Prevalence and risk factors of hypertension among adults: A community based study in Addis Ababa, Ethiopia.

BACKGROUND: In all areas of the World Health Organization, the prevalence of hypertension was highest in Africa. High blood pressure is a significant risk factor for coronary and ischemic diseases, as well as hemorrhagic stroke. However, there were scarce data concerning the magnitude and risk factors of hypertension. Thus, this study aimed to identify the prevalence and associated factors of hypertension among adults in Addis Ababa city.
METHOD: A community-based cross-sectional study was conducted from June to October 2018 in Addis Ababa city. Participants aged 18 years and older recruited using a multi-stage random sampling technique. Data were collected by face-to-face interview technique. All three WHO STEPS instruments were applied. Additionally, participants' weight, height, waist, hip, and blood pressure (BP) were measured according to standard procedures. Multiple logistic regressions were used and Odds ratios with 95% confidence intervals were also calculated to identify associated factors.
RESULTS: In this study, a total of 3560 participants were included.The median age was 32 years (IQR 25, 45). More than half (57.3%) of the respondents were females. Almost all (96.2%) of participants consumed vegetables and or fruits less than five times per day. Eight hundred and sixty-five (24.3%) of respondents were overweight, while 287 (8.1%) were obese. One thousand forty-one 29.24% (95% CI: 27.75-30.74) were hypertensive, of whom two-thirds (61.95%) did not know that they had hypertension. Factors significantly associated with hypertension were age 30-49 and ≥50 years (AOR = 2.79, 95% CI: 1.39-5.56) and (AOR = 8.23, 95% CI: 4.09-16.55) respectively, being male (AOR = 1.88, 95% CI: 1.18-2.99), consumed vegetables less than or equal to 3 days per week (AOR = 2.44, 95% CI: 1.21-4.93), obesity (AOR = 2.05, 95%CI: 1.13-3.71), abdominal obesity (AOR = 1.70, 95% CI: 1.10-2.64) and high triglyceride level (AOR = 2.06, 95% CI: 1.38-3.07).
CONCLUSION: In Addis Ababa, around one in three adults are hypertensive. With a large proportion, unaware of their condition. We recommend integrating regular community-based screening programs as integral parts of the health promotion and disease prevention strategies. Lifestyle interventions shall target the modifiable risk factors associated with hypertension, such as weight loss and increased vegetable consumption.

Introduction

Between 1980 and 2010, the proportion of the world’s population with high blood pressure (defined as systolic and or diastolic blood pressure ≥ 140/90 mmHg) or uncontrolled hypertension had dropped modestly. However, sharp rises due to population growth and aging have been recorded across the World Health Organization (WHO) regions over the past decade, with the largest rise in Africa at 30%. The lowest prevalence of raised blood pressure was noted in the Americas region, at 18%, while the global estimate among adults aged 18 years and above was around 22% in 2014. According to the WHO estimates,Ethiopia tops at 24.4% for all adults combined [1-3].

High blood pressure accounts for about 13.5% of annual deaths in the world. Moreover, hypertension directly accounts for 54% of all strokes and 47% of all coronary artery disease worldwide. At the same time, the most productive segment of the population is those aged 45 to 69, who make up more than half of this burden [4].

High blood pressure is a major risk factor for coronary and ischaemic diseases as well as bleeding stroke. It has been shown that blood pressure levels are positively associated with the risk of stroke and coronary heart disease [5]. One of the most modifiable risk factors for cardiovascular diseases is hypertension. However, awareness towards the treatment and control of hypertension is extremely low among the low and middle-income counties (LMICs), including Ethiopia.On top of this, the health care resources of the LMICs are overwhelmed by other priorities, including HIV/AIDS, tuberculosis, and malaria. As a result, many LMICs have not yet given due attention to its prevention and control [6].

In Ethiopia, non-communicable diseases such as hypertension and diabetes mellitus have begun to emerge as the leading causes of hospital admissions, morbidity, and mortality in health facilities located around the nation [7]. A 2016 report by the Ethiopian Public Health Institute (EPHI) found that 95% of Ethiopian adult populations have 1 to 2 risk factors for non-communicable diseases [8,9]. But there was little information on the extent and risk factors for hypertension at the community level in Ethiopia, including the Addis Ababa study area.

That little information was done by using the WHO stepwise tool step one and step two only [6,10]. And the study setting was at the facility level, though; there was a single study done at the national level using all the three World Health Organization stepwise tools [8,11]. Besides, the study area, Addis Ababa, is the largest urban center and capital of Ethiopia, providing approximately one-quarter of the urban population in Ethiopia [6]. This study aimed to determine the prevalence and associated factors of hypertension in the adult population of Addis Ababa using the three stepwise tools of the World Health Organization.

Methods

Study design and area

A cross-sectional community study was conducted from 1 June to 31 October 2018 in Addis Ababa City. Addis Ababa city is the capital city of Ethiopia. Administratively, Addis Ababa subdivided into ten sub-cities and 116 woredas [12]. According to the Central Statistical Agency of the Federal Democratic Republic of Ethiopia, the city was projected to inhabit 3,433,999 population by 2017 [13].

Sampling techniques and sample size determination

Multi-stage cluster sampling techniques were employed by first identifying seven of the ten sub-cities based on preset criteria, including the location of the area, population density, and socioeconomic status. Then, one woreda was randomly selected from each selected sub-cities. After that, two ’ketenas’ were randomly picked from the chosen woredas, which are the smallest geographical units within woredas. Finally, for each ketena, the first household was randomly selected, while subsequent households were selected based on proximity to the first and the preceding household.

A total of 3,724 eligible adults aged 18 and over were interviewed at the selected households. The required sample size was determined using the single population proportion formula by considering: prevalence of hypertension 31.5% from a previous study done in Addis Ababa, Ethiopia [6], α = 0.05 (z = 1.96), the margin of error 2%, design effect of 1.5 and 20% possible non-response rate. We also determined the sample size for the risk factors of hypertension by using two population proportion formula. But the maximum sample size was attained during the single population proportion formula. As well, the total sample size for each sub-city was determined using with probability proportional to size (PPS).

Data collection instruments and measurements

We used the adapted WHO STEPwise approach to surveillance tools. These tools have a sequential process and aim to serve as an entry point for low- and middle-income countries to monitor chronic diseases and their risk factors. All the three WHO STEPS instrument was applied to collect data on the selected information, including socio-demographic, behavioral, physical, and biochemical measurements as a part of the core and expanded modules [14]. The tools were first pretested among adults found outside the study area and, then modifications were made based on the findings.

The data were collected via face-to-face interview by trained baccalaureate nurse and laboratory technicians. Weighing scales and non stretch tape were used to measure body weight and height. Weight and height were measured as participants were standing without shoes and wearing lightweight clothing. Height was recorded to the nearest 0.5 cm; weight was recorded to the nearest 100g. Body Mass Index (BMI) was calculated as weight in kilograms divided by height in meters squared (weight (kg)/height (m2) and classified as underweight (<18.5), normal (18.5–24.9), overweight (25–29.9) and obese (≥ 30.0).

Waist circumference was measured at the level of the iliac crest using a non stretch tape measure. Hip circumference measured at the maximum circumference of the hip and; waist-to-hip ratio (WHR) calculated as a ratio of waist and hip circumference.

