Comparative Analysis of Clinical History, Sociodemographic, Behavioural Factors and Cardiovascular Risk Factors among Hypertensive in Awka, Nigeria

Background: Hypertension is a major modifiable risk factor for cardiovascular diseases and research studies done in Nigeria observed prevalence rate of hypertension to range from 26.4% to 36.9%. Aim: This study aimed to evaluate the sociodemographic, clinical, behavioral and cardiovascular risk factors associated with hypertension in Awka, South East, Nigeria. Methods: Cross-sectional study was used.391 participants aged from 18 years above were recruited for this study. Structured questionnaires were constructed in line with World Health


INTRODUCTION
Hypertension is a major public health problem with increasing level of cardiovascular mortality and morbidity both in developed and developing countries [1,2].The prevalence of hypertension is on the increase.It has been projected that by the year 2025, the global prevalence of hypertension would be about 29.4% (about 1.54 billion people) [3] Africa has the highest prevalence of hypertension and as such, it is described as a disease for Africa [4].About 90% of diagnosed cases of hypertension are primary hypertension and 10% are secondary hypertension [2].Several risk factors are associated with primary hypertension although the cause is yet unknown [4].These factors are characterized into modifiable and non-modifiable risk factors [5].The modifiable risk factors of hypertension are those attributes of an individual that can be adjusted or changed [6,7].These includes: obesity, alcohol consumption, tobacco use, lack of exercise etc.The non-modifiable risk are attributes of an individual that cannot be changed.This includes sex, family history, genetic composition race [8,9,10].Hypertension if not properly controlled and managed may lead to cardiovascular complications which include coronary heart disease, heart failure, renal damage, ischemic heart disease, strokes [11,12].Previous studies showed a positive relationship of cardiovascular risk factor and hypertension and suggested implementation management of cardiovascular disease and prevention policy; this includes management of obesity, blood pressure, lipid and glucose metabolism, increase physical activity, strictly compliance of drug complication [13].In Nigeria, complications of hypertension attributes to 25% of all emergency admission in health institutions [12].This has been proven to be associated to individuals who are unaware of their health condition or whose conditions were poorly managed [2].
Few research studies have been done in southsouth and south-east Nigeria and have shown prevalence rate of hypertension and its complications ranges from 21% and 21.3% respectively [14].However, there is need to explore more on associated risk factors with hypertension.This study aimed to evaluate the sociodemographic, clinical and behavioral factors that are associated with hypertension in Awka, South east, Nigeria.

Study Population
A total of three hundred and ninety-one subjects (n=391) were recruited for this research study and comprises of Male (n=181) and female (n=210).This research study was carried out in Chukwuemeka Odimegwu Ojukwu University Teaching Hospital, Awka at General Outpatient Department (GOPD).A cross-sectional design study was used.The research study participants were adults aged from 18years and above.This study was carried out between November 2018 to April 2019.

Assessment of Associated Risk Factors
Structured questionnaires were constructed in line with WHO Steps Instrument 1 and 2 [15].Informed consents were obtained from each participant and also explained what it is being used for and its importance.The questionnaire consists of two steps parts.
Step Step 2; captured the anthropometric measurements and Body Mass Index (BMI).BMI was determined as weight/height 2 (Kg/M 2 ).Height and weight was measured using a stadiometer.In measuring height, participants were made to remove their shoes, stand on top of the stadiometer scale, standing erect, facing forward and height measured from the meter rule.Also, weight was measured during the procedure.BMI were classified according to WHO standard; in four groups.They are underweight (<18.5 kg/m 2 ), normal weight (18.5 -24.9 kg/m 2 ), overweight (25-29.9kg/m 2 ) and obesity (>30 kg/m 2 ).Blood pressure measurements were taken using sphygmomanometer.Participants were asked to sit on a chair with their feet flat on the floor and left arm made to rest on the upper arm and participants assured to be calm.Auscultation was done over the brachial artery with a stethoscope.The first appearance of korotkoff sounds as the cuff swings was taken as systolic and the disappearance of the sounds taken as diastolic [16].Blood pressure measurements were recorded in mmHg.This procedure was measured for three times over a period of 3 minutes.Subjects were classified hypertensive if their blood pressure were greater or equal to 140 mmHg (systolic) and 90 mmHg (Diastolic) [17].Pulse rate was also gotten from participants using a Pulse oximeter.The Right thumb is placed inside the pulse oximeter and the participant assured to be calm when the pulse rate is taken.Socio-economic status was also taken.Their occupational status was grouped into civil servants, public servants, Business, Applicant, and Retired.Marital status was also grouped into; Married, Single, Divorced, Widowed.
Participants were assured of Oath of secrecy and well explained that it is voluntary and has the right to withdraw from the study if need be.Participants that were found to be hypertensive through BP readings were informed, counseled and urged to commence treatment as soon as possible.Data generated we analyzed using statistical package for social sciences version 21 software.Chi square test was used to test comparison between the two groups and independent sample T test for normally distributed data and also for comparison, value <0.001 was taken as to be statistically significant.

