention practice among adults in Southwest, Ethiopia: a community-based cross-sectional study

¹Department of Nursing, Institute of Health, Jimma University, Jimma, Ethiopia, ²Departments of Health, Behavior, and Society, Faculty of Public Health, Jimma University, Jimma, Ethiopia, ³Department of Nursing, College of Health Science, Dembi Dollo University, Dembi Dolo, Ethiopia, ⁴Department of Midwifery, Institute of Health, Jimma University, Jimma, Ethiopia

^&Corresponding author
Aster Fayisa Dare, Department of Nursing, Institute of Health, Jimma University, Jimma, Ethiopia

Introduction    

Cardiovascular diseases (CVD) have continued to be the leading cause of premature death and disability globally for the preceding 20 years. Now, more people are dying from CVD than ever before [1]. According to a World Health Organization (WHO) report in 2019, an estimated 17.9 million people died from CVDs representing 32% of all global deaths [2]. Greater than 80% of CVD deaths take place in Low- and Middle-Income Countries (LMIC) countries and occur almost equally in men and women [3]. While CVD deaths typically occur later in life in high-income countries, in LMIC countries it often affects working-age people, leading to high healthcare costs, limited ability to work, and financial insecurity [4]. Contributing to poverty due to catastrophic health expenditures and extraordinary out-of-pocket expenditures [5,6].

The CVD epidemic in sub-Saharan Africa (SSA) is driven by changes in demographics and altered lifestyles as a result of increasing urbanization and socioeconomic development [6]. With the rising epidemic of CVD in SSA, behavioral modification interventions are essential in supporting populations to attain better cardiovascular health. In addition, inadequate resources and the high cost of CVD treatment necessitate prevention should be a high priority for CVD control in SSA [7,8].

Ethiopia is no exception to the impact of CVD where it is the leading cause of death and a major cause of chronic disease and disability [9]. Now the country is experiencing an epidemiologic change mainly driven by demographic and lifestyle changes. Prompt urbanization has attracted a huge population from rural areas to cities. Urban life endorses a sedentary lifestyle and increases the chance of CVDs. Taking these facts into consideration, the burden of CVDs in Ethiopia might be even higher than anticipated [7,9]. As the study conducted in Jimma Town in 2017 showed the prevalence of CVD risk factors was high wherein 70% of adults were presented with one or more risk factors [10].

However, to the best knowledge of the investigators, there were no studies conducted on factors associated with CVD prevention practices among the community in Ethiopia, particularly in Jimma Town. As a result, this study aimed to identify CVD prevention practices and associated factors among adults in Jimma Town, Southwest Ethiopia.

Methods     

Study setting and design: a community-based cross-sectional study was conducted among adults aged 18 years or older in Jimma Town from August 30 to September 30, 2021. Jimma Town is the capital city of Jimma Zone of the Oromia Regional State, located 357 Km away from Addis Ababa, which is the capital city of the country in Southwest Ethiopia [11]. All adults (≥ 18 years) residing in Jimma Town were the source of population and all sampled adult (≥ 18 years) population in Jimma Town who fulfilled the inclusion criteria were the study population. Adults aged 18 years or older who lived in Jimma Town for at least six months and were willing to participate were included in this study. Patients with major psychiatric problems and critical illness that can interfere with the recognition of CVD prevention practices were excluded from the study.

The sample size was determined using the formula for estimating sample size for a single population proportion. Since, no previous similar studies the p-value was taken as 0.5, the margin of error 0.05, and a non-response rate of 10% were used. After a design effect of 1.5, inferred from the WHO estimate for CVD risk factor assessment studies, the final sample size became 634. A multistage sampling technique was used to select the study participants for this study. Initially, a simple random sampling technique was used to select 7 kebele from a total of 17 kebele assuming that the kebele is homogeneous. A proportional allocation of a sample was implemented for each selected kebele. From each kebele, households were selected using a systematic random sampling technique with a specified sampling interval; every 30^th household in each kebele was selected using lists of all households (from the existing lists of households from the registration book of health extension workers) as a sampling frame. Then, eligible individuals from the households were enrolled in the study. In cases where there was more than one eligible individual in the household, a lottery method was used to choose one among them, and if there was no eligible individual in a household, the next house was visited.