Physical activity was measured using the Global Physical Activity Questionnaire (GPAQ) section of the STEPS instrument, and the total physical activity is presented in MET (metabolic equivalent) minutes per week. The instrument explores three main areas of day-to-day activities: work (including domestic work), transport, and recreational activities. The level of total physical activity was subsequently classified into high, moderate, or low using the GPAQ analysis guideline provided along with the STEPS instrument [14].

Using a standardized automated blood pressure monitor, blood pressure was measured on the left arm as per the WHO protocol by informing the participants to remain seated and relaxed.Three blood pressure measurements were taken with at least 3-minute intervals between them. The mean value of the 2ndand 3rd measurements was used for analysis [14]. Blood pressure (BP) classified according to the Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) [3].

To ensure the quality of the data collection, data collectors were trained by the principal investigator; and later on, daily checks were carried out by field supervisors and the principal investigator. The weight of the participants, measured on a pre-calibrated electronic scale. Weighing scales checked and zero levels adjusted between measurements; we also placed the scale on a firm flat surface. The blood pressure was measured in a seated position by a digital device (OMRON M2 Eco). The instrument has been clinically approved and recommended by the World Health Organization. In addition, WHO’s STEPwise tools have been previously validated and implemented in mainly developing countries, including Ethiopia [6,8].

Operational definitions

Hypertension: defined as a mean measured blood pressure of ≥ 140 mmHg systolic and/or the mean measured diastolic blood pressure of ≥ 90 mmHg or self-reported history of hypertension.

Body Mass Index (BMI): calculated as weight in kilograms divided by height in meters squared (weight (kg)/height (m2). BMI was categorized as per the World Health Organization guidelines [14], underweight (BMI <18.5), normal (BMI ≥18.5 to ≤ 24.9), overweight (BMI ≥ 25.0 to ≤ 29.9) or obese (BMI ≥ 30.0).

Waist to hip ratio: calculated as waist circumference in cm divided by hip circumference in cm and it was used as a measure of abdominal obesity. Waist to hip ratio ≥ 0.90 m in men and ≥ 0.85m in women is defined as having abdominal obesity [15].

High physical activity: a person reaching any of the following criteria is classified in this category:

Vigorous-intensity activity on at least 3 days achieving a minimum of at least 1,500 MET-minutes/week OR

7 or more days of any combination of walking, moderate- or vigorous intensity activities achieving a minimum of at least 3,000 MET-minutes per week.

Moderate physical activity: a person not meeting the criteria for the "high" category, but meeting any of the following criteria is classified in this category:

3 or more days of vigorous-intensity activity of at least 20 minutes per day

OR

5 or more days of moderate-intensity activity or walking of at least 30 minutes per day OR

5 or more days of any combination of walking, moderate- or vigorous intensity activities achieving a minimum of at least 600 MET-minutes per week.

Low physical activity: a person not meeting any of the above mentioned criteria under moderate or high physical activities falls in this category.

Raised fasting blood glucose was defined as capillary whole blood value ≥110 mg/dl.

Raised total cholesterol was defined as total blood cholesterol level ≥190mg/dl.

Raised triglyceride was defined as raised triglyceride level ≥150 mg/dl.

Data analysis

Double data entry procedures were performed using the EpiData 3.1 statistical software, and analyses were performed using IBM SPSS software version23. Binary logistical regression was used to identify risk factors for hypertension. Initially, possible risk factors were assessed using bivariate analyses; then we did the multivariable logistic regression model to control confounding factors, and statistical significance was accepted when the P-value < 0.05. The Hosmer-Lemeshow goodness-of-fit statistic was used to evaluate whether or not the assumptions necessary for the application of multiple logistic regression are met. Odds ratios (OR) with 95% Confidence Intervals (CI) were computed.

Ethical clearance

Ethical clearance was obtained from the Addis Ababa University, College of Health Sciences Institutional Review Board (IRB), and the city government of Addis Ababa Health Bureau Ethical Review Committee (ERC). A letter of permission was obtained from the selected sub-city health offices. Respondents were fully informed about the purpose of the study and gave verbal and written consent. Participants having high blood pressure, high blood glucose level, and or abnormal lipid profiles during the study period were referred and informed to go to nearby health facilities for further diagnosis and management.

Results and discussion

Description of the study participants

From the total 3724 sampled population, consent was given to the 3560 participants to involve in step one and two questionnaires, making an overall response rate of 95.59%. Using a random sampling technique, 582 (20%) of the study participants who participated in the interview and physical measurements were selected for the step three questionnaires (biochemical assessment).

Respondents were between 18 and 95 years old and, the median age was 32 years old (IQR 25, 45). More than half (57.3%) of the respondents were females. The majority (74.8%) were Orthodox Christians, followed by Muslims (14.9%). Above one-third (37%) of them were self-employed, while nearly a half (49.6%) were currently married (Table 1).

Table 1

Socio-demographic characteristics of the study participants in Addis Ababa, Ethiopia, October 2018.

Characteristics	Frequency	Percent
Sex
Male	1520	42.7
Female	2040	57.3
Religion
Orthodox	2664	74.8
Muslim	530	14.9
Protestant	333	9.4
Catholic	14	0.4
Other	19	0.6
Employment status
Government employee	388	10.9
Non-government employee	257	7.2
Self employed	1316	37.0
Student	301	8.5
House wife	750	21.1
Daily laborer	83	2.3
Merchant	69	1.9
Unemployed(able to work)	173	4.9
Unemployed(unable to work)	47	1.3
Retired (pensioner)	176	5.0
Age
18–29	1508	42.4
30–49	1304	36.6
50 and above (50–95)	748	21.0
Family size
1–4	2178	61.2
≥5	1382	38.8
Marital status
Never married	1331	37.4
Currently married	1767	49.6
Separated	49	1.4
Divorced	139	3.9
Widowed	271	7.6
Non response	3	0.1
Highest education level
Primary	1176	33.0
Secondary	719	20.2
Preparatory	464	13.0
Technique	67	1.9
College and above	539	15.1
Not attended formal education	595	16.7

Behavioral risk factors of the study participants

Tobacco use

Tobacco use was assessed by interviewing respondents about their current smoking status, previous smoking experience, the age they started smoking, and exposure to second-hand smoke. Overall, about 4.2% (150) of survey respondents were current smokers (daily smokers and non-daily smokers) (Table 2). Of these, a majority (88.66%) smoke cigarettes on daily basis, with an average of 10 cigarettes per day. More than three-fourth 136 (90.66%) of current smokers were male compared to female (p < 0.001). The average age at which smokers started smoking was 21 ± 6.58 years. Fifty-five (1.61 percent) have smoked cigarettes in the past. One hundred nineteen (3.4%) were passive smokers or second-hand smokers.

Table 2

Prevalence of hypertension across different characteristics of respondents in Addis Ababa city, October 2018.

