|Year : 2015 | Volume
| Issue : 1 | Page : 8-17
Prevalence of hypertension and its correlates among employees of a tertiary hospital in Yenagoa, Nigeria
Oghenekaro Godwin Egbi1, Stella Rotifa2, Johnbull Jumbo1
1 Department of Medicine, Niger Delta University, Okolobiri; Department of Medicine, Federal Medical Centre, Yenagoa, Bayelsa State, Nigeria
2 Department of Community Medicine, Federal Medical Centre, Yenagoa, Bayelsa State, Nigeria
|Date of Web Publication||7-Jan-2015|
Oghenekaro Godwin Egbi
Dialysis Unit, Federal Medical Centre, P. M. B 502, Yenagoa, Bayelsa State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Hypertension (HTN) is a common medical problem with increasing prevalence and dire consequences. Considering the relative proximity of hospital workers to health care delivery, one may expect a better control of HTN and associated risk factors in this population. The objective of the current study was to determine the prevalence of HTN and risk factors among hospital employees in a Nigerian tertiary hospital.
Materials and Methods: All employees of the Federal Medical Center, Yenagoa (Bayelsa State, Nigeria) were invited for a HTN screening exercise on the world kidney day on March 14, 2013. A total of 231 participants completed this cross-sectional study. Data was obtained with a pre-tested interviewer-administered structured questionnaire while blood pressure was taken with an Accoson sphygmomanometer. Anthropometry was done using standardized protocols. Urine and blood were analyzed for glucose. HTN was defined as blood pressure >140/90 or prior diagnosis or use of antihypertensives. Data was entered, stored and analyzed with Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) version 20.
Results: The crude and age-adjusted prevalence of HTN among the hospital employee was 21.3% and 23.8% respectively. Age, marital status, educational level, body mass index, waist circumference (WC) and waist hip ratio showed significant association with HTN in the univariate analysis. However, in multivariate regression analysis, only older age and abnormal WC predicted HTN.
Conclusion: The prevalence of HTN among the hospital employees compared with reports in other population and was predicted by advancing age and abnormal WC. The study underscores the need for introduction of HTN screening programs among hospital employees especially staff that are older with truncal obesity.
| Abstract in French|| |
Contexte: L'hypertension (HTN) est un problème médical commun avec l'augmentation de la prévalence et les conséquences désastreuses. Compte tenu de la proximité relative des travailleurs de l'hôpital à la prestation des soins de santé, on peut attendre un meilleur contrôle de HTN et facteurs de risque dans cette population. L'objectif de cette étude était de déterminer la prévalence de HTN et facteurs de risque chez les employés de l'hôpital dans un hôpital tertiaire nigérian .
Matériaux et Méthodes: tous les employés du centre médical fédéral, Yenagoa (Etat de Bayelsa, Nigeria) ont été invités pour un HTN dépistage exercice sur la journée mondiale du rein le 14 mars 2013. Un total de 231 participants ont complété cette étude transversale. Données ont été obtenues avec un questionnaire structuré pré-testée intervieweur, tandis que la pression artérielle a été prise avec un sphygmomanomètre Accoson. L'anthropométrie a été fait à l'aide de protocoles standardisés. Sang et urine ont été analysés pour le glucose. HTN a été défini comme sang pression >140/90 ou diagnostic préalable ou utilisation des antihypertenseurs. Données a été entrées, stockées et analysées avec Logiciel de statistiques pour les Sciences sociales (SPSS Inc., Chicago, IL, USA) version 20.
Résultats: La prévalence brute et ajusté selon l'âge du HTN chez l'hôpital employé était de 21,3 % et 23,8 % respectivement. Âge, état matrimonial, niveau d'instruction, indice de masse corporelle, tour de taille (WC) et taille hip ratio a montré l'association significative avec HTN dans l'analyse univariée. Toutefois, dans l'analyse de régression multivariée, seulement plus âgés et WC anormale prédit HTN .
Conclusion: La prévalence de HTN parmi les employés de l'hôpital par rapport aux rapports dans d'autres populations et a été prédite par l'âge et WC anormale. L'étude met en évidence la nécessité d'introduire des HTN parmi les employés de l'hôpital en particulier du personnel qui sont plus âgé avec obésité abdominale, les programmes de dépistage.
