Prevalence of hypertension, and related factors among adults in Wolaita, southern Ethiopia: A community-based cross-sectional study.

INTRODUCTION: Hypertension is a global public health challenge. There is a lack of evidence on the prevalence of hypertension, prehypertension, and related factors among adult populations of Wolaita, southern Ethiopia. AIM: To assess the prevalence of hypertension, prehypertension, and related factors among adult populations of Wolaita, southern Ethiopia.
METHODS: A community-based cross-sectional study was conducted on 2483 adult residents, selected using a two-stage random sampling technique. The quantitative data collected from structured questionnaires; anthropometric and biochemical measurements were entered into EpiData version 3.1 using double-entry systems. We determined the weighted prevalence of hypertension and pre-hypertension for the two-stage survey. The multivariate logistic regression analysis was used to assess factors associated with hypertension and carried out after declaring the data set as survey data to account for the effect of clustering. An adjusted coefficient with 95% CI was used to ascertain the significance of the association.
RESULTS: The weighted prevalence of hypertension and prehypertension in the Wolaita area was 31.3% (27.7%-35.1%) and 46.4% (42.9%-50.0%) respectively. The weighted prevalence of hypertension of those who were not aware of their hypertension until the time of the survey was 29.8%% (26.5%-33.3%). Where the weighted prevalence of self-reported cases of hypertension was 2.2% (1.2%-3.8%). Obesity, sugar-sweetened food consumption, male sex, elevated total cholesterol, raised fasting blood sugar, and advancing age were positively associated with hypertension.
CONCLUSION: The prevalence of hypertension among adults in Wolaita was high. A small proportion of the affected people are aware of their high blood pressure. This study reported a high prevalence of pre-hypertension; which indicates a high percentage of people at risk of hypertension. It is essential to develop periodic screening programs, and primary intervention strategies such as the prevention of obesity, and reduction of sugar-sweetened food consumption.

Introduction

The burden of non-communicable diseases (NCDs) in developing nations is increasing as a result of expanding urbanization, a growing economy, and shifting lifestyles [1, 2]. Hypertension, as a significant contributor to the burden of non-communicable diseases, is a global public health challenge [3, 4]. The global burden of hypertension is projected to be 1.56 billion in 2025; two-thirds of this will be occurring in developing countries [3]. Hypertension disproportionately affects populations in low- and middle-income countries [5].

Hypertension, defined as a systolic blood pressure greater or equal to 140 mmHg and/or diastolic blood pressure greater or equal to 90 mmHg or a self-reported case for medication [6]. Hypertension was believed to be rare in Africa, but it is currently perceived as one of the most important causes of cardiovascular diseases contributing to about 40% of the cases in the continent [5, 7]. According to the World Health Organization (WHO) report on NCDs 2014, hypertension among adults was highest in the African region with a prevalence of 30% [8]. It is a widespread problem with great economic impact because of its effect on productive subpopulations [9].

Studies around the world reported different levels of prevalence of hypertension and factors associated with blood pressure. A study conducted on the prevalence of hypertension among Indian adults reported an overall prevalence of 30% [10]. A study from Ghana showed a 13% prevalence of hypertension [11], and in Kenya, 24% of the population was hypertensive [12]. Factors reported as having associations with hypertension comprise older age, being male, being married, overweight, added sugar intake, alcohol drinking, and fruit consumption [10-14].

Evidence from the national NCDs STEPS survey of Ethiopia showed a 15% overall prevalence of hypertension [15]. Community-based cross-sectional surveys from other areas in Ethiopia reported prevalence rates ranging from 28% to 35% [16, 17]. In some places of southern Ethiopia, the prevalence of hypertension ranged from 22% to 35% [18, 19]. Identified risk factors of hypertension from studies in Ethiopia include older age, male sex, urban residence, higher formal education, physical inactivity, overweight or obesity, total cholesterol, raised fasting glucose, poor vegetable diet, and alcohol drinking [15-19]. In the study area, there is a lack of evidence on the prevalence and factors associated with hypertension (See S1 File). Therefore, this study aimed at determining the prevalence of hypertension, prehypertension, and related factors among adult populations of Wolaita, southern Ethiopia.

Materials and methods

Study design and setting

A community-based cross-sectional study was conducted from May 2018 to February 2019 in Wolaita Sodo town and Ofa rural areas, Wolaita Zone, southern Ethiopia. According to the projection based upon the 2007 population census, the population of Wolaita Zone in 2019 is about 2,042,593 people. Out of which, the proportion of the 25–64 years population is about 30.5%. We surveyed urban Wolaita Sodo and rural Ofa to assess variation in the prevalence of hypertension between urban and rural settings. Wolaita Sodo is the largest town in the zone with an estimated population of 165,596, and Ofa, one of the distant districts in the zone with a population of about 141,339 [20].

Study subjects and sample size determination

The source population consists of people residing in the selected administrative areas of Wolaita Sodo town and Ofa rural district. The study population was permanent residents of randomly selected households aged between 25 to 64 years.