Characteristics	Number	Percent	Hypertension (%, CI)
Age
18–29	1508	42.4	12.86 (11.17–14.56)
30–49	1304	36.6	31.29 (28.77–33.81)
≥50	748	21.0	58.69 (55.15–62.23)
Current smoker
Yes	150	4.2	34.67 (26.96–42.37)
No	3410	95.8	29.00 (27.48–30.53)
Current khat use
Yes	330	9.3	31.2 (26.19–36.24)
No	3229	90.7	29.0 (27.45–30.58)
Current alcohol use
Yes	1162	32.6	32.79 (30.09–35.49)
No	2397	67.4	27.53 (25.74–29.32)
Fruit servings consumed in days per week
None	1107	31.1	34.24 (31.44–37.04)
1–3 days	2126	59.7	27.19 (25.29–29.08)
4–7 days	266	7.5	24.81 (19.59–30.04)
Don’t know	61	1.7	29.51 (17.73–41.29)
Vegetable servings consumed in days per week
None	530	14.9	30.19 (26.27–34.11)
1–3 days	2549	71.6	29.23 (27.46–30.99)
4–7 days	448	12.6	28.57 (24.37–32.77)
Don’t know	33	0.9	24.24 (8.81–39.67)
High physical activity
Yes	542	15.2	21.77 (18.29–25.26)
No	3018	84.8	30.58 (28.94–32.23)
Low physical activity
Yes	986	27.7	30.53 (27.65–33.41)
No	2574	72.3	28.75 (27.00–30.50)
Raised blood glucose (≥110 mg/dl)
Yes	51	8.5	58.82 (44.84–72.80)
No	551	91.5	37.57 (33.51–41.62)
Raised cholesterol (≥190 mg/dl)
Yes	255	43.8	49.80 (43.63–55.98)
No	327	56.2	31.50 (26.44–36.56)
Raised triglyceride (≥150 mg/dl)
Yes	241	41.4	54.36 (48.02–60.69)
No	341	58.6	29.03 (24.19–33.87)
Family history of hypertension
Yes	718	20.2	38.30 (34.74–41.87)
No	2714	76.2	26.46 (24.79–28.12)
Don’t know	128	3.6	37.50 (29.00–46.00)

Khat chewing

There were 330 (9.3%) participants who reported chewing khat (Table 2). Over a third of the respondents, 105 (31.53%) and half, 172 (51.65%) chew khat on a daily and weekly basis, respectively. On the other hand, 153 participants (4.3%) had previously chewed khat.

Alcohol consumption

One thousand one hundred sixty-two (32.6%) participants consumed alcohol and of that 783 (22.0%) consumed alcohol during the last month (Table 2). Binge drinking is defined; as consuming alcohol for men five and above, or women four and above drink on one occasion and, the result showed that 269 (7.6%) of men and 81 (2.3%) of women binge drunker.

Dietary habits of the study participants

Two thousand three hundred ninety-two (67.2%) consumed fruits, at least one time per week, and the mean fruit consumption per week was 2.12 (±1.48) days, as well, the majority 2268 (94.77%) ate fruit 1–2 serving per day with a mean of 1.36 (±0.58) times per day. Similarly, more than three forth 2997 (84.2%) of the participants ate vegetables at least one time per week with a mean of 2.46 (± 1.46) per week, and most of them 2827 (94.33%) ate it 1–2 times per day with mean serving time per day was 1.55 (±0.61). Nearly three fourth 2511 (70.6%) of respondents reported that they usually use vegetable oils like Nug (Guizotia Abyssinica), Sesame, and Sunflower oil for meal preparation, while nearly one-fourth 839 (23.6%) use a vegetable oil which was solid at room temperature. Nearly all 3423 participants (96.2%) consumed vegetables and fruits less than five times a day.

Physical activity

The total median physical activity of the respondents was 7440 (IQR 2888, 12240) and, the median total physical activity (TPA, in MET-minutes per week) was estimated to be 7800 (IQR 3000, 14280) in males and 7200 (2880, 11320) in females. Approximately 29.5% of males and 4.6% of females were; categorized as having a high (vigorous) level of TPA. However, significantly more women (36.4%) than men (16.0%) classified as having low levels of TPA (P < 0.001). In addition, most of the study participants, 3198 (89.8%), walked or cycled for a minimum of 10 minutes per day.

Physiological characteristics of the study participants

Body mass index and waist to hip ratio

Weight and height measured in all participants at 3560; the average BMI for respondents was 23.54 (±4.39 kg/m2). Eight hundred and sixty-five (24.3%) were overweight, while 287 (8.1%) were obese. Moreover, the average hip-waist ratio was 0.88 (±0.086 m2)) with 0.89 (± 0.086 m2) and 0.87 (±0.085 m2) for men and women, respectively. Over two-thirds of females (67.06%) and 32.9% of males had abdominal obesity.

Biochemical measurements of the respondents

Of the total number of participants, the blood sample was collected from 582 participants (20 percent). The average FBS was 86.7 (±36.2 mg/dl), and the prevalence of high blood sugar, high cholesterol, and triglycerides was 8.5%, 43.8%, and 41.4%, respectively (Table 2).

Prevalence of hypertension

Three consecutive blood pressure measurements took from 3,560 respondents (95.16%) and; an average of the second and third measurements used for blood pressure analysis. The mean systolic and diastolic blood pressure of the respondents was 125.03 (95% CI: 124.39–125.62) mm Hg and 79.58 (95% CI: 79.8–79.97) mm Hg, respectively. The mean SBP was 126.95 (95% CI: 126.03–127.87) mmHg among males and 123.59 (95% CI: 122.72–124.47) mmHg among females. Likewise, the mean DBP was 80.76 (95% CI: 80.14–81.38) mm Hg in males and 78.69 (95% CI: 78.17–79.21) mm Hg in females. Both mean SBP (P < 0.001) and DBP (P < 0.001) were significantly higher in men compared to women.

The overall prevalence of hypertension was 29.24% (95% CI: 27.75–30.74), slightly higher among men 30.13 (95% CI: 27.82–32.44) than women 28.58 (95% CI: 26.66–30.54). Of the 1041 hypertensive respondents, 645 (61.95%) had just been diagnosed in the survey (new screening).

Factors associated with hypertension

Multivariable logistic regression analysis found that of several non-modifiable factors, age and gender were associated with hypertension. The odds of hypertension increased with increased age. The odds of hypertension increased almost three times AOR = 2.79 (95% CI: 1.39–5.56) among respondents aged 30–49 years, and it was eight times AOR = 8.23 (95% CI: 4.09–16.55) higher among respondents aged 50 years and above as compared to those 18–22 years old. The odds of hypertension were almost twice as high AOR = 1.88 (95% CI: 1.18–2.99) in men compared with women.

From modifiable and other factors, eating fewer vegetables per week, body mass index, abdominal obesity, and high triglycerides levels were associated with hypertension. The odds of hypertension increased more than two times AOR = 2.44 (95% CI: 1.21–4.93) among respondents who consumed vegetable less than or equal to three days per week compared to those who ate more than three days per week.

The chance of hypertension reduced by 73% among underweight participants AOR = 0.27 (95% CI: 0.07–0.97), but the odds were two times higher AOR = 2.05 (95%CI: 1.13–3.71) among obese participants as compared to those having normal BMI. Moreover, the odds of hypertension was almost two times higher AOR = 1.70 (95% CI: 1.10–2.64) among participants with abdominal obesity as compared to their counterparts.

The odds of hypertension was also increased by two AOR = 2.06 (95% CI: 1.38–3.07) among participants who had high triglyceride level as compared to their counterparts.