Mots-clés: Bcorrélats, employés, hypertension, ayelsa, prévalence
Keywords: Bayelsa, correlates, employees, hypertension, prevalence
|How to cite this article:|
Egbi OG, Rotifa S, Jumbo J. Prevalence of hypertension and its correlates among employees of a tertiary hospital in Yenagoa, Nigeria. Ann Afr Med 2015;14:8-17
|How to cite this URL:|
Egbi OG, Rotifa S, Jumbo J. Prevalence of hypertension and its correlates among employees of a tertiary hospital in Yenagoa, Nigeria. Ann Afr Med [serial online] 2015 [cited 2020 Aug 5];14:8-17. Available from: http://www.annalsafrmed.org/text.asp?2015/14/1/8/148709
| Introduction|| |
Hypertension (HTN) is a common medical problem of increasing magnitude and disturbing consequences. In Nigeria like in most other countries in sub-Saharan Africa, it is considered a major contributor to morbidity and mortality.  The overall prevalence of HTN in Nigeria ranges from 8% to 64%  depending on the study target population, type of measurement and cut-off value used for defining HTN. It has been projected that by 2025, about 75% of the world's hypertensive population will be in developing countries.  Although, it is commonly asymptomatic, the damage it does to arteries and organs can lead to significant morbidity. HTN is a major risk factor for stroke, heart failure and kidney disease making it a key priority for prevention, early detection and control. Risk factors for HTN include increasing age,  obesity,  sedentary lifestyle,  family history of HTN,  diet,  alcohol,  and tobacco use. 
Patient education by physicians and other members of the heath team about lifestyle modifications plays an important role in the control of HTN.  The effectiveness of patient education may be enhanced by a healthy lifestyle of the attending health care worker. For example, the predictors study  highlighted how physicians who drank less alcohol, smoked tobacco and engaged in healthier habits were more likely to have higher success rates in patient management. Similarly, the nurses' body size study  indicated that patients showed more confidence in health education when being given by a normal weight nurse than when being delivered by an overweight nurse.
Considering the health-related knowledge at the disposal of the hospital workers and their proximity to health care delivery, the assumption will be that the control of HTN and its modifiable risk factors would be relatively high. An earlier study done among civil servants working in the Bayelsa State, South-South Nigeria had put the prevalence of HTN at 27.8%.  Similarly, in Port Harcourt, a nearby town in Rivers State, Onwuchekwa et al. have reported prevalence of 32.0% among civil servants and 30.0% among professionals including engineers, lawyers and accountants.  Furthermore in Port Harcourt, Ordinioha et al. revealed prevalence of 21.3% among lecturers.  In Benin City, Nigeria, prevalence of 17.7% was reported among bankers.  However, there are only scanty reports on the prevalence of HTN among hospital workers in Nigeria. The lecturers in Ordinioha's series were however also medical consultants in the University Teaching Hospital. 
A few reports exist on the prevalence of HTN among hospital employees outside Nigeria. For instance, some Brazilian studies reported prevalence rates of 26%  and 36%  among physicians and female nurses respectively.
Against this background, the aim of this study was to determine the prevalence of HTN and associated risk factors among hospital workers in a tertiary hospital in Bayelsa State, Nigeria.
| Materials and Methods|| |
The study was cross-sectional and observational in design. It was carried out in the Federal Medical Center, Yenagoa. The hospital is the largest hospital in Bayelsa State with a total bed capacity of about 200 and an average annual in-patient load of 10,000. It serves as a referral center to other smaller hospitals in the state as well as hospitals in neighboring states such as Delta, Rivers, Edo and Akwa-Ibom. The hospital has a total of about 815 full time employees which includes various cadres of doctors, nurses, laboratory staff, pharmacists, technicians and administrative staff. A minimum acceptable sample size of 246 was determined using Daniel's sample size formula with finite population correction,  HTN prevalence of 27.8% (from Egbi's report),  with a precision of 5.0%, 95% confidence interval (CI) set at 1.96 and an allowable error of 10%.