Data collection tools and procedure: a structured interviewer-administered questionnaire was used to collect the data. For CVD prevention practices survey designed by WHO was adapted and used [12]. The questionnaire comprised CVD preventive practices in which respondents were required to indicate, on a four-point Likert-type scale, how often they performed each preventive practice. Response options are Likert-type and range from high to low: 4-always, 3-frequently, 2-seldom, and 1-never. However, the scale was rated inversely in the case of smoking, alcohol, eating fast foods and fried foods, and salt and butter consumption. The total score ranged from 21 to 84, the higher the score, the better the CVD prevention practices would be. Cronbach´s alpha obtained for this section was 0.79. This section has six dimensions (smoking, alcohol, physical activity, diet, stress management, and health maintenance check-ups).

In addition, a cover page containing closed-ended questions collecting demographic data of the respondents was included such as age, gender, education, marital status, occupation, and income [12]. Additionally, participants were asked about personal, interpersonal, and community environment-related factors by using tools adapted from various relevant studies [13-21] The questionnaire was translated into local languages (Afaan Oromo and Amharic) by a person who is fluent in English, Afaan Oromo, and Amharic languages and was checked for consistency by a third independent person and expert in all the mentioned languages. Then, Amharic and Afaan Oromo version questionnaires were used for data collection.

Data were collected over one month by three BSc nurses who had previous data collection experience and were supervised by one MSc nurse. Closed houses were visited three times during the time of data collection while proceeding to the next house in the interval. Training was provided for the data collectors and supervisor for two days on the technique of data collection, the purpose of the study, and the content of the questionnaires by the project members. To assure the quality of data validated tool was used. Pretesting of the data collection tools was conducted at Agaro Town using 5% (32 adults) of the total sample and then the tool was improved in terms of its clarity and simplicity in collecting the data required for the study. Data collectors and supervisors check for completeness of the data every day during data collection.

Variables and measurement

Dependent variables: CVD Prevention practice.

Independent variables: age, gender, educational level, income, occupation, marital status knowledge of CVD, attitude, self-perceived estimate of CVD risk, family and personal history of CVD, having a friend or knowing someone with CVD, self-efficacy, social support (family, friend), body weight norm, peer pressure, availability and accessibility of healthy diets, place for physical activity, working hours.

Operational definition and definition of terms

Cardiovascular disease (CVD) prevention practices: are those measures undertaken to prevent the risk of developing CVDs. These include physical activity, not starting or cessation of smoking, following healthy diets, maintenance of optimal blood pressure, normal cholesterol and glucose levels, and stress management [22]. The mean value of the preventive practice questions was used to classify the respondents' preventive practices as either good or poor. Those who scored above or equal to the mean value of the preventive practice questions had good CVD prevention practices, while those who scored below the mean value of the preventive practice questions had poor CVD prevention practices [23].

Knowledge of CVD risk factors: categorized based on the mean score of knowledge questions either as good (greater equal to mean score) or poor (less than mean score) knowledge of CVD risk factors [23,24].

Self-efficacy: dichotomized based on the mean value as either high (equal to or above the mean value) or low (less than the mean value) [25,26].

Social support: the mean value of social support questions was used to dichotomize either adequate social support ( above and equal to the mean value) or inadequate social support (below the mean value) [27-29].

Self-perceived estimate of CVD risk: it was assessed on a 5-point Likert-type scale and collapsed into three categories: low (1-2), intermediate (3), and high (4-5) [30,31].

Working hours: refers to the number of hours that a person usually works in a typical day or week, regardless of whether he/she is paid or not. Dichotomized into two (< or = 8 hours or > 8 hours) based on the normal working hours of our country´s standard (8 hours per day or 48 hours per week) [32,33].