The odds of hypertension was also increased by two AOR = 2.06 (95% CI: 1.38–3.07) in participants with high triglyceride level compared to their counterparts. In this particular study, risky behaviors, including alcohol use, vigorous physical activity, family history of hypertension or diabetes, high blood sugar, and high cholesterol level not significantly associated with hypertension (Table 3).

Table 3

Bivariate and multivariable logistic regression analysis of factors associated with hypertension among study participants in Addis Ababa city, October 2018.

Variable	Hypertension		Crude OR (95% CI)	Adjusted OR (95% CI)	P-value
	Yes	No
Age
18–29	194	1314	1.00	1.00
30–49	408	896	3.08 (2.55–3.73)	2.79 (1.39–5.56)*	0.003
≥50	439	309	9.62(7.80–11.87)	8.23 (4.09–16.55)**	< 0.001
Sex
Female	538	1457	1.00	1.00
Male	458	1062	1.08 (0.93–1.25)	1.88 (1.18–2.99)*	0.004
Education
Primary	334	842	1.00	1.00
2ry & preparatory	304	879	0.87 (0.73–1.05)	1.03 (0.58–1.80)	0.66
Technique & college	142	464	0.77 (0.62–0.97)	0.97 (0.49–1.89)	0.94
Unable to read & write	261	334	1.97 (1.60–2.42)	1.10 (0.64–1.88)	0.65
Alcohol
No	660	1737	1.00	1.00
Yes	381	781	1.28 (1.10–1.49)	1.35 (0.87–2.09)	0.34
High physical activity
No	923	2095	1.00	1.00
Yes	118	424	0.62 (0.51–0.79)	1.05 (0.51–2.15)	0.88
Family history of diabetes
Yes	848	2142	1.00	1.00
No	169	300	0.70 (0.57–0.86)	1.02 (0.59–1.78)	0.93
Family history of hypertension
Yes	718	1996	1.00	1.00
No	275	443	0.58 (0.48–0.69)	0.73 (0.45–1.19)	0.34
Body Mass Index
18.5–24.9	504	1539	1.00	1.00
<18.5	48	319	0.46 (0.33–0.63)	0.27 (0.07–0.97)*	0.036
25–29.9	341	519	2.01 (1.69–2.34)	1.48 (0.95–2.32)	0.072
≥ 30	145	139	3.19 (2.47–4.10)	2.05 (1.13–3.71)*	0.011
Abdominal obesity ≥ 0.90 m (Men) & ≥ 0.85 m (Women)
No	350	1308	1.00	1.00
Yes	691	1211	2.13 (1.84–2.48)	1.70 (1.10–2.64)*	0.026
Raised blood glucose
No (< 110 mg/dL)	207	344	1.00	1.00
Yes (≥ 110 mg/dL)	30	21	2.37 (1.32–4.27)	0.943 (0.35–2.54)	0.74
Raised cholesterol
No (<190 mg/dL)	103	224	1.00	1.00
Yes (≥ 190 mg/dL)	127	128	2.158 (1.54–3.03)	0.92 (0.46–1.86)	0.48
Raised triglyceride
No (<150 mg/dL)	99	242	1.00	1.00
Yes (≥ 150 mg/dL)	131	110	2.91 (2.06–4.11)	2.06 (1.38–3.07)**	< 0.001
Vegetable servings consumed in days per week
>3 days	128	320	1.00	1.00
≤ 3 days	905	2174	1.04 (0.84–1.29)	2.44 (1.21–4.93)*	0.009

P-value < 0.05 * and <0.000**, (backward logistic regression method was employed).

Discussion

The study found that approximately one in three adults aged 18 and over is hypertensive. During childhood, there are modest facts about a gender change in blood pressure. However, beginning with youth, males tend to have a higher average level. But later in life, the difference gets smaller, and the pattern can even be changed [16]. The prevalence of hypertension in the current study is slightly higher among men than women, which is comparable; a community-based study conducted in Addis Ababa, Ethiopia, reported prevalence of hypertension was 31.5% and 28.9% among males and females, respectively [6]. Moreover, this study is also comparable with other community-based studies conducted in Jalalabad, Afghanistan (28.4), Kenya (29.4%), Uganda (30.5%), and Gondar city (28.3%) [10,17-19].

The prevalence of hypertension in this study is considerably higher as compared to other studies Bangladesh (16.0%), Eritrea (16.4%), Addis Ababa (25%), Bahir Dar (25.1%), Durame Southern Ethiopia (22.4%), Gilgel Gibe South West Ethiopia (5.8%) and Mekelle (20.1%) [11,20-25]. The difference may be explained by the age differences of the surveyed populations (18 years and above in our case, whereas in the other studies, the age of the participants varies between 15 and 64 years). Differences may also be attributed to the diversity of sociodemographic characteristics, sample size, lifestyle, and dietary patterns of the study participants.

On the contrary, the prevalence of hypertension in our study is lower than other similar community-based studies conducted in South Africa (38.9%), Sudan (35.7%), Nigeria (33.1%) and Cameroon (47.5%) [26-29]. This disparity can be due to variations in race, genetics, and prevalence of obesity (higher among others), all of which are likely to influence blood pressure.

From non-modifiable risk factors, age is one of the risk factors of hypertension proved by many studies; there is a positive association between age and hypertension when age increases, the odds of hypertension also increases [6,10,11,17,18,21,24,26]. It is primarily due to the increase in systolic blood pressure with age, mainly due to the reduction in elasticity (increased stiffness) of large duct arteries [30]. Inthe same vein, this study, this study found out that respondents aged 30–49 years had 3 times higher odds of hypertension, and 8 fold higher odds among participants aged 50 and above. In terms of gender, the prevalence of hypertension was almost two times higher in males compared to females in the current study, which is consistent with other study findings [11,22,25,28].

According to the World Health Organization, overweight and obesity are a major risk factor for heart disease, including high blood pressure, which is the number one cause of death [31]. In our study, the odds of hypertension were two times higher among obese participants compared to those with normal body mass index; however, the chances of hypertension were reduced by 73% among underweight participants. This finding (especially the obese category) was in line with previous reports from Ethiopia, Kenya, Uganda, Sudan, Bangladesh, and Cameroon [10,18,21,22,24,25,27,28,32], and this showed that obesity is one of the risk factor associated with hypertension almost all studies. Moreover, the odds of hypertension were two times higher among abdominally obese respondents compared to their counterparts, the result is also consistent with other studies [27,28,33,34].

Hypertriglyceridemia is a powerful predictor of cardiovascular disease, which causes endothelial damage, and loss of physiological vasomotor activity that results from endothelial damage can occur in the form of high blood pressure [35]. In our study, having a high triglyceride level was independently associated with hypertension. The odds of hypertension increased by two among participants with high triglyceride levels relative to their counterparts; our findings are consistent with those of others [33,36].

Previous studies done so far suggested that use of alcohol, cigarette smoking, Khat use, literacy level, physical activity, raised fasting glucose level, family history of hypertension, family history of diabetes, and excessive salt use were significantly associated with hypertension. In contradiction, in this study, the above variables were not significantly associated with hypertension [4,17,18,24,25,27,37]. A contradicting finding was noted in this current study where all the above variables showed no significant association with hypertension.The inconsistency in these results may be due to the variation of sample size, study settings, and population characteristics. These variations may also be explained by the research design issues (as a cross-sectional design can’t distinguish the sequences of explanatory variables and the outcome). The other element of this study included adults 18 years of age or older, but different studies used a different age class, which should make comparisons difficult. Additionally, the respondents might not know whether they had a family history of hypertension or not due to the silent killer and asymptomatic nature of the diseases this may underestimate the risk factors of the disease. Though, we use the standardized WHO STEPs risk factor questionnaire allows for comparability on the presence of risk factors between various communities, regions, and countries.