RESULTS AND DISCUSSION
A total of three hundred and ninety one subjects comprising of 181(46.3%)male and 210(53.7%)females participated in this study.The mean (SD) age of all subjects was 45.87± 17.
In this cross-sectional study, the prevalence of hypertension was 24.0%.This finding is consistent with earlier reports by [18,19,20].This consistency in prevalence rate is a cause for concern especially in a country like Nigeria that is struggling with the issue of over population.This is so because with a constant prevalent rate of hypertension in a continuous growing population in Nigeria, more and more people are becoming hypertensive.

Study Population According to Their Demographic and Clinical Characteristics
Table 1 shows the result of frequency distribution of clinical variables.Respondents who had family history of hypertension were 101(25.8%)compared to 290(74.2%) of respondents who had no traits of hypertension.317(81.1%) of the subject study presented with a normal heart rhythm while 68(17.4%)presented with heart rhythm greater than 100 beats per/minute.285(72.9%) of the participants had their systolic blood pressure ≤140 mmHg compared with 106(27.1%) of the participants had their systolic pressure ≥140 mmHg.Likewise, 274(70.1%) of the subjects had their diastolic blood pressure ≤90 mmHg compared to 117(29.9%) of the subjects with diastolic blood pressure ≥90 mmkHg.90(23.0%) of the subjects had their age range between 28-37 compared to other age range.

Relationship between Sociodemographic Characteristics and Prevalence of Hypertension
In occupational status of subjects, 31(33.7%) of retired subject had the highest prevalence and was statistically associated with hypertension, (P<0.001)(Table 2).Male subjects had high prevalence 51(54.3%)compared to female subjects 43(45.7%), the difference was not statically significant (x 2 =3.151,P>0.001).Prevalence of hypertension was slightly different from 58(53.4%) subjects who responded to pass through stress compared to 36(38.3%)subjects that responded not to have pass through stress, thus the difference was statistically insignificant(x 2 =6.490,P>0.001).Marital status was significantly associated with hypertension, (P<0.001) and prevalence of hypertension was highest among married participants 77(81.9%)followed by widowed 9(8.6%) and single participants 8(8.5%).Prevalence of hypertension were higher with participants admitted to be involved in physical activities 64(68.1%)than those participants that are not involved in physical activity 30(31.9%), the difference between hypertension and physical activity was statically insignificant (X 2 =11.917, df=2, P>0.001).
The results data demonstrated a strong significant association between age and hypertension.Increase in age has been found to be a risk predictor of hypertension [21].This findings are consistent with the study results on prevalence of hypertension and associated factors among residents in Ibadan, Nigeria [18], prevalence of hypertension in Akwa Ibom, South-South, Nigeria [1] and similar study conducted in Anambra, Nigeria [20].Stress and hypertension showed no linear relationship as P value is >0.001.Exposure to chronic stress has been stated as risk factors/biomarker of hypertension.Chronic stress stimulates the release of cortisol which increases cardiovascular reactivity in the body.This results finding are contrary with a study that observed a positive association between stress and hypertension in their study of sociodemographic correlates of hypertension in a rural setting of Oyo state, Nigeria.[16] Also, results data expressed a significant relationship between hypertension and economic status.Prevalence of hypertension were seen more among retired (33.7%), followed by public servants and business people with the same percentage rate (27.2%).This study findings agreed with the study carried out by [2], however noted a slight difference in prevalence rate of hypertension to have been more among minor retailers (60.7%).This may be attributed to the study population.Prevalence of hypertension were higher among married subjects (81.9%) when compared to other status; widowed (8.5%), single (8.5%) and also observed a significant association between hypertension and marital status.These findings are similar with the findings on a survey of hypertension and its socio-economic factors in a market population, Awka, Nigeria [2].There have been varying reports on the association of hypertension with sex.However, this study observed no positive association between hypertension and Gender.In females, cardiac output is less than in males because of less blood volume and so cardiac index is more than in males, because of less body surface area.Increased in cardiac output has been noted to be strongly associated with hypertension.This result is consistent with a study carried out by [2].

