Abstract

Introduction: Hypertension affects women in all phases of life and ranks among the most common chronic medical condition characterized by a persistent elevation in the arterial pressure. More than one billion adults worldwide have hypertension with up to 45% of the adult populace being affected with the disease. The high prevalence of hypertension is consistent across all socio-economic and income strata, and the prevalence rises with age accounting for up to 60% of the population above 60 years of age. The main objective of this study is to assess the “factors influencing self-care practices of hypertension in women aged 40 and above accessing health care services at Kafue General Hospital”. Methods: This was a descriptive cross-sectional study design where 200 respondents aged 18 years and above participated in the study. Participants were randomly selected. A self-administered questionnaire was used to collect data. SPSS computer software package version 26.0 was used to analyze data. Chi-square and Fisher’s exact tests were used to test the significance of the association between Knowledge on Hypertension, Attitude towards self-care practices among Hypertensive women. A 95% confidence interval and the P value of 0.05 were used to ascertain the degree of significance. Results: Majority of the respondents 66% demonstrated good self-care practices. Slightly more than half of the respondents, 56%, had low knowledge levels. Majority 58% had a positive attitude towards self-care practices. Chi-square test on knowledge (P-value: 0.013) and P < 0.05 indicates significance between self-care practices and knowledge levels of Hypertensive women and attitude (P-value: 0.025), P > 0.05 indicates that there is an association between self-care practices and attitude of Hypertensive women. On multivariable logistic analysis, patients who had high knowledge levels were 1.939 times more likely to achieve good self-care practices compared to those who had low knowledge levels, and this effect was significant (OR: 1.939, CI: 0.541 - 6.945, P < 0.013). Further analysis showed that patients who had a positive attitude were 4.208 more likely to achieve good self-care practices compared to those who had a negative attitude and this effect was highly significant (OR: 4.208, CI: 1.198 - 14.779, P < 0.025). Conclusion: The study has established presence of good self-care practices and low knowledge levels on self-care practices among Hypertensive women. This does not support the initial assertion that Hypertensive women have good self-care practices of Hypertension as they did not comply with health care advice. The findings have also demonstrated a positive attitude towards self-care practices among Hypertensive women, being the key component in the hypertension management.

Keywords

Self-Care Practices, Knowledge, Attitude, Hypertension

Share and Cite:

1. Introduction

Hypertension affects women in all phases of life and ranks among the most common chronic medical condition characterized by a persistent elevation in the arterial pressure. The current definition of hypertension (HTN) is systolic blood pressure (SBP) values of 130 mmHg or more and/or diastolic blood pressure (DBP) more than 80 mmHg [1]. Most cases of hypertension are idiopathic, which is also known as essential hypertension [1].

More than one billion adults worldwide have hypertension with up to 45% of the adult populace being affected with the disease (NCD Risk Factor Collaboration [2]. The high prevalence of hypertension is consistent across all socio-economic and income strata, and the prevalence rises with age accounting for up to 60% of the population above 60 years of age (NCD Risk Factor Collaboration [2]. In the year 2010, the global health survey report was published in Lancet, which comprised of patient data from 67 countries, reporting Hypertension as the leading cause of death and disability-adjusted life years worldwide since the year 1990. Recent estimates have suggested the number of patients with hypertension could increase by as much as 15% to 20%, which could reach close to 1.5 billion by 2025. In Zambia, hypertension accounts for the highest proportion of deaths due to cardiovascular diseases, causing 3.3% of all deaths, killing an average of 670 people per year [3].

There are various mechanisms described for the development of hypertension which include increased salt absorption resulting in volume expansion, an impaired response of the renin-angiotensin-aldosterone system (RAAS), and increased activation of the sympathetic nervous system. These changes lead to the development of increased total peripheral resistance and increased afterload which in turn leads to the development of hypertension [1]. Common risk factors and sex-specific risk factors offer opportunities to impact HTN and CVD burdens in women. Common risk factors include obesity, physical inactivity, increased salt intake, diabetes, and alcohol use. Evidence suggests that multiple sex-specific processes also mediate HTN development among women (e.g., estrogen receptors and sympathetic nervous system [SNS] activation [4].