Conclusion

There was a high prevalence of hypertension among adults in the city of Addis Ababa, which may indicate a hidden epidemic in the population. Even though the study was conducted in the capital city, there was a large proportion of hypertensive respondents (61.95%) were unaware of having the condition and newly screened for the first time by the current study. Increasing age, gender being male, obesity and abdominal obesity, consumption of low vegetables, and raised triglyceride levels were significantly associated with hypertension.

As a result, lifestyle changes and the introduction of obesity and hypertension screening programs are recommended. These programs should focus on lifestyle changes, including eating fruits and vegetables, maintaining a normal weight, and weight loss intervention. The findings also underscore the vital need for community-based screening programs for the early detection of hypertension and obesity.

(SAV)

Click here for additional data file.

English version questionnaires.

(PDF)

Click here for additional data file.

Amharic version questionnaire.

(PDF)

Click here for additional data file.

21 Dec 2020

PONE-D-20-26679

Prevalence and risk factors of hypertension among adults: a Community Based Study in Addis Ababa, Ethiopia

PLOS ONE

Dear Dr. MESERET MOLLA ASEMU,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

As you will recognize from the comments of the reviewers both raised major points of critique, especially regarding design of the study and presentation of data.

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We look forward to receiving your revised manuscript.

Kind regards,

Rudolf Kirchmair

Academic Editor

PLOS ONE

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7. Thank you for submitting the above manuscript to PLOS ONE. During our internal evaluation of the manuscript, we found significant text overlap between your submission and the following previously published works, some of which you are an author.

https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/1471-2261-12-113

https://ejcm.journals.ekb.eg/article_11046_f56232e3d004cc38fe78b7b616f2799e.pdf

https://www.scribd.com/doc/115910728/Ncd-Report-Full-en-English

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736927/

https://link.springer.com/article/10.1186/s12889-015-2610-8?code=241bf12b-10c4-493b-805c-c06d7a2cbf80

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We will carefully review your manuscript upon resubmission, so please ensure that your revision is thorough.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Line 71- Which are the "Non Communicable Diseases risk factors?

Line 164- Why p-value of < 0.20 was used as criteria to include it in the multivariable logistic

regression model?

Quite a small group of the study population were smokers in this study- can you explain why?

It is recommended that the diagnosis of hypertension should be based on:

repeated office BP measurements on more than one visit in the ESC-guidelines from 2018-

in this study the definition hypertension was defined on just one visit. Is the definition of hypertension chooses too weakly in this study?

Reviewer #2: Manuscript ID number:

PONE-D-20-26679

Title of paper:

Prevalence and risk factors of hypertension among adults: a Community Based Study in Addis Ababa, Ethiopia

Evaluation

Despite careful approach to investigate Prevalence and risk factors of hypertension, manuscript needs minor revisions to make it easy to understand before being published.

General comments:

1. Language editing strongly recommended

2. The body of the text suffers from several spelling and grammatical errors. Please consider a professional language edit. Example: scare (page 3 first paragraph),

3. Standardized your tables by removing the boarders and include P values in table 3

Page 2

4. In the abstract result section, almost all (96.2%) of participants consume vegetables and or fruits less than five times per day.

Is that feasible consuming vegetable & fruits five times per day in Ethiopian context? Or you mean five times per week? Make it clear

Page 3 & 4

5. Moreover, in Ethiopia non-communicable diseases such as hypertension and diabetes mellitus appear on the list of leading causes of morbidity and mortality in the hospitals and regional health bureaus across the country. A report by Ethiopian Public Health Institute (EPHI) in 2016 showed that 95% of the Ethiopian adult populations have 1-2 Non-Communicable Diseases risk factors (6, 7). But, there were scare data with regard to the magnitude and risk factors of common non communicable disease at the community level in Ethiopia including the study area Addis Ababa. Moreover, the study area represents the largest urban center in Ethiopia, hosting about 25% of the urban population in the country (5).

Since you are not intended to study all types of non-communicable diseases better to focus on hypertension). Paragraph 4, page 3 needs both language & grammatical edition.

Page 5

6. The method section, selection of the study participant,

the last paragraph a total of 3724 all needs to reconsider again

page 4

7. A community based cross-sectional study was conducted from June to October 2018 in Addis.

Please provide more precise date of study begin and termination

Page 5

8. Multi-stage cluster sampling techniques was employed. Seven of the ten sub-cities were selected purposefully by considering the area that was found, the population density and the economic activities.

You didn’t say anything about how you determine the sample size. How you calculate your sample size, what assumptions you used to calculate your sample size both for the magnitude & factors. Also, important you should show us how you allocate the number of participants to Sub-cities or Woreda Or Kebeles, Ketenas & households?

Page 5

9. One of the methods of maintaining the quality of data is keeping the data collection instrument valid & reliable (in you case weight scale & BP apparatus, the STEPS Questionnaire). In this regard you didn’t say anything.

How you maintain the reliability & validity of this instruments? We need more clarification on this issue

Page 9

10. In the description of the study participants, result section, you calculate both the mean with SD and Median with IQR for the respondents’ age.

What was the reason and which one was appropriate for your data? Need clarification

Page 11

11. In Tobacco use section to told us about 4.2% (150), of the survey participants were current smokers (daily and non-daily smokers) again in the last two sentence of the same section you presented, fifty-five (1.61%) were ever smoked cigarettes and One hundred nineteen (3.4%) were passive smoking or second-hand smoke.

What does this imply? Are these 55 peoples being among 150 who currently smoke? Needs to be clarified.

Page 13

12. Weight and height measurement were taken from all participants 3560 and the BMI was calculated for those participants. But you didn’t show how you calculate the BMI (only you defined BMI in the operational definition).

It is important to show how was the BMI calculated in the methods section. The procedure you used needs to be clearly kept in the method section

Page 13

13. You told us that blood sample was collected from 20% of the total study participants.

It is not sufficient to write 20% of total you need to write the actual number of participants you collect blood sample.

Page 13

14. In the result section, prevalence of hypertensin, you presented the overall prevalence of hypertension was 29.24% (95% CI: 27.75-30.74), slightly higher among men 30.13 (95% CI: 27.82-32.44), than women 28.58 (95% CI: 26.66-30.54) even though the difference was not statistically significant (χ2=1.015, P= 0.314).

But in the factors associated with you stated that sex had significant association with hypertension (The odds of hypertension was almost two times higher AOR= 1.88 (95% CI: 1.18-2.99) among males as compared to females). Needs clarification and reconsideration.

Page 19 discussion section

15. Hypertension is an important modifiable risk factor for cardiovascular disease (CVD). It currently accounts for about 13.5% of annual global deaths. Hypertension is directly responsible for 54% of all strokes and 47% of all coronary heart disease worldwide. Moreover, over half of this burden occurs in individuals aged 45–69 years, which is the most productive segment of the population (31).