All employees of the hospital were invited for a HTN screening program through a circular sent from the office of the head of administration to the respective heads of departments several days before the event. Sensitization banners were also placed at strategic positions in the hospital. The screening exercise took place as part of the event to commemorate the world kidney day on March 14, 2013.
Non-probability consecutive sampling was used in recruitment of participants. Individuals <18 years, pregnant individuals and individuals on steroids were excluded from the study.
The study was approved by the Ethical Committee of the Federal Medical Centre, Yenagoa.
Employees who agreed to participate in the study were included after giving their informed consent. Anonymity was maintained by the use of serial numbers randomly assigned rather than use of names or hospital numbers of participants. Individuals diagnosed with HTN were referred to appropriate health units.
The exercise was divided into various stages with several stations and interviewers attached. The research team for the exercise comprised seven medical officers, seven house officers, four trained nurses, two laboratory scientists, and three consultants in internal medicine, family medicine and public health drawn from both the Federal Medical Center and the Niger Delta University Teaching Hospital, which is also in Bayelsa State.
The research team was briefed and trained in the research protocol, methodology of the questionnaire and its administration as well as the various clinical procedures. The consultants played a supervisory role. At the first station, a pre-tested semi structured questionnaire was used, which collected information on demographic characteristics such as age, sex, marital status, level of education and professional cadre. Other elements of history obtained include a history of prior diagnosis of HTN and diabetes, family history of both conditions as well as information regarding habits of alcohol and tobacco consumption. Administration of the questionnaire was done by three house officers. Participants were grouped according to professional cadre into five main groups: Physicians (all cadres of medical doctors), nursing staff (registered nurses, auxiliary nurses, nursing aides and technicians), allied health workers (pharmacists and pharmacy technicians, optometrists, physiotherapists and laboratory health workers), hospital administrative staff and "others." Those in the last category were hospital staff whose job description could not fit into any of the afore-mentioned groups.
At the second station, blood pressure was measured by four medical officers using an Accoson mercury sphygmomanometer with an appropriate cuff size and a Littman stethoscope (3M, Brookings). Blood pressure was measured in the right arm after at least 15 min of rest and while participants were sitting down.  The cuff (about 12.5 cm wide) was applied evenly and snugly around the bare arm, with the lower edge 2.5 cm above the antecubital fossa. The participants must not have eaten, ingested alcoholic drinks, or smoked tobacco for at least 30 min before the measurements. The first and fifth Korotkoff sounds were taken as the systolic blood pressure (SBP) and diastolic blood pressures (DBP) respectively. The mean of two separate readings was determined after an interval of 10 min and recorded to the nearest 2 mm.  HTN was defined if SBP was 140 mmHg and above or DBP 90 mmHg, and above or upon self-report of a medical diagnosis of HTN or current treatment for HTN with prescription medication.  Blood pressure was classified according to the Seventh Joint National Committee criteria.  Pre-HTN was defined as BP above 120/80 mmHg but <140/90 mmHg.  For the previously diagnosed hypertensives, blood pressure of <140/90 mmHg was considered as controlled HTN while uncontrolled HTN was defined as any value greater than this.
The next step involved anthropometric measurements. The research workers in this station comprised four trained nurses and four house officers. The nurses measured the weight and height of participants. Weight was measured to the nearest 0.1 kg, using a portable weighing scale. A stadiometer was used in measurement of height. This was taken in a standing position with shoes removed and measured to the nearest 1 cm. A house officer then calculated the body mass index (BMI) using a standard calculator with the formula: Weight (in kilogram), divided by a square of the height (in meter). Generalized obesity was defined as BMI of greater or equal to 30 while Participants with BMI between 25.0 and 29.0 were considered overweight. Normal weight individuals were those with BMI between 18.5 and 24.9 while those with BMI <18.5 were considered underweight.  Truncal obesity was determined using waist circumference (WC) and waist hip ratio (WHR). This was assessed by three medical house officers. Using a standard measuring tape, WC was measured in the standing position and midway between the iliac crest and the lowermost margin of the ribs with bare belly and at the end of normal expiration. The hip circumference was similarly measured with a measuring tape at the largest circumference in the horizontal plane over the buttocks. WC cut-offs used were 88 cm for females and 102 cm for males. Abnormal WC was defined as WC >102 cm for males and 88 cm for females while lesser values were normal. 
