|Year : 2016 | Volume
| Issue : 2 | Page : 82-88
Awareness of blood pressure status, undiagnosed hypertension and proteinuria among adults in Umuahia, South-East Nigeria
Chimezie Godswill Okwuonu1, Nnamdi Ezekiel Ojimadu2, Oluchi Justina Chimezie3, Uche Madudonu4, Nkechi Ogbulafor5, Okechukwu Samuel Ogah6
1 Department of Internal Medicine, Nephrology Unit, Federal Medical Centre, Umuahia, Abia State, Nigeria
2 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
3 Department of Ophthalmology and Eye Centre, Abia Specialist Hospital and Diagnostic Centre, Umuahia, Abia State, Nigeria
4 Department of Paediatrics, Federal Medical Centre Umuahia, Umuahia, Abia State, Nigeria
5 Nursing Service Division, Federal Medical Centre Umuahia, Umuahia, Abia State, Nigeria
6 Ministry of Health, Nnamdi Azikiwe Secretariate, Umuahia, Abia State, Nigeria
|Date of Web Publication||12-Jul-2016|
Chimezie Godswill Okwuonu
Department of Internal Medicine, Nephrology Unit, Federal Medical Centre, Umuahia, Abia State
Background: Hypertension and proteinuria are risk factors for cardiovascular disease. They are also important risk factors for further deterioration of renal function in chronic kidney disease (CKD) irrespective of the cause of CKD. Both are asymptomatic at early stages and can only be detected during medical consultation for a related or unrelated illness. Materials and Methods: This was a cross-sectional study carried out to assess awareness of blood pressure (BP) status among adults in a semi-urban community in Southern Nigeria. The magnitude of undiagnosed hypertension and proteinuria in the community was also assessed. BP measurement was by standardized method while proteinuria was detected by use of urinary dipstick. Data was analyzed using SPSS version 21.0. Results: A total of 389 people were recruited. There were 223 (57.3%) males and 116 (42.7%) females. Only 104 (26.7%) were aware of their BP status before the study. Awareness was higher in females but did not differ significantly among the different age groups, educational status or occupations. Hypertension was newly diagnosed in 105 (27%) of the participants while proteinuria was diagnosed in 47 (12.1%). Proteinuria and overweight were higher among participants with prehypertension than other BP categories. Conclusions: The study revealed a low level of awareness of BP status and a high prevalence of undiagnosed hypertension and proteinuria in the community. Concerted efforts are needed to improve the awareness of BP and other risk factors for cardiovascular and kidney diseases.
Keywords: Chronic kidney disease, hypertension, Nigeria, obesity, proteinuria
|How to cite this article:|
Okwuonu CG, Ojimadu NE, Chimezie OJ, Madudonu U, Ogbulafor N, Ogah OS. Awareness of blood pressure status, undiagnosed hypertension and proteinuria among adults in Umuahia, South-East Nigeria. Sahel Med J 2016;19:82-8
|How to cite this URL:|
Okwuonu CG, Ojimadu NE, Chimezie OJ, Madudonu U, Ogbulafor N, Ogah OS. Awareness of blood pressure status, undiagnosed hypertension and proteinuria among adults in Umuahia, South-East Nigeria. Sahel Med J [serial online] 2016 [cited 2019 Oct 15];19:82-8. Available from: http://www.smjonline.org/text.asp?2016/19/2/82/186035
| Introduction|| |
Hypertension is an important public health problem and the leading cause of cardiovascular disease globally., It accounts for about 6% of deaths worldwide  and affects approximately 11–42% of Africans.,, Hypertension ranks first among noncommunicable diseases in Nigeria  with prevalence ranging from 8% to 46.4% in both men and women in rural and urban communities.,,, A recent noncommunicable disease survey in Abia State obtained a prevalence of 31.8% among 2999 respondents. However, the awareness of blood pressure (BP) status among the participants was not assessed. Studies have shown that most people in the general population are not aware of their BP status., With relative lack of symptoms, most people with hypertension are unaware and some who are aware are nonadherent to prescribed pharmacologic and nonpharmacologic measures required for optimal BP control.,, One of the first steps toward the prevention of a disease is awareness of the disease.