Statistical analysis: following the data collection, data were rechecked for completeness and were entered into Epidata version 4.6 and then exported to SPSS version 23.0 for analysis. Appropriate coding and re-coding were done at each step for the variables as necessary. Descriptive statistics like frequencies, percentages, means and standard deviations were performed. CVD preventive practices were dichotomized into either good or poor practice based on the mean value of practice questions. Accordingly, a score equal to or above the mean value represented a good practice and a score below the mean value represented poor practice. A binary logistic regression analysis was done to sort variables candidate for multiple logistic regression having a p-value less than or equal to 0.25. Multivariable logistic regression analysis was conducted to identify factors strongly associated with cardiovascular disease prevention practice among adults. Finally, the association was declared with a p-value less than 0.05 with an adjusted odds ratio (AOR) at a 95% confidence interval. The dependent variable was checked for normality and independent variables were checked for multicollinearity. The Shaipro Wilk test results of dependent variables satisfied the assumption of normality (p = 0.064). Hosmer and Lemeshow´s test was used to determine the model fitness. Finally, the result of the analysis was presented in texts, tables, and graphs as appropriate.

Ethics approval and consent to participate: ethical clearance to conduct the study was obtained from the institutional review board of Jimma University, Institute of Health [IHRPG1/370/21] and submitted to each kebele administration for permission and cooperation before data collection. Verbal consent was obtained from each participant that participation was voluntary, and they had the right to withdraw at any time from the study. The consent consisted of the study purpose and procedures, potential risks and benefits, voluntary participation, and right of withdrawal; the information provided by each respondent was kept strictly confidential. Respondents were also informed that their answers to the questions would be grouped with others.

Results     

Description of the participants: out of 634 study participants who were identified for the study, 605 of them were included in the study with a response rate of 95.4% (Table 1). More than half of the respondents were (57.4%) females.

Personal related factors

Having the disease (personal, family, friend, or others): seventy-three (12.1%) of the participants had a history of CVD, 71 (11.7%) had a family history of CVD, and 234 (38.7%) knew any person with CVD condition (Figure 1).

Knowledge of CVD risk factors: the study showed that the mean (SD) knowledge score of CVDs risk factors among the participants was 7.01 (2.1) (Table 2).

Attitude towards CVD prevention practice: in this study, the mean (SD) score of respondents' attitude towards CVD prevention practice was 33.92 (4.38), with minimum and maximum scores of 16 to 40 respectively (Table 3).

Participants´ self-efficacy: in this study, self-efficacy was measured using a general self-efficacy tool. The minimum and maximum scores were 12 and 36 respectively, with a mean ± (SD) score of 26.9 ± 4.53. Based on this mean value, 341 (56.4%) of study participants had high self-efficacy.

Self-perceived estimate of CVD risk: regarding the self-perceived estimate of CVD risk among adults in Jimma town, more than half 356 (58.8%) were perceived that they were at low risk for developing CVD in the next 10 years. Only, 120 (19.8%) perceived that they were at high risk for developing CVD in the next 10 years (Figure 2).

Interpersonal-related factors (body weight norm, social support, and peer pressure): with regards to body weight norm, almost more than half (53.2%) of participants reported having a partner whose body weight is higher than what is considered normal as compared to their height (overweight/obese). One hundred sixty-six (27.4%) and 150 (24.8%) of the respondents reported that the BMI (the figures) which represents overweight would be considered as normal (preferred) body weight for males and females respectively according to the expectation of people living around them.

Concerning the social support of study participants, the most frequent (29.8%) obtained social support (family, friends) item compared to others was to be encouraged not to eat unhealthy foods when they were interested in doing so. Regarding the peer pressure of adults, two hundred seventy-four (45.3%) respondents strongly agreed that they would resist pressure from their friends to drink alcohol when they were at home.