WHR was calculated by dividing the WC obtained by the hip circumference. WHR >0.85 for females and >0.95 for males were considered as abnormal while lesser values were normal. 
Fresh capillary blood specimen from finger puncture was obtained by the laboratory scientists for determination of random blood glucose using an Accucheck Active® blood glucose monitor with (serial no: GC 15181884 and art no: 05088810001). A random blood glucose <7.8 mg/dl was considered as normal while higher values were impaired. The cut-off value of 7.8 mmol/l was chosen because it is well-known that in people with normal glucose tolerance, plasma glucose generally rises no higher than 7.8 mmol/l in response to meals and typically returns to pre-meal levels within 2-3 h.  Participants were counseled on lifestyle modifications by any of five medical officers in the last station following which referral to the appropriate health unit was made as necessary.
The Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) version 20.0 statistical software was used for data entry, storage and analysis. Descriptive data were presented as mean ± standard deviation and absolute and relative frequencies. Age-standardization of HTN prevalence was carried out using the direct method, with standardization to the World Health Organization (WHO) standard population.  The relationship between various socio-demographic and clinical variables with HTN was analyzed with cross tabulation and Chi-square or Fisher's exact. Pearson correlation analysis was used to determine the association between numeric variables and blood pressure. Univariate regression analysis was done to identify risk factors associated with HTN followed by an unconditional multivariate logistic regression analysis to determine the independent predictors of HTN. Variables entered in the logistic regression analysis include age, gender, marital status, level of education, family history of HTN, past diagnosis of diabetes, family history of diabetes, history of alcohol consumption, history of smoking, BMI, WC and WHR. Unadjusted and adjusted odds ratio (AOR) were developed with the corresponding 95% CI. All tests were two-tailed with P < 0.05 taken as statistically significant.
| Results|| |
Characteristics of the study population
A total of 255 hospital employees took part in the study, but of these, 231 (90.6%) had analyzable data. Data on HTN was incomplete in the remaining 19 (9.4%) subjects and they were therefore not included in the analysis.
The mean age of the respondent was 37.2 ± 8.9 years with a range of 18-65 years. Out of the 231 participants, 126 (54.6%) were within the age group 30-45 years, 64 (27.7%) participants were below 30 years of age while 41 (17.7%) were above 45 years old. There were 84 (36.4%) males and 147 (63.6%) females. Nurses (38.1%) and hospital administrative staff (32.9%) constituted the highest proportion of participants. One hundred and sixty seven (72.3%) had tertiary level of education. One hundred and forty seven (63.6%) respondents were currently married.
A total of 55 (23.8%) participants had generalized obesity while central obesity as defined by abnormal WC and WHR was found in 32 (13.9%) and 86 (37.2%) respectively. Glycosuria occurred in 3 (1.5%) of the 197 participants who did an urinalysis while out of the 184 participants that had blood glucose check, 5 (2.7%) had impaired random blood glucose. 34 participants did not agree to have urine and blood collected for analysis. The socio-demographic data and clinical characteristics of participants are shown in [Table 1] and [Table 2], respectively.
Prevalence of HTN and risk factors
Out of 231 participants, 49 met the criteria for diagnosis of HTN, giving a crude prevalence rate of 21.3%. The age-adjusted prevalence rate of HTN with reference to WHO standard population was 23.8%. Out of the 49 persons who met criteria for diagnosis of HTN, 17 (34.7%) were previously diagnosed hypertensives already on medications while 32 (65.3%) were not aware they had HTN. 28 (12.1%) of all participants had stage 1 HTN while 8 (3.5%) had stage 2 HTN. Pre-HTN was found in 82 (35.1%) of all participants while 110 (47.6%) had normal blood pressure.
Among the 17 previously diagnosed hypertensives on medications, blood pressure was uncontrolled in 4 (23.5%) while it was controlled in the remainder, 13 (76.5%).
Association of HTN with risk factors
The prevalence of HTN among male and female participants was 19.0% and 22.4%, respectively. Even though more females had HTN, the difference was not statistically significant (P = 0.531) [Table 3].