Longstanding hypertension is commonly complicated by widespread vascular endothelial dysfunction which in the kidney leads to proteinuria. Proteinuria in a person with high BP may be an indicator of declining kidney function. If the hypertension is not controlled, the person can develop chronic kidney disease (CKD) which can progress to end stage renal disease. On the other hand, CKD can lead to hypertension through salt and water retention in the body.
Hypertension and proteinuria are important risk factors for further deterioration in renal function irrespective of the cause of CKD. Studies have established that interventions that decrease BP level in patients with proteinuria and renal insufficiency consistently delay the progression of CKD., Because neither hypertension nor CKD generally shows symptoms in the early stages, many people are unaware of their presence until detected during routine check-up or investigation for a related/unrelated illness. Assessment for proteinuria as a marker of CKD was also not part of the noncommunicable disease survey carried out in the state.
As part of a medical screening and free treatment exercise carried out in Olokoro, Umuahia South Local Government Area of Abia State, South-East Nigeria, we designed a study aimed at assessing the awareness of BP status, define (if any) the magnitude of undiagnosed hypertension and proteinuria in this semi-urban community. We also sought to assess factors that may influence these variables.
| Materials and Methods|| |
Study design and site
This was a cross-sectional study carried out in Olokoro, a semi-urban community in Umuahia South Local Government Area of Abia State, South-East Nigeria. The community is about 8 km from Umuahia town, the state capital. The inhabitants are predominantly Igbos, mostly Christians and traders with few civil servants and farmers. The study was conducted from August 15th to 18th, 2013.
The study population included adults from the age of 18 years and above who presented during the medical screening exercise carried out in the study site.
Sample size and sampling
The sample size was calculated using appropriate formula  based on prevalence of hypertension in Abia State of 31.8% with 95% confidence and a margin of error of 5%. Participants who consented to the study were consecutively selected.
Inclusion and exclusion criteria
Consenting adults, 18 years or older were included in the study. Those participants that had psychiatric illness, who were chronically ill-looking, had features suggestive of urinary tract infection or manifested hypertensive emergency were excluded from the interview. Also, females who were pregnant or currently menstruating at the time of the study, and participants with symptoms suggestive of urinary tract infection were excluded from the study. This is because proteinuria can occur in these settings.
Recruitment and data collection
A researcher-administered questionnaire was used in data collection. The questionnaire was pretested with 38 patients seen in a health center in the adjacent community. The aim of the pretesting was to reveal difficulties in understanding the meaning of the questions, estimate the amount of time for completion of the questionnaire and to assess the participants' willingness to be involved in the study. The face and content validity of the questionnaires were also evaluated by one family physician and two resident doctors. On the basis of the feedback obtained, some questions were modified and the clarity of some questions improved.
The screening exercise was executed in two stages:
- Stage 1 involved recording the sociodemographic data of the participants in the questionnaire and taking a brief medical history
- Stage 2 involved measurement of BP, anthropometric data collection, treating any diagnosed medical illness and dipstick urine test for protein.
At this stage also, participants with abnormal results were informed and referred to the nearby hospital for follow-up.
The BP was measured on the nondorminant arm using a mercury sphygmomanometer (Accoson, England) at heart level using appropriate cuff size. The subjects were allowed to relax for 3–5 min in a sitting position before assessment of BP. Hypertension was defined as a systolic BP (SBP) ≥140 mmHg or diastolic BP (DBP) ≥90 mmHg and/or concomitant use of antihypertensive agents. Two readings were obtained at an interval of 5 min and the average of the two reading recorded. The BP findings were grouped according to the Seventh Joint National Committee Report (JNC 7) on detection, evaluation and treatment of high BP (JNC 7) report staging of hypertension in which the systolic and diastolic pressures were equally weighted and either of them qualified the patient for a BP group. The JNC 7 guideline described the optimal BP as a SBP <120 and DBP of <80 mmHg. The next category of BP measurements comes under the term prehypertension which includes the range of SBP of 120–139 or diastolic pressure of 80–89 mmHg; either of which qualified the individual as having prehypertension. Blood pressure readings equal or greater than a systolic of 140 mmHg and/or diastolic of 90 mmHg were classified as hypertension stage 1 (SBP 140–159 mmHg and/or DBP 90–99 mmHg) or stage 2 for BPs equal or greater than 160 mmHg systolic and/or 100 mmHg diastolic.