Despite the existence of extensive evidence on the benefits of hypertension treatment, control has been unsatisfactory [5]. Worldwide, assessments show that less than 50% of treated hypertensive patients reach their blood pressure goals, increasing their risk of hypertension-induced complications [6]. Control rates of hypertension vary widely across and within populations. An example is the congruent finding where females achieved BP control more than their male counterparts [7]. Factors that were significantly associated with BP control were sex, education and the presence of comorbidity. In a study conducted by Hailu, et al., (2025), with results of good self-care practices for hypertension being observed in 44.8% of participants and significant predictors of good hypertension self-care practices included age ≥ 60, education level of secondary school or higher, employment in government positions, controlled blood pressure, good knowledge about hypertension, strong social support, and a positive perceived health status.

BP management is a key healthcare priority for all women who are hypertensive. Poor treatment adherence is a roadblock to a better quality of life. However, little is known about the perceptions and barriers to self-care practices of hypertension among women aged 40 and above. The statistics from the Health Management System (HMIS) show that women aged 40 and above accessing health care services at Kafue General Hospital have poor self-care practices and little has been documented on the cause of poor self-care practices. This is in contrast with most studies that indicate that female patients are more compliant to hypertensive self-care practices compared to male patients [8] [9]. Therefore, the purpose of our study is to determine factors influencing self-care practices to hypertension management among hypertensive women aged 40 and above accessing health care services at Kafue General Hospital (KGH).

2. Materials and Methods

2.1. Study Design, Setting, and Participants

A descriptive cross-section design was used to investigate an association between self-care practices and knowledge and attitude among hypertensive patients. The study was conducted at Kafue General Hospital in Kafue township catchment area. Kafue is a town in Southern Province of Zambia with a catchment population of 189,893 people [10]. The study population comprised hypertensive women aged 40 and above, seeking health services and those who were coming for routine medical checkups during the period of our study. They were considered eligible if they had been on HTN treatment for at least more than 6 months, had blood pressure check-up profile and consented to participate. The study excluded patients who were very sick and could not stand the interview, mentally ill and hypertensive patients who were not residents of Kafue. The study was conducted from October 2022 to October 2023.

2.2. Data Collection Procedure

Ethical clearance and permission were sought from the University of Zambia Biomedical Research Ethics Committee (UNZABREC REF. No. 1662-2021) and interviews were conducted over a period of 10 weeks. Participants were assured of anonymity and confidentiality by interviewing them in privacy individually after consenting to participate with their signature. The researcher administered a questionnaire in face-to-face interviews that lasted about 30 minutes.

2.3. Instruments

A modified structured interview schedule was used to assess the self-care practices of hypertension among hypertensive women in Kafue, Lusaka Province, Zambia. The tool was validated for measuring hypertensive women’s self-care practices by conducting a pilot study in a similar study setting. Internal consistency was measured with Cronbach’s Alpha of 0.771 on self-care practice questions, 0.82 on knowledge questions and 0.780 on attitude questions. The instrument comprised of a series of questions that were closed-ended. The interview schedule contained questions under six sections: Section A: Demographic Characteristics (age, marital status, employment status, education level and income), Section B: knowledge on hypertension. Knowledge on HTN self-care practices among patients was graded as high with a score of 5 and above out of 10 questions and low with a score of 4 and below out of 10 questions on Knowledge. Section C: Attitude towards self-care practices among women. Attitude towards HTN self-care practices among women was graded as positive if the patient scored above 4 out of 10 questions and negative if the patient scored 4 and below out of 10 questions in section C. Section D: Self-care practices among women. Self-care practices among women were graded as good with a score of 4 and above out of 8 questions and poor with a score of 3 and below out of 8 questions in section D.

2.4. Data Analysis

Data were analyzed using the IBM^® Statistical Package for Social Sciences (SPSS^®) for Windows version 27.0. The chi-square test was used to determine an association between predictor variables (demographic factors, knowledge of hypertensive women on self-care practices, Attitude of hypertensive women towards self-care practices) and the outcome variable (self-care practices among hypertensive women). For those categorical variables, a Fisher’s exact test was used. The Confidence Interval (CI) of (95%) was set and set level of significance at 5%. The binary logistic regression analysis was used to determine the true predictor of self-care practices.