Better to start your discussion by summary of your results and good if you use this in the introduction section

Page 19

16. …………. So, the prevalence of hypertension in the current study is slightly higher among men than women which is comparable with a community based study conducted in Addis Ababa, Ethiopia which reported the prevalence of hypertension was 31.5% and 28.9% among males and females, respectively (5). Moreover, this study is also comparable with other community-based studies conducted in Jalalabad, Afghanistan (28.4), Kenya (29.4%), Uganda 375 (30.5%), and Gondar city (28.3%) (12-15).

Here first you talk about the association between hypertension and gender or sex and on the next paragraph back to compare the prevalence with other studies. I see some confusion here I think you would want to change the order of the paragraph?

Page 20

17. ……… which the risk of hypertension increases with age. This is mainly due to systolic blood pressure increase with age, mainly because of reduced elasticity (increased stiffness) of the large conduit arteries (26). In this study respondents aged 30-49 years; had 3 times higher risk of hypertension and even moreover, it is 8 times higher risk among participants aged 50 years and above.

What is your message here for the patients and health care providers you provide? Is there anything that recommend to tackle this problem or age? You should better to emphasize on modifiable factors than non-modifiable like age & sex. Need your consideration

Page 20,

18. This finding (especially obese category) was in line with previous reports from Ethiopia, Kenya, Uganda, Sudan, Bangladesh, and Cameroon (13, 15, 17, 18, 21, 22, 24, 25, 27). Moreover, the risk of hypertension was 2 times higher among abdominally obese respondents and this finding is in line with other studies (24, 25, 28, 29) and the same to the level of triglyceride also.

Since this is the most important area that your recommendation is focused, comparing the findings is not sufficient. Better to find the reason of similarity or differences and give your recommendation or message based on that. Therefore, you need to work on it and put your recommendation.

Page 21, first paragraph

19. In contradiction, in this study the above variables were not significantly associated with hypertension. The inconsistency of these findings may be due to the low prevalence of these factors in the community especially among females.

What does it mean? I don’t think your reason for differences is correct. May you need to find tangible reason for this difference.

Page 21

20. Additionally, the respondents might not know whether they had a family history of hypertension or diabetes due to the silent killer nature of the diseases this may underestimate the prevalence of the diseases.

How the silent killer nature of the disease affects the prevalence of hypertension since the prevalence was determined by measuring their blood pressure? Or you want to say the severity of the disease? Not clear

Do you think diabetes is a silent killer? Since your objectives did not include diabetes why you include here?

Page 21

21. The other reason should since some of the information was based on self-report and is subjected to social desirability and recall biases.

These issues are very critical in research. How you manage this social desirability and recall biases since this can affect severely your findings? You have to show us either in the discussion or method section how you control theses biases clearly? In addition, with all these short comings or limitations do think your research could be eligible for publication? Better to avoid those limitations that can be controlled methodologically

Page 21

22. In the conclusion section …. There was a high prevalence of hypertension among adults in the Addis Ababa city and this may show a hidden epidemic in the population. What is your reference to say high prevalence or to conclude this is a hidden epidemic? You have to show here

**********

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Manuscript ID number.docx

Click here for additional data file.

6 Feb 2021

A rebuttal letter

Manuscript PONE-D-20-26679

Response to Reviewers

Dear Rudolf Kirchmair,

Thank you for the opportunity to provide a revised version of the manuscript. “Prevalence and risk factors of hypertension among adults: a Community Based Study in Addis Ababa, Ethiopia” for publication in PLOS ONE Journal. We appreciate the time and effort you and the examiners put into providing comments on our manuscript. We have incorporated the suggestions and comments made by the reviewers. These changes are highlighted in the manuscript. A point-by-point response to the reviewers’ comments and concerns is provided below in blue.

PONE-D-20-26679

Prevalence and risk factors of hypertension among adults: a Community Based Study in Addis Ababa, Ethiopia

PLOS ONE

Dear Dr. MESERET MOLLA ASEMU,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

As you will recognize from the comments of the reviewers both raised major points of critique, especially regarding design of the study and presentation of data.

Please submit your revised manuscript within 2 months. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Rudolf Kirchmair

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

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https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Authors’ response: Dear academic editor, thank you for providing the link. We carefully read and edited our manuscript as per the guidelines.

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services. If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following:

• The name of the colleague or the details of the professional service that edited your manuscript

• A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

• A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

Authors’ response: Thank you for your feedback and suggestion. We accepted the comments on language usage, spelling, and grammar, based on the comments we edited our manuscript as much as possible by using online grammar and language checkers (Grammarly) and with my friend speaks fluent English at our university. We have prepared and attached our manuscript highlighting the changes and uploaded it as a *supporting information* file. We have also prepared and attached the edited manuscript and uploaded it as the new *manuscript* file.

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Authors’ response: Thank you for your comment. We have attached the questionnaires we used for the current survey in both the original (Amharic) and English language as Supporting Information.

4. In the Methods, please discuss whether and how the questionnaire was validated and/or pre-tested. If this did not occur, please provide the rationale for not doing so.

Authors’ response: Thank you for your feedback. This was incorporated into the method portion of our manuscript. The questionnaire was also adapted from the World Health Organization and validated in various previous studies in Ethiopia. However, pretesting took place.

5. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Authors’ response: Thank you for your comment. The current study is part of a large study with multiple objectives to assess Epidemiology of common non communicable diseases, among adults in Addis Ababa, Ethiopia. Further publication is expected from the dataset which prevents us from making it publicly right now. So, we made changes in our cover letter and we have included in the updated Data Availability statement part.

6. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Authors’ response: Thank you for your comment. We ensured that we have an ORCID iD.

7. Thank you for submitting the above manuscript to PLOS ONE. During our internal evaluation of the manuscript, we found significant text overlap between your submission and the following previously published works, some of which you are an author.

https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/1471-2261-12-113

https://ejcm.journals.ekb.eg/article_11046_f56232e3d004cc38fe78b7b616f2799e.pdf

https://www.scribd.com/doc/115910728/Ncd-Report-Full-en-English

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736927/

https://link.springer.com/article/10.1186/s12889-015-2610-8?code=241bf12b-10c4-493b-805c-c06d7a2cbf80

We would like to make you aware that copying extracts from previous publications, especially outside the methods section, word-for-word is unacceptable. In addition, the reproduction of text from published reports has implications for the copyright that may apply to the publications.

Please revise the manuscript to rephrase the duplicated text, cite your sources, and provide details as to how the current manuscript advances on previous work. Please note that further consideration is dependent on the submission of a manuscript that addresses these concerns about the overlap in text with published work.

We will carefully review your manuscript upon resubmission, so please ensure that your revision is thorough.

Authors’ response: Thank you for your comment. We have redrafted the entire duplicate text into the manuscript based on your recommendation.

[Note: HTML mark up is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

________________________________________

Authors’ response: Thank you for your comment. The manuscript is revised accordingly to improve its scientific writing. The conclusions are revised as well to reflect the data presented.

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

________________________________________

Authors’ response: Thank you for your comment. We accepted your comment, and we have incorporated it into the result part of our manuscript. We have included the p value in table 3, as suggested by the reviewer. Moreover, we also incorporated other comments from the reviewers.