Association between Behavioral Risk Factors and Hypertension
No significant association was observed between hypertension and Subjects that are strong addicts to alcohol (df =1, x 2 =1.527,P>0.001) and subjects that are strong addicts to smoking (df=1, x 2 =0.256,P>0.001) (Table 3).There was also no positive association between hypertension and subjects that takes high vegetable (df=2, x 2 =0.6999,P>0.001) and subjects that occasionally use salt often (df=1, x 2 =0.341,P>0.001).The effect of smoking on hypertension is transient.Another report found no association between smoking and hypertension.Our findings suggests that smoking is not an associated risk factor in the study population.
This study observed insignificant association between increased salt intake and hypertension.Increased salt intake had been positively associated with progression of cardiovascular disorders.A study had a contrary study that observed high salt intake to be associated with progression of cardiovascular and renal dysfunction, suggesting high salt intake to be a

Comparative Analysis of Clinical Factors, between Hypertension and Their Control
Table 4 shows the comparison between hypertension and clinical risk factors.The mean (SD) systolic pressure of hypertensive subjects (143.02±33.484)were increased compared to Normotensive subjects (117.62±25.570)and the difference were statistically significant (P<0.001).The mean (SD) diastolic pressure of hypertensive subjects (84.93±20.069) of normotensive subjects, there was significant association with hypertension, (P<0.001).Also, the relationship between subjects that have family history of hypertension and hypertension was statistically significant, P<0.001.
Heart rate was not statistically significant with hypertension in this study, P value is >0.001.This result is contrary to a research findings that suggest heart rate is strongly associated with peripheral and central blood pressures [25].Heart rate is an independent risk factor of cardiovascular disease with high mortality rate among hypertensive subjects [25].A clinical study had observed patients with increase heart rate are more likely to develop atherosclerosis and acute coronary syndromes [26].Also recent studies analyzed an increased heart rate is frequently associated with high blood pressure, obesity, dyslipidemia and increase haematocrit.However, this finding is in contrast with [21] that explains heart rate greater than 80 beats per minute has a positive association with hypertension.This study demonstrated a strong positive association between participants that has family history of hypertension and hypertension, P<0.001.This finding is consistent with the study that reported a statistically significant association between hypertension and family history [2,15].

CONCLUSION
This study observed that family history of hypertension, marital status, and occupational status, is associated to increase in blood pressure and increase in age may be positively associated with hypertension and a cardiovascular risk factor in Awka, Nigeria.This calls for an increase sensitization and an improved health policy on these associated risk factors.

CONSENT
As per international standard, patient's written consent has been collected and preserved by the author(s).

COMPETING INTERESTS
Authors have declared that no competing interests exist.

Table 4 . Comparative analysis of clinical factors, between hypertension and their control
*P<0.001 is considered statistically significant