3. Results

The interview was conducted with 200 participants of whom slightly less than half, 40% were aged between 40 to 50 years. Majority of the respondents 60% were married, majority 80%, lived in the rural area. Most of the respondents, 50% were not employed, and 40% were in self-employment. Of the respondents, 24% reached college, 28% reached senior secondary school, while only 12% had never been to school as presented in Table 1. Table 2 shows majority of the respondents 54%, had low knowledge levels, while 46% had high knowledge levels, whereas Table 2 shows that majority 58%, had a positive attitude towards self-care practices while 48%, had a negative attitude. Table 2 shows that majority 66% of respondent, had good self-care practices while 34% had poor self-care practices.

Table 1. Demographic characteristics of the patients (n = 200).

Table 2. Overall knowledge levels on hypertension (n = 200).

Table 3 shows that there was a statistically significant association between knowledge levels and self-care practices of hypertensive women, between attitude and self-care practices of hypertensive women.

Table 3. The relationship between self-care practices and other factors (n = 200) using a cross tabulation analysis.

Table 4 shows that the binary logistic regression model was tested for multicollinearity, Hosmer and Lemeshow test of fitness for data, and omnibus test of model coefficients and classification accuracy. The dependent variable was self-care practices: Good (1) and Poor (0). The results of the binary logistic regression analysis showed that holding other variables constant, patients who had high knowledge levels were 1.939 times more likely to achieve good self-care practices among hypertensive women compared to those who had low knowledge levels, and this effect was significant (OR: 1.939, CI: 0.541 - 6.945, P < 0.013) on the contrary, low knowledge increases the risk of poor HTN self-care practices. Further analysis showed that patients who had a positive attitude were 4.208 more likely to achieve good self-care practices among hypertensive women compared to those who had a negative attitude and this effect was highly significant (OR: 4.208, CI: 1.198 - 14.779, P < 0.025), on the contrary, negative attitude lowers chance of self-care practices.

Table 4. Binary logistic regression analysis of HTN self-care practices by knowledge and attitude.

4. Discussion of Findings

Results revealed that majority 60% of respondents were aged between 51 to 60 years. These results are slightly different from the study that was conducted by Rahman et al. [11] which illustrates that 31.67% of the respondents were 36 to 50 years. Additionally, in another study by Shrestha et al. [12], 26.5% were in the age range of 30 - 40 years. This could be due to the differences in the study settings. In the current study, the study settings involved both the rural and urban areas both from a third world country as opposed to the studies by Rahman et al. [11] and Shrestha et al. [12]. Results of the current study are also contrary to the study results by Ralapanawa et al. [13], results showed that a total of 371 hypertensive patients comprised both females and males and that all females, had never been to school. Differences in gender and education level could be due to the different study settings as the majority of respondents in the current study were from urban areas. This could have also been affected by the small sample size.

With regard to self-care practices, results revealed majority 66% with good self-care practices. Of the respondents who had good self-care practices, the specific areas where respondents had good self-care practices included “Compliance to diet chart helps maintain normal BP, Taking medication as prescribed, Avoiding stress helps, Regular physical activities done to achieve normal BP” while those where there was poor self-care practices were “Daily blood pressure check up with attention, keeping doctors’ appointments for self-care practices”. The findings of this study disagree with the study by and a study conducted by Hailu, et al. [3], with results of good self-care practices for hypertension being observed in 44.8% of participants and significant predictors of good hypertension self-care practices included age ≥ 60, education level of secondary school or higher, employment in government positions, controlled blood pressure, good knowledge about hypertension, strong social support, and a positive perceived health status. In contrast to the current study, a study conducted by Musimbaggo et al. [14], showed that comorbid diabetes mellitus and the disclosure of an individual’s HIV status to a close person were associated with poor blood pressure control among persons living with HIV who had hypertension.

Therefore, it is assumed that good self-care practices found in the current study could be due to the level of education among respondents as education level of an individual is believed to play a role in the level of understanding. The differences in self-care practices between the current study and a study conducted by Hailu, et al. [3], with results of good self-care practices for hypertension being observed in 44.8% of participants and significant predictors of good hypertension self-care practices included age ≥ 60, education level of secondary school or higher, employment in government positions, controlled blood pressure, good knowledge about hypertension, strong social support, and a positive perceived health status.