Participants were instructed on modality of collecting mid-stream urine specimen. Thereafter they provided urine samples which were tested using urinary dipstick Combi-10 test strips (CHUNGO Pharm, Korea). Significant proteinuria was defined as dipstick positive for protein of 1+ and above.
Weights were taken using bathroom scale (Hana Weighing Scale, China) after removal of shoes and heavy clothings, while the heights were recorded using stadiometer (RGZ-160; made by Health Medical Equipment). The body mass index (BMI) was calculated from the measured weight (in kilograms) and height (in meters) and was categorized as normal (BMI <25 kg/m 2), overweight (BMI = 25–29.9 kg/m 2) or obese (BMI ≥ 30 kg/m 2) according to the WHO criteria.
Permission for the screening and study was obtained from the local government authorities and informed consent from the participants.
The Statistical Package for Social Sciences (SSPS Inc., Chicago, IL, USA) version 21.0 statistical software was used for data analysis. For continuous variables, mean values and standard deviations (SDs) were calculated and the means compared using two sample t-test. Categorical variables were compared using the nonparametric tests - Chi-squares. The cross-tabulation was used to analyze the relationship between the BMI, grades of BP (SBP and DBP), and proteinuria in the respondents. Correlation analysis was used to assess the relationship between age and BP (SBP and DBP) in respondents. All tests were two-tailed with P < 0.05 taken as statistically significant.
| Results|| |
A total of 389 participants were screened. The sociodemographic characteristics of the participants were as shown in [Table 1]. Among the participants, 26.7% (104/389) were aware of their BP status before the screening while 73.3% (285/389) were not aware. More females (16.7%) were aware of their BP status than men (10%). This difference, however, was not statistically significant (χ2 = 1.55, P = 0.25). The mean age (SD) of those who were aware of their BP status (57.1 [12.0]) and those not aware (56.4 [12.8]) did not differ significantly (t = 0.437, P = 0.66). Also, there was no significant difference in awareness of BP status among the different educational groups (χ2 with trend = 0.16, P = 0.69), occupations (χ2 = 8.57, P = 0.12) or marital status (χ2 = 3.08, P = 0.22).
One hundred and forty-seven participants (37.8%) had hypertension [Table 2]. Among these, 10.8% (42/389) had been previously diagnosed while 27% (105/389) were undiagnosed prior to the screening exercise. There was a weak positive significant correlation between age and both systolic (r = 0.16, P < 0.01) and diastolic (r = 0.12, P = 0.02) BPs.
Forty-seven participants (12.1%) had significant proteinuria [Table 2]. Among these, 3.3% (13/389) had stage 1 hypertension while 1% (4/389) had stage 2 hypertension. There was a statistically significant difference in the finding of significant proteinuria among the different BP categories (χ2 = 9.39, df = 3, P = 0.03); more participants with normal BP and prehypertension were found with significant proteinuria compared with participants found with different stages of hypertension [Table 3]. There was also a significant difference in the distribution of BMI across the different BP categories (χ2 = 14.55, df = 6, P = 0.024); a higher percentage of overweight individuals had prehypertension [Table 4].
| Discussion|| |
The main findings of this study were that more than 70% of the participants were unaware of their BP status prior to this study; more than 70% of those diagnosed with hypertension in this study were previously undiagnosed; also significant proteinuria and overweight was found in participants with prehypertension more than in other BP categories.
Our study is similar to earlier studies in Nigeria among hypertensives ,,, in terms of mean age of hypertensives and the age category commonly reported to have a high prevalence of hypertension. This is also in line with the observation that BP increases with age.
Most of the participants had some form of education, corroborating earlier report by the Abia State Planning Commission in 2008 which gave a high literacy rate of 85.6% in the state.
Hypertension is one of the most important causes of cardiovascular morbidity and mortality.,,, Previous studies have shown that the proportion of people who are aware of their high BP status is usually low since the condition is often without symptoms.,, In this study, only 26.7% of the participants were aware of their BP status before the study. Among those found to be hypertensive, only 10.6% were aware of their condition before the screening. This is lower than what was obtained in the national survey on noncommunicable diseases in Nigeria  where it was reported that 33.8% of the hypertensives were aware of their BP status. It is even lower than 18.5% obtained in Benin Nigeria  and 20% in Tanzania. The sample size and sampling procedure in our study differs with these other studies and could account for such differences. Of interest also is that none of the sociodemographic variables (age, educational level, occupation, marital status) seems to be a determinant of this awareness. One would have expected that people with higher education would be significantly more aware of their BP. However, people with higher educational status tend to be preoccupied with their job and may not have time for regular BP checks.