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

Authors’ response: Thank you for your comments. The current study is part of a large study with multiple objectives to assess Epidemiology of common non communicable diseases, among adults in Addis Ababa, Ethiopia. Although additional publications are planned based on the dataset, we have included the raw data in SPSS format in the data availability section.

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

Authors’ response: Thank you for your comments. The manuscript has been reassessed and all grammatical mistakes have been corrected.

5. Review Comments to the Author

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Reviewer #1: Line 71- Which are the "Non Communicable Diseases risk factors?

Authors’ response: Thank you for your question. The 1-2 non communicable risk factors were over-weight (BMI ≥ 25 kg/m2), consumption of fruit and vegetables less than 5 servings per day and raised BP (SBP≥140 and/or DBP ≥ 90 mmHg or currently on medication for raise blood pressure and insufficient physical activities.

Line 164- Why p-value of < 0.20 was used as criteria to include it in the multivariable logistic

regression model?

Authors’ response: Thank you for your question. We read different articles and as a rule of thumb, they selected all the variables whose p-value < 0.2 on binary logistic regression for multivariable logistic regression. But we could not obtain from the standard biostatistics books, so corrected by entering all the variables we used in binary logistics analysis into multivariable logistic regression.

Quite a small group of the study population were smokers in this study- can you explain why?

Authors’ response: Thank you for your question. As we have seen from different studies conducted in Ethiopia, including the study area, Addis Ababa, the prevalence of smoking was low; the possible reason may be the number of smokers in the study setting was low.

It is recommended that the diagnosis of hypertension should be based on:

repeated office BP measurements on more than one visit in the ESC-guidelines from 2018-

in this study the definition hypertension was defined on just one visit. Is the definition of hypertension chooses too weakly in this study?

Authors’ response: Thank you for your comment. We have measured the blood pressure of study participants three times, and we took the mean of the second and the third records because mostly the first record became high. The World Health Organization; and the American Health Association recommends one visit three times measurements to define hypertension during a community survey. The definition is not weak because we measured three times; moreover, we measured their blood pressure in their home; this also minimizes the white coat false records of high blood pressure. Also, the literature that we used in the discussion part used this method.

Reviewer #2: Manuscript ID number:

PONE-D-20-26679

Title of paper:

Prevalence and risk factors of hypertension among adults: a Community Based Study in Addis Ababa, Ethiopia

Evaluation

Despite careful approach to investigate Prevalence and risk factors of hypertension, manuscript needs minor revisions to make it easy to understand before being published.

General comments:

1. Language editing strongly recommended

Authors’ response: Thank you for your feedback and suggestion. We accepted the comments and strongly recommended issues on language editing and based on the comments we thoroughly edited our manuscript as much as possible by using online grammar and language checkers (Grammarly) and with my friend speaks fluent English in our university.

2. The body of the text suffers from several spelling and grammatical errors. Please consider a professional language edit. Example: scare (page 3 first paragraph),

Authors’ response: Thank you for your feedback and suggestion. We accepted the comment and made corrections.

3. Standardized your tables by removing the boarders and include P values in table 3

Page 2

Authors’ response: Thank you for your feedback and suggestion. The comment was accepted and the p-values were added to Table 3.

4. In the abstract result section, almost all (96.2%) of participants consume vegetables and or fruits less than five times per day.

Is that feasible consuming vegetable & fruits five times per day in Ethiopian context? Or you mean five times per week? Make it clear

Page 3 & 4

Authors’ response: Thank you for your clarification question. Healthy eating, including an adequate intake of fruits and vegetables (five servings a day), is one of the key public health measures to prevent NCDs. Eating fruits and vegetables five times daily is recommended by the World Health Organization in developed and developing countries, including Ethiopia. But, in many countries worldwide, the vast majority of the population consumes less than the recommended amount of five servings of fruit and vegetables per day, though low intake of fruits and vegetables was estimated to cause 4.7% of the global disease burden – as estimated in DALYs. And in our study, as we mentioned in the method part we used the WHO STEPS instrument and one of the major core questions was to assess the dietary habit, including the fruits and vegetables of participants whether they are in line with the WHO recommendation or not.

5. Moreover, in Ethiopia non-communicable diseases such as hypertension and diabetes mellitus appear on the list of leading causes of morbidity and mortality in the hospitals and regional health bureaus across the country. A report by Ethiopian Public Health Institute (EPHI) in 2016 showed that 95% of the Ethiopian adult populations have 1-2 Non-Communicable Diseases risk factors (6, 7). But, there were scare data with regard to the magnitude and risk factors of common non communicable disease at the community level in Ethiopia including the study area Addis Ababa. Moreover, the study area represents the largest urban center in Ethiopia, hosting about 25% of the urban population in the country (5).

Since you are not intended to study all types of non-communicable diseases better to focus on hypertension). Paragraph 4, page 3 needs both language & grammatical edition.

Page 5

Authors’ response: Thank you for your comments. We accepted the comment and made corrections.

6. The method section, selection of the study participant,

the last paragraph a total of 3724 all needs to reconsider again

page 4

Authors’ response: Thank you for your comment. We accepted the comment and made corrections.

7. A community based cross-sectional study was conducted from June to October 2018 in Addis.

Please provide more precise date of study begin and termination

Page 5

Authors’ response: Thank you for your comment. We accepted the comment and incorporated and re-wrote the exact start and end date of the study.

8. Multi-stage cluster sampling techniques was employed. Seven of the ten sub-cities were selected purposefully by considering the area that was found, the population density and the economic activities.

You didn’t say anything about how you determine the sample size. How you calculate your sample size, what assumptions you used to calculate your sample size both for the magnitude & factors. Also, important you should show us how you allocate the number of participants to Sub-cities or Woreda Or Kebeles, Ketenas & households?

Page 5

Authors’ response: Thank you for your comment. We accept the comment, and we have incorporated the sample size determination. We also explained how we allocate the number of participants in the selected sub-cities in the method part of our manuscript.

9. One of the methods of maintaining the quality of data is keeping the data collection instrument valid & reliable (in you case weight scale & BP apparatus, the STEPS Questionnaire). In this regard you didn’t say anything.

How you maintain the reliability & validity of this instruments? We need more clarification on this issue

Page 9

Authors’ response: Thank you for your questions. We agree with the question and have responded to it in the method portion of our manuscript.

10. In the description of the study participants, result section, you calculate both the mean with SD and Median with IQR for the respondents’ age.

What was the reason and which one was appropriate for your data? Need clarification

Page 11

Authors’ response: Thank you for your comment. We accepted the comment. Because our variable age was skewed, we chose the median as a measure of central tendency rather than as a mean. We have corrected in the result part of our manuscript.

11. In Tobacco use section to told us about 4.2% (150), of the survey participants were current smokers (daily and non-daily smokers) again in the last two sentence of the same section you presented, fifty-five (1.61%) were ever smoked cigarettes and One hundred nineteen (3.4%) were passive smoking or second-hand smoke.

What does this imply? Are these 55 peoples being among 150 who currently smoke? Needs to be clarified.

Page 13

Authors’ response: Thank you for your clarification question. From the total participants, 150 (4.2%) of them was currently a smoker. But if they were not current smokers, we asked them whether they smoke cigarettes or not by saying, “In the past, did you ever smoke any tobacco products?” If they said yes to the above question, we considered them as previous smokers or Ex-smoker. So, from the total current non-smokers, we got 55 participants, classified under the previous smoker; this number is not included in the 150 current smokers.