With regards to knowledge of Hypertension, majority 54% had low knowledge levels while 46% had high knowledge levels. Of the respondents who had low knowledge, the specific areas where respondents had low knowledge included, “Knowing Hypertension is genetic, Knowing hypertension can cause eye damage, Knowing the types of Hypertension, Knowing about Hypertension being curable, Knowing exercises help to prevent Hypertension, Knowing avoiding smoking can control hypertension” while those where there was high knowledge were “Knowing reducing body weight helps control Hypertension, Knowing reduced salt intake can reduce Hypertension, Knowing how to measure BP, Knowing blood pressure check-up, Definition of Hypertension”. Having low knowledge levels is a risk as shown in a study by Sinyinza [15] in Zambia, around 40 % out of 100 UNZA employees have Hypertension and low knowledge about their own health status. Further, low knowledge can serve as one of the contributing factors towards self-care practices. The findings of this study disagree with the studies by Mekonnen et al. [16], which revealed good knowledge (51.7%) about self-care practices. The current study results are similar to the studies by Chimberengwa and Naidoo [17], which revealed poor knowledge levels on hypertension. This could be due to similar study settings and sample characteristics. Therefore, there is need to initiate programs that create community awareness regarding information on BP so that there is an improvement in self-care practices among Hypertensive women.

In relation to attitude, 59% had a positive attitude towards self-care practices while 41% had a negative attitude. Of the respondents who had positive attitude the specific areas were “Importance of taking medication every day, Importance of special diet, Importance of BP control, Importance of regular exercises, Doctor Visits only when there is a problem by patients” while the specific areas of respondents with negative attitude included “Control of Hypertension with diet alone is superior to diet with medication, Hypertension causing blindness”.

One possible reason for the positive attitude towards self-care practices in this study could be the women’s beliefs and expectations about various aspects of their plight, their own coping capacity and the health care system which influence the reports of hypertension self-care practices, activity, disability and response to treatment. Some patients have adaptive beliefs and expectations about hypertension like self-care practices that promote their coping resources. In another context, the health care team also plays a role in either promoting a positive or negative attitude of such patients, especially that Hypertension is a chronic condition. The findings of this study agree with the studies conducted by Machaalani et al. [18] in which they had good level of attitude concerning hypertension and 47.8% of them have good attitude and only 39.5% of the study participants have good practice towards self-care practices of hypertension respectively. This might be due to similar study setting involving general hospitals.

According to Table 3 above, out of 200 participants, 73.4% with high knowledge levels and 98.1% with low knowledge levels had poor self-care practices compared to 26.9% with high knowledge levels and 1.9% with low knowledge levels who revealed good self-care practices. Following a statistical analysis result with the chi-square test on knowledge (P-value: 0.013) and P < 0.05, indicates that there was an association between self-care practices and knowledge levels of Hypertensive patients (Table 3). Result on the relationship between attitude and self-care practices revealed that out of 200 participants, 87.9% with a positive attitude and 88.1% with a negative attitude revealed poor self-care practices compared to 12.1% with a positive attitude and 11.9% with a negative attitude who revealed good self-care practices. Chi-square test on attitude (P-value: 0.025), P > 0.05 indicated statistical significance between self-care practices and attitude of Hypertensive patients (Table 3 above).

The study indicated statistical significance between self-care practices and knowledge and attitude was analyzed. Chi-square Fisher’s exact test was used to test for significance with the P-value set at 0.05. In this study, it was revealed that there was an association between self-care practices and knowledge levels of Hypertensive patients. Therefore, in this study, respondents with high knowledge also had good self-care practices. These findings disagree with the findings of Kebede et al. [19], whose study revealed that knowledge was independently associated with practices towards lifestyle modification of hypertensive patients. Results also revealed statistical significance between self-care practices and attitude of Hypertensive women. Therefore, majority of respondents who had a positive attitude also had good self-care practices. It can then be concluded that a positive attitude of hypertensive women, has a positive influence towards good self-care practices among women.