Females were more aware of their BP status than men. This is in agreement with other studies , and could be due to differences in health seeking behavior; as females are more likely than men to present to hospital for various health related issues including antenatal visits, family planning and well woman clinics. All these are opportunities for casual BP checks.
The prevalence of hypertension obtained in this study (37.8%) is comparable to 38% obtained in a similar study in Ile-Ife. However, it was slightly higher than 31.8% obtained in a recent noncommunicable disease survey carried out in the State where this index study was carried out. The reason for this higher prevalence of hypertension in this present study may be because majority of the participants in this study were traders. Ulasi et al. had earlier reported a high prevalence of hypertension among traders in Nigeria. This is because they sit in one place to conduct their businesses (sedentary lifestyle) and may not have regular exercise. In addition, they spend most of the day at the market and depend on food vendors for most of their meals. The typical local meal of this community consists mainly of root crops of yam and processed cassava. These have been shown to have naturally low sodium and mineral content. Hence they are often salt-laden during preparation to improve taste. All these are possible risk factors for high BP in traders.
Proteinuria is not only a marker of kidney disease but also a risk factor for CKD progression, and its amelioration shown to retard progression of CKD.,,, Earlier studies have demonstrated that individuals with proteinuria are at higher risk of cardiovascular disease and CKD.,
The prevalence of proteinuria in a population varies depending on method of detection of proteinuria (urinary dipstick, spot urine albumin-creatinine ratio, 24-h proteinuria), age of the participants, presence or absence of co-morbid conditions such as diabetes, hypertension and CKD.,, Up to 12.1% of the participants in this study have significant proteinuria based on dipstick measurement. This is comparable to 11.7% obtained in the National Health and Nutrition Examination Survey III among 14,836 noninstitutionalized population of the United States of America, although a different method was used in detecting proteinuria. Our finding, however, is lower than 19.6% obtained from Kano  Nigeria where a similar method of detection of proteinuria was used. This may be due to the strict exclusion criteria employed in this study as participants with symptoms suggestive of urinary tract infection, pregnant women and menstruating females were excluded from urine analysis. These criteria were not reported in the other study compared.
Of importance in this study also is the fact that individuals with prehypertension had a higher prevalence of proteinuria than other BP categories; and this was statistically significant. This has implication for targeted intervention. Institution of lifestyle measures among individuals with prehypertension has been shown to be effective in prevention of hypertension., Hence screening for proteinuria should not only be done for hypertensive patients but also in people with prehypertension. If detected, measures that ameliorate proteinuria should be instituted at this stage to avert further progression of proteinuria with its adverse consequences.
| Conclusion|| |
There is poor awareness of BP status in the studied population especially among the males. The prevalence of undiagnosed hypertension, prehypertension and proteinuria is equally high. The finding of a higher prevalence of proteinuria among participants with prehypertension is particularly alarming. This finding calls for vigilance in screening for proteinuria among people with prehypertension.
| Recommendation|| |
The first step toward prevention of any disease is awareness of the disease. We, therefore, recommend institution of awareness program to enlighten the general populace on need for routine BP check both casually and during encounter with medical personnel. Knowledge of risk factors for kidney disease and screening for them in every patient has been advocated for by the national kidney foundation. Patient with risk factors for kidney disease should be screened for kidney damage using simple cost-effective laboratory investigations including urinalysis.
Finally, patients with prehypertension should be screened for proteinuria as such individuals might be at risk for renal damage.
Proteinuria was semi-quantitatively assessed using urinary dipstick. This would have included individuals with lower degrees of (detectable) proteinuria as having significant proteinuria; hence may be the reason why proteinuria rate is high among normals more than hypertensives in this study. Quantitative measurement using spot urine albumin to creatinine ratio would have given a reliable estimate of proteinuria.,,,, Also, we did not employ standard mental state assessment tools in excluding psychiatric illness. Administering such to all patients would be cumbersome within the limits of the medical screening exercise of this nature.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]