12. Weight and height measurement were taken from all participants 3560 and the BMI was calculated for those participants. But you didn’t show how you calculate the BMI (only you defined BMI in the operational definition).

It is important to show how was the BMI calculated in the methods section. The procedure you used needs to be clearly kept in the method section

Page 13

Authors’ response: Thank you for your comment. We accepted your comment, and we have incorporated it into the method part of our manuscript.

13. You told us that blood sample was collected from 20% of the total study participants.

It is not sufficient to write 20% of total you need to write the actual number of participants you collect blood sample.

Page 13

Authors’ response: Thank you for your comment. We accepted your comment, and we have incorporated it into the result part of our manuscript.

14. In the result section, prevalence of hypertensin, you presented the overall prevalence of hypertension was 29.24% (95% CI: 27.75-30.74), slightly higher among men 30.13 (95% CI: 27.82-32.44), than women 28.58 (95% CI: 26.66-30.54) even though the difference was not statistically significant (χ2=1.015, P= 0.314).

But in the factors associated with you stated that sex had significant association with hypertension (The odds of hypertension was almost two times higher AOR= 1.88 (95% CI: 1.18-2.99) among males as compared to females). Needs clarification and reconsideration.

Page 19 discussion section

Authors’ response: Thank you for your comment. We accepted your comment, and we have corrected it into the result part of our manuscript.

15. Hypertension is an important modifiable risk factor for cardiovascular disease (CVD). It currently accounts for about 13.5% of annual global deaths. Hypertension is directly responsible for 54% of all strokes and 47% of all coronary heart disease worldwide. Moreover, over half of this burden occurs in individuals aged 45–69 years, which is the most productive segment of the population (31).

Better to start your discussion by summary of your results and good if you use this in the introduction section

Page 19

Authors’ response: Thank you for your comment. We accepted your comment, and we have corrected it.

16. …………. So, the prevalence of hypertension in the current study is slightly higher among men than women which is comparable with a community based study conducted in Addis Ababa, Ethiopia which reported the prevalence of hypertension was 31.5% and 28.9% among males and females, respectively (5). Moreover, this study is also comparable with other community-based studies conducted in Jalalabad, Afghanistan (28.4), Kenya (29.4%), Uganda 375 (30.5%), and Gondar city (28.3%) (12-15).

Here first you talk about the association between hypertension and gender or sex and on the next paragraph back to compare the prevalence with other studies. I see some confusion here I think you would want to change the order of the paragraph?

Page 20

Authors’ response: Thank you for your comment. Your feedback is accepted and corrected.

17. ……… which the risk of hypertension increases with age. This is mainly due to systolic blood pressure increase with age, mainly because of reduced elasticity (increased stiffness) of the large conduit arteries (26). In this study respondents aged 30-49 years; had 3 times higher risk of hypertension and even moreover, it is 8 times higher risk among participants aged 50 years and above.

What is your message here for the patients and health care providers you provide? Is there anything that recommend to tackle this problem or age? You should better to emphasize on modifiable factors than non-modifiable like age & sex. Need your consideration

Page 20,

Authors’ response: Thank you for your comment. Our message for the patients was to be screened and get treatment. So, they can prevent complications associated with untreated hypertension. For the health providers, especially the Health Extension Workers (in our country, they went to each community house to deliver contraception, vaccine), we told them to take blood pressure whether they have a symptom or not for those aged peoples. The other thing we give more emphasis on modifiable factors since they can modify them.

18. This finding (especially obese category) was in line with previous reports from Ethiopia, Kenya, Uganda, Sudan, Bangladesh, and Cameroon (13, 15, 17, 18, 21, 22, 24, 25, 27). Moreover, the risk of hypertension was 2 times higher among abdominally obese respondents and this finding is in line with other studies (24, 25, 28, 29) and the same to the level of triglyceride also.

Since this is the most important area that your recommendation is focused, comparing the findings is not sufficient. Better to find the reason of similarity or differences and give your recommendation or message based on that. Therefore, you need to work on it and put your recommendation.

Page 21, first paragraph

Authors’ response: Thank you for your comment. Your feedback is accepted and corrected.

19. In contradiction, in this study the above variables were not significantly associated with hypertension. The inconsistency of these findings may be due to the low prevalence of these factors in the community especially among females.

What does it mean? I don’t think your reason for differences is correct. May you need to find tangible reason for this difference.

Page 21

Authors’ response: Thank you for your comment. Your feedback is accepted and corrected.

20. Additionally, the respondents might not know whether they had a family history of hypertension or diabetes due to the silent killer nature of the diseases this may underestimate the prevalence of the diseases.

How the silent killer nature of the disease affects the prevalence of hypertension since the prevalence was determined by measuring their blood pressure? Or you want to say the severity of the disease? Not clear

Do you think diabetes is a silent killer? Since your objectives did not include diabetes why you include here?

Page 21

Authors’ response: Thank you for your comment. Your feedback is accepted and corrected. Additionally, the respondents might not know whether they had a family history of hypertension due to the silent killer nature of the diseases this may underestimate the risk factors of the diseases. Since family history of hypertension is one of the risk factors of hypertension.

21. The other reason should since some of the information was based on self-report and is subjected to social desirability and recall biases.

These issues are very critical in research. How you manage this social desirability and recall biases since this can affect severely your findings? You have to show us either in the discussion or method section how you control theses biases clearly? In addition, with all these short comings or limitations do think your research could be eligible for publication? Better to avoid those limitations that can be controlled methodologically

Page 21

Authors’ response: Thank you for your comment. Your feedback is accepted and corrected.

We used different mechanisms to avoid biases. To avoid social desirability bias, first, we explained the aim of the survey for each participant and during data collection; we kept it anonymous and confidential. After data collection, the information is kept in a safe and secured place. Moreover, to avoid recall bias we asked timeline timeliness of the information and standard questionnaires prepared by the World Health Organization. So, since we did all the activities that help us to minimize the biases we excluded the sentence included as a limitation

22. In the conclusion section …. There was a high prevalence of hypertension among adults in the Addis Ababa city and this may show a hidden epidemic in the population. What is your reference to say high prevalence or to conclude this is a hidden epidemic? You have to show here

Authors’ response: Thank you for your question. Our finding showed that 30% of study participants had hypertension but a study conducted in one of the urban areas of Ethiopia showed that the prevalence of hypertension was 20%; moreover, a large proportion, 62% of them unaware of having the problem; that is why we would like to say this showed the hidden epidemic of the disease among adults aged 18 year and above. Moreover, hypertension is a chronic disease if it is not diagnosed and treated early may end up with life-threatening complication and death.

________________________________________

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Reviewer #1: No

Reviewer #2: No

Authors’ response:Thank you. We agreed and corrected that comment.

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9 Mar 2021

Prevalence and risk factors of hypertension among adults: a Community Based Study in Addis Ababa, Ethiopia

PONE-D-20-26679R1

Dear Dr. ASEMU,

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Reviewer #2: Yes: Daniel G/Tsadik W/giorgis

11 Mar 2021

PONE-D-20-26679R1

Prevalence and risk factors of hypertension among adults: a Community Based Study in Addis Ababa, Ethiopia

Dear Dr. Asemu:

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