There was a stepwise increase in prevalence of HTN with increasing age. The prevalence rates were 6.2%, 23.0% and 39.0% in participants who were <30 years old, between 30 and 45 years and those >45 years respectively; P < 0.001, P for trend <0.001) as shown in [Table 3].
The prevalence of HTN among participants with normal BMI, overweight and generalized obesity were 12.4%, 22.0% and 34.5%, respectively (P = 0.02). HTN was similarly more prevalent among those with abnormal WC and WHR (P = 0.02 each). This is also shown in [Table 4].
Correlation of blood pressure with variables
Both SBP and DBP were positively correlated with age (r = 0.255 and 0.278, P < 0.001 for SBP and DBP respectively), BMI (r = 0.295 and 0.271; P < 0.001 for SBP and DBP respectively) and WC (r = 0.237 and 0.640, P < 0.001 respectively) while DBP was also significantly correlated with random blood glucose (r = 0.199, P = 0.007).
Regression analysis of variables associated with HTN
In univariate regression models, factors significantly associated with HTN were age, marital status, level of education, BMI, WC and WHR. However, in multivariate analysis, only age and WC were significantly associated with HTN [Table 5] and [Table 6]. Compared to respondents <30 years of age, respondents who were in the age range 30-45 years and >45 years were 4 and 5 times more likely to have HTN respectively; AOR: 4.135 (1.251-13.670) and 5.448 (1.455-22.798) respectively. Also compared to respondents with normal WC, participants with abnormal WC were 3 times more likely to have HTN AOR: 3.223 (1.147-9.058). The multivariate regression model used had a −2 likelihood ratio of 198.407, Cox and Snell R2 = 0.160 and Nagelkerke R2 = 0.249.
| Discussion|| |
Prevalence of HTN
The crude prevalence of HTN among the hospital employees in Bayelsa State was 21.3% while the age-adjusted prevalence rate was 23.8%. Although the prevalence is quite lower than an earlier report of 27.8% among secretariat staff in the same town,  possibly contributed to by the younger age of our participants, this rate is nonetheless disturbing. We expected a better HTN control rate in our study population which comprised of workers in a hospital environment where there is relatively easy access to health information as well as access to prevention methods, early disease diagnosis and treatment of HTN. Mion Jr et al. similarly found a prevalence of 26.0% among hospital employees in Brazil  while Aquino et al. reported a prevalence of 36.0% exclusively among female nursing staff also in a Brazilian hospital.  Even though only 8.6% of hospital employees in Iran had HTN, up to 37% of them were pre-hypertensive.  Similarly, pre-HTN was found in over 35% of our participants. Our study therefore suggests that a vast proportion of hospital employees are either hypertensive or pre-hypertensive similar to reports elsewhere.
We also found that almost two-thirds of the employees discovered to be hypertensive were ignorant about their hypertensive status. The proportion will even be more disturbing if those found with pre-HTN are also considered. Low level of awareness of HTN is thought to be a global phenomenon.  Ulasi et al. have reported low awareness in spite of high prevalence of HTN among traders in Enugu, Nigeria.  This situation may not be much different among elites, literate and high income groups. 
Correlates and determinants of HTN
We report a significant positive association between age and prevalence of HTN. There was a graded increase in prevalence of HTN as age increased. Also in regression analysis, age was among the independent predictors of HTN. Those who were above 45 years old had the highest odd to have associated HTN. This is similar to the report of Goma et al.  This finding may suggest the need for targeting screening of individuals in this category for HTN.
We also found a significant and independent association between WC and HTN in this study. The unadjusted and AOR for participants with abnormal WC to develop HTN was 3.6 and 3.2 times the odd of those with normal WCs respectively. Similarly, Okosun et al. reported a strong association of WC with HTN among a population that consisted of Nigerians, Jamaicans and African-Americans.  Furthermore, Guagnano et al. revealed that WC was the most important anthropometric factor associated with HTN risk among Iranians.  In that report, males with WC >102 cm had odds ratio for HTN 3 times that of males with WC <94 cm while females with WC >88 cm had a risk for HTN twice that of females with WC <80 cm. This is quite similar to our findings.
The association between blood glucose and DBP in the study did not come as a surprise. Abnormalities of glucose metabolism have been reported to contribute significantly to increase SBP and especially DBP in some series.  However, the reason for a lack of association with SBP is not clear.