Community environment-related factors: the study revealed less than half (47.6%) of participants agreed that the cost of a healthy diet was affordable. However, more than three-fourths (76.9%) agreed that they had easy access to a healthy diet in a nearby home. Three hundred and twenty-three (53.4%) of participants reported that it was difficult to get a facility for physical activity near home. More than two-thirds (68.3%) of the respondents spent 8 hours or less on work every day.

Cardiovascular disease prevention practices: the mean (SD) score of CVD prevention practice was 48.38 ± 5.06 out of 84, with the minimum and maximum scores as 33.00 and 62.00, respectively. Accordingly, about 46.8% (95 % CI 42.8, 50.8) of the study participants had good CVD prevention practices (Table 4).

Factors associated with cardiovascular disease prevention practices: the bivariate analysis revealed that at p-value less or equal to 0.25 significance level 13 (occupation, educational status, marital status, personal history of CVD, knowledge, attitude, self-efficacy, self-perceived estimate of CVD risk, social support, body weight norm, accessibility of healthy diet, place for physical activity and working hours) variables were identified as; candidate variables for multivariable logistic analysis. All candidate variables were entered together into a multivariable logistic regression using the backward method to determine final predictors of CVD prevention practices by controlling for potential confounders.

In a multivariable logistic regression, five variables were found to be the statistically significant predictors of CVD prevention practices with a p-value of < 0.05 and 95% CI. Accordingly; hours spent on work per day, knowledge of CVD risk factors, self-efficacy, social support, and self-perceived estimate of CVD risk were the final independent predictors of CVD prevention practices. The overall model adequately fits the data (p = 0.674) (Table 5).

Discussion     

This study revealed that the overall percentage of individuals who had a good CVD prevention practice was suboptimal. That means only less than half of the participants had good CVD prevention practices. Knowledge of cardiovascular disease risk factors, self-efficacy, self-perceived estimate of cardiovascular disease risk factors, social support, and working hours were found to be significantly associated with CVD prevention practice.

This finding is almost consistent with studies conducted in Nepal (48.2%) and India (49.5%) of participants had satisfactory CVD prevention practices [34,35]. This similarity might be due to the relatedness of the socioeconomic status of participants; in all studies, participants were from developing countries as well as it could also be due to sample size consistency.

On the other hand, this result is much higher than studies conducted in Uttar Pradesh in India (12.40%) and Cameron (15%) [36,37]. The discrepancy might be due to: the small sample size and inclusion criteria in the case of the study done in Uttar Pradesh where only adults aged 20 to 40 years were included; during a period early in life adults tend to be involved in health risk behaviors like smoking, heavy drinking, unhealthy diet and less attentive to medical check-up [38]. The study done in Cameron used items as a basis for categorizing CVD prevention practice in which a good practice was considered as having practiced five or more CVD prevention practice items, this might explain the reason for variation with the present study.

However, the findings of the study are lower than the findings of previous studies done in Japan (56.9%), Iran (63.3%), Thailand (64.90%), and Malaysia (65%) [39-42]. The discrepancy of this finding might be due to: variations in socioeconomic status and Socio-demographic background of participants. The difference in socioeconomic status between the developing country, Ethiopia, and the developed country in the case of Japan, which influences individuals' lifestyle behavior may contribute to this variation. The previous study done in Iran included adults who had previous military experience and their spouses, which may promote the development and maintenance of healthy lifestyle behaviors [43].

In the case of the study done in Thailand, the study was conducted among adults living in rural areas who are at risk for developing CVD; being rural dwellers might increase the chance of being physically active and having access to fresh fruit and vegetables rather than processed foods [4]. Additionally, knowing one's risk for developing CVD might also be accompanied by improvement in undertaking preventive measures. The possible reason for the discrepancy with the study conducted in Malaysia might also be due to the socio-demographic background of participants in which most of the participants attended tertiary education, this might lead to having more information on CVD preventive measures.

In this study, respondents who had good knowledge of CVD risk factors were two times more likely to have good CVD prevention practices. This finding is consistent with a finding of a study conducted in Nepal [34]. The possible explanation might be due to knowledge about CVD and its modifiable risk factor is a fundamental pre-requisite to change the individuals´ behaviors and lifestyle practices. It may also help reduce the individuals´ exposure to those risk factors [5, 44,45].