The binary logistic regression model was tested for multicollinearity, Hosmer and Lemeshow test of fitness for data, and omnibus test of model coefficients and classification accuracy. On multivariable logistic analysis, patients who had high knowledge levels were 1.939 times more likely to achieve good self-care practices compared to those who had low knowledge levels, and this effect was significant (OR: 1.939, CI: 0.541 - 6.945, P < 0.013), thus, low knowledge increases the risk of poor self-care practices. Further analysis showed that patients who had a positive attitude were 4.208 more likely to achieve good self-care practices compared to those who had a negative attitude and this effect was highly significant (OR: 4.208, CI: 1.198 -14.779, P < 0.025), thus, negative attitude lowers chance of self-care practices.

The binary logistic regression model was tested for multicollinearity, Hosmer and Lemeshow test of fitness for data, and omnibus test of model coefficients and classification accuracy. The test was used to analyze the combined impact of dependent (self-care practices) and independent variables (knowledge) and (attitude). All variables (dependent and independent variables) were coded. The results of the logistic regression analysis, according to Table 4, showed that holding other variables constant, patients with high knowledge levels were 1.939 times more likely to achieve good self-care practices; this effect was highly significant with the odds ratio of (OR: 1.939, CI: 0.541 - 6.945, P < 0.013). These findings are similar to the findings of Musimbaggo et al. [14], in a multivariable logistic regression to determine baseline factors associated with self-care practices after 6 months of antihypertensive treatment. The study reviewed that comorbid diabetes mellitus and the disclosure of an individual’s HIV status to a close person were associated with poor blood pressure control among persons living with HIV who had hypertension.

Further analysis showed that patients with a positive attitude were 4.208 more likely to achieve good self-care practices; this effect was significant with the odds ratio of (OR: 4.208, CI: 1.198 - 14.779, P < 0.025). These findings are contrary to the findings of Mekonnen et al. [16], whose multivariable analysis results reviewed that the odds of being knowledgeable were 2.80 for can read and write, secondary, preparatory and above education, respectively, compared to cannot read and write. A study by Mekonnen et al. [16] also demonstrated that occupation was significantly associated with the knowledge of blood pressure control.

5. Conclusion

The study identified two factors (attitude and knowledge) as being significant in influencing self-care practices among hypertensive women. This implies that, in order to improve self-care practices, there is a need for promoting a positive attitude and providing adequate information on hypertension self-care practices. This can be achieved through continuous health education by health care workers, formation of community peer support groups to promote awareness and disseminate much more needed information through drama and role plays, in order to improve the quality of life.

6. Recommendations

1) The Ministry of Health should ensure that attention is also focused on Hypertension as a communicable disease with increasing prevalence and mortality rate and formulate guidelines on the management of Hypertensive women. Work place policies are disseminated and implemented with emphasis on the need for comprehensive health education towards Hypertensive women.

2) Emphasis should be made in the nurse training curriculum on the importance of reinforcing the provision of vast information education and communication on self-care practices among Hypertensive women to allow them to graduate as nurse educators upon completion of training.

3) Members of staff managing Hypertensive women should intensify the provision of information, Education and Communication (IEC) sessions during the follow-up visit to patients. The IEC should include reducing fat intake, performing regular exercises, adherence to drugs, checking of blood pressure and keeping appointment schedules.

4) Support groups should be formed in communities in collaboration with the non-governmental organizations, health care providers and family members to assist Hypertensive women to access recommended treatment services.

5) To have this study replicated using a larger sample in order to evaluate a large-scale representation of self-care practices among Hypertensive women.

7. Limitations of the Study

The study sample size (n = 200) was limited; thus, generalization of results should be done with caution, as it only represented the views of women who accessed medical services from Kafue General Hospital. The sample size comprised women from the urban and peri-urban settings, hence the result may not be generalized for the rest of Zambia. The case may be different from patients in rural areas, as rural hospitals do not have specialized health professionals to provide sufficient information on Hypertension and self-care practices. The data collection tool used comprised closed-ended questions, and this could have limited the respondents from giving more required information.

Acknowledgements

Thanks to my fellow researchers/co-authors for their guidance and support, without which I would not have succeeded with this study. Also, thanks to the management of Kafue General Hospital for supporting me to undertake this research in the clinical setting at Kafue General Hospital.

Conflicts of Interest

The authors declare no conflicts of interest.

Conflicts of Interest

The authors declare no conflicts of interest.

References