WHR and BMI were associated with HTN in univariate analysis though they did not make any significant contribution in multivariate analysis in our model. This suggests that unlike WC, these anthropometric indices may not have independent association with HTN. Similarly, Guagnano et al. reported that BMI and WHR had less important effect on blood pressure as compared with WC.  Notwithstanding, patients who were at least overweight were 2.5 times likely to be hypertensive compared with patients who had BMI <25 kg/m 2 . There was a progressive increase in proportion of participants with HTN from normal BMI to obese category similarly to findings of the HYDRA study. 
Apart from age, demographic data having some association with HTN in our report were marital status and level of education. There was a lower prevalence of HTN among those who were unmarried compared with their married counterparts. This is similar to a report by Onwuchekwa et al.  Conversely, there are reports of higher blood pressure readings among unmarried individuals compared with married people.  Although being single may have a relative adverse effect on health, including the likelihood of having high blood pressure,  marital transition from unmarried to married life has also been associated with changes in lifestyle, some of which may negatively impact on blood pressure.  It is possible that loss of spousal support and associated stress which may be experienced by separated and widowed individuals could increase the likelihood of HTN.
Participants with primary level of education had higher proportions of hypertensives compared with those with a minimum of a secondary level of education. This inverse relationship of education to blood pressure has been reported in literature as early as the 1970s.  Among Brazilian nurses, the prevalence of HTN ranged from 54.8% among women with lower educational levels to 22.8% among those with a college education.  While the mere act of sitting in the class room for more years would not produce lower blood pressure per see, it is more likely that education, as a marker of socio-economic status, may be associated with lifestyle habits that help account for differences in blood pressure and lower HTN prevalence rates.
There was no gender difference in prevalence of HTN in this study similar to some previous reports.  There was also no significant difference in prevalence of HTN among the various cadres of hospital employees. This is however different from Mion Jr's report who found that workers in the "others" category had higher prevalence of HTN. This difference between our findings and Mion Jr's report may be due to different classification methods of job positions.
In the study, alcohol consumption, history of cigarette smoking, family history of HTN and family history of diabetes did not show statistically valid higher rates of HTN even though they are commonly considered as risk factors. Our finding is however in tandem with a previous report in a nearby community in Rivers State which also showed lack of significant association between these factors and HTN. It is possible that doses of exposure in these individuals may not have been enough to cause significant association with HTN. For example, alcohol use was simply dichotomized into "yes/no history." No differences were made in terms of actual quantity, type or brand consumed because of the difficulties that may be encountered in a subjective report of this nature. However, the link between alcohol and blood pressure may still be quite controversial. Apart from the well-known positive association with HTN,  there are a few reports indicating that certain subsets of drinkers of small to moderate amounts of alcohol have blood pressures no higher or even lower than non-drinkers.  The negative association (though not significant) between alcohol and HTN observed in this study may therefore not be surprising. It is also important to note that since the information on these social habits was obtained through self-report, it may be difficult to exclude report bias.
Another limitation of the study was inability to perform urine and blood glucose testing in all participants as some individuals objected to blood and urine sampling. Furthermore, the non-probability sampling method which was the method employed in this study is fraught with selection bias. Only employees who were available for the screening exercise took part in the study and therefore may not have been a perfect representation of the entire population. However, in spite of these limitations, the findings remain valid. The calculation of age-adjusted prevalence rate of HTN in reference to a standard population is a major area of strength in this study.
| Conclusion|| |
The study has revealed high prevalence of HTN among hospital employees. Despite relatively easy access to health care, HTN control was poor. Increasing age and central obesity were the determinants of HTN. There is therefore need for special health care programs in the hospital work place especially targeted at the older and obese individuals. It may be foolhardy to think that such programs are unnecessary for health care workers. Emphasis should be placed on creation of increased awareness of HTN, facilitating the adoption of healthy lifestyles and measures to prevent high blood pressure, favoring early diagnosis of the disease as well as ensuring adequate HTN control.
| Acknowledgment|| |
We wish to acknowledge Dr. Dimie Ogoina of the Niger Delta University, Bayelsa State for his critical review of this manuscript.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]