Similarly, this study revealed that adults who had good self-efficacy were approximately two times more likely to be involved in CVD prevention practices than those who had poor self-efficacy. It is supported by a study done in Samutprakan, Thailand [46]. This might be because self-efficacy encourages a person to take an active role in self-management activities and adopt a healthy lifestyle [47]. Therefore, the more confident individuals are the more they will be motivated to modify their lifestyle as required.

In addition, this study showed that adults who perceived that they were at intermediate and high risk of developing CVD were approximately two times more likely to have a good CVD prevention practice than those who had a low self-perceived estimate of CVD risk. This finding is consistent with the study conducted in Thailand [48]. The possible explanation might be that being aware of one's risk for developing CVD may lead to undertaking preventive measures.

This result also revealed that adults who had adequate social were 2.4 times more likely to have a good CVD prevention practice. This result is comparable with the studies conducted in the USA and Korea [14,28]. The reason might be that social support is one of the effective factors in the maintenance, continuity, and promotion of healthy lifestyle practices [49]. Those who get social support from family or friends are more likely to value and repeat their efforts for healthy lifestyle modification.

Finally, the longer working hours of the participants were found to have a significant effect by lowering CVD preventive practices by 54.9%. This finding is in line with a finding of a previous study conducted in Korea [14]. This might be because people working more hours are more likely to have poor eating habits, do less physical activity, and lead stressful lives [50]. The strength of this study is it includes a large sample size and used valid tools. Even though the study depicted significant findings on cardiovascular disease prevention practices, it is not free of limitations. One of its limitations is being a cross-sectional study which does not show cause and effect relationships. The other limitation is a recall bias because of self-reporting. Therefore, we recommend a longitudinal study to depict more significant factors.

Conclusion     

In this study the overall cardiovascular disease prevention practice among the community was suboptimal. Hours spent on work per day, knowledge of cardiovascular disease risk factors, self-efficacy, social support, and self-perceived estimate of cardiovascular disease risk were the identified independent predictors that were significantly associated with cardiovascular disease prevention practice. Therefore, it is necessary to establish effective interventional programs aimed at promoting positive health behaviors regarding cardiovascular disease risk factors in the community.

Competing interests     

All the authors declare no competing interests.

Authors' contributions     

All authors equally contributed to this work beginning from the conception, study design, execution, and acquisition of data, analysis, and interpretation, they also took part in the drafting, revising, and/or critically reviewing of the article and finally agreed on the journal to which the article was submitted. All the authors also read, reviewed, and agreed on all versions of the article before submission, during revision, agreed to be accountable for all aspects of the work, and approved the final version of this manuscript.

Acknowledgments     

We are grateful to study participants and data collectors, in particular for their cooperation and the information they provide. Last but not least, appreciation goes to colleagues and friends for their encouragement and support for the work of this paper.

Tables and figures     

Table 1: socio-demographic characteristics of respondents among adults in Jimma Town, Southwest Ethiopia (September 2021)

Table 2: knowledge of cardiovascular disease risk factors among adults in Jimma Town, Southwest Ethiopia (September 2021)

Table 3: attitude towards cardiovascular disease prevention among adults in Jimma Town, Southwest Ethiopia (September 2021)

Table 4: cardiovascular disease prevention practices among adults in Jimma Town, Southwest Ethiopia (September 2021)

Table 5: multivariable logistic regression showing independent factors of cardiovascular disease (CVD) prevention practices among adults in Jimma Town, Southwest Ethiopia (September 2021)

Figure 1: frequency distribution of participants by personal and family history status of cardiovascular disease (CVD) and familiarity with a person who had CVD among adults in Jimma Town, Southwest Ethiopia, 2021

Figure 2: frequency distribution of self-perceived estimate of cardiovascular disease (CVD) risk among adults in Jimma Town, Southwest Ethiopia, 2021

References