We calculated the sample size using Epi Info 7 StatCalc for two population proportions. Initially, the overall sample size (2486) was calculated to measure differences in dietary intake and nutrition transition among rural and urban populations as a general objective. Since our primary exposure variable is residence; the sample size was calculated based upon the prevalence of hypertension in urban and rural populations. The following assumptions from the study entitled prevalence of high blood pressure, hyperglycemia, dyslipidemia, metabolic syndrome and their determinants in Ethiopia: evidence from the national NCDs STEPS survey, 2015 were considered to calculate the sample size for this study [15]: 14.9% prevalence of hypertension in rural, 19.7% prevalence of hypertension in urban, 95% confidence level, 80% power, one for the ratio of unexposed and exposed groups, 10% non-response rate, and the total sample size became 2233. Therefore, the above sample size used in this study was sufficient to assess the prevalence of hypertension, prehypertension, and related factors among adult populations of Wolaita, southern Ethiopia.

Sampling techniques and procedures

Data were collected in a two-stage cluster survey, with the villages from the urban and rural study sites being selected at the first stage, and a random sample of households within each village selected at the second stage. Initially, eleven out of 54 villages with urban characteristics of Wolaita Sodo town were selected using a simple random sampling technique. Similarly, ten out of 52 villages with rural characteristics of Ofa district were selected using a simple random sampling technique (Fig 1).

Fig 1

Flow chart of the study subjects selection from villages in Wolaita Sodo town and rural Ofa, Wolaita, southern Ethiopia 2018.

The distribution of samples in urban and rural areas was equal. Hence, 1243 people were selected from each study area. The estimated sample size was proportionally allocated to the selected villages based on their population size (Fig 1). The secondary unit of the study was the household and was selected using a simple random sampling technique from the list of enumerated households. To ensure the independence of observation, one eligible adult from each household was selected using simple random sampling. Each household was visited twice during the data collection time, one for the interview and anthropometric measurements, and the other for blood sample collection. After conducting interviews and taking anthropometric measurements during the first visit, the study participants were instructed overnight fasting and were appointed for blood sample collection for the next day.

Data collection procedures and techniques

Data for this study were collected using structured questionnaires, laboratory investigations, and anthropometric measurements. A series of questions about the potential risk factors and related variables were adapted from the World Health Organization (WHO) protocol for chronic non-communicable diseases (WHO STEPS survey) [21]. The English version (See S1 Questionnaire) of the questionnaire was translated into Amharic (See S2 Questionnaire), and Wolaita (See S3 Questionnaire) languages; and these were retranslated into English by an independent professional to ensure the accuracy of the translation.

Six field data collectors, five laboratory technicians, one field supervisor, one field coordinator, and two data clerks were recruited and given one week of training on data collection instruments. The training consisted of the purpose of the study, the contents of the questionnaire, interviewing skills, anthropometric measurements, laboratory procedures and analysis, format completion, and storage of samples.

Self-reported daily fruit and vegetable intakes were assessed using food frequency questions adapted from the WHO STEPwise approach to surveillance [21]. Physical activity was assessed based on the self-reported performance of moderate-intensity and vigorous-intensity activities, walking; time spent in minutes to carry out each activity, and MET (Metabolic equivalents) value of the respective activity. MET-minutes/week for a particular activity was computed by multiplying the number of days per week taken to perform each activity, with the time spent in minutes per day to perform the activity and the respective MET value of the activity [21, 22]. Finally, a combination of MET-minutes per week of walking, moderate-intensity, and vigorous-intensity activities was considered as the total MET-minutes/week [21, 22]. The recall period for the physical activity assessment was one week [21].

BMI was calculated as weight (kg) divided by height squared (m2). Weight was measured to the nearest 0.1 kg using a portable digital weight scale (Seca electronic scale, 22089 Hamburg, Germany). The study subjects were weighted standing with light clothes on the scale with their shoes off. Before every measurement, the scale was tested for zero adjustments. Height was measured using a portable stadiometer (Seca, 22089 Hamburg, Germany), which consisted of a simple triangular headboard. For height measurement, the study subjects took off their shoes, stood straight, and held their head erect. The external auditory and the lower borders of the eyes were kept in one horizontal plane. The buttocks, shoulder blades, and heels touched the scale while legs with their knees stayed together and arms hanged by their sides. Height was measured to the nearest 0.1 cm. People with conditions not suitable for anthropometric measurements such as pregnant women and two people who were not suitable for height measurement such as participants who were unable to stand on the stadiometer were excluded from the study.

WHO STEPS data collection instrument was adapted for measurements of blood pressure (BP), and biochemical markers such as total cholesterol, fasting blood sugar level, and triglyceride values [21]. Whole venous blood samples were collected from participants in the morning after overnight fasting; and the application of 70% alcohol. Then the samples were stored in 3 ml vacutainer tubes holding ethylenediaminetetraacetic acid (EDTA). The test tubes with the samples were placed in the icebox and transported to Wolaita Sodo University (WSU) Hospital Laboratory for analysis of lipid profiles. Serum total cholesterol, HDL (High-Density Lipoprotein cholesterol), and triglycerides were determined using BS-200 Chemistry Analyzer with specific reagents for each biochemical value as per the manufacturer’s instructions. The laboratory technicians performed the laboratory work within 12 hours of the blood sample collection at the WSU Hospital Laboratory. The fasting blood sugar level was determined on-site using a glucose meter (SensoCard®).

Blood pressure was measured using a digital sphygmomanometer (Riester, Germany). Blood pressure was measured three times, while the study subject was in a sitting position with the right upper arm placed at the level of the heart and after the subject had 10 minutes rest [23]. The average of the two measurements was considered to compute systolic and diastolic blood pressure [24]. There was a ten-minute interval between two blood pressure measurements.

Operational definitions

Hypertension

Defined according to the 2018 European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) Guidelines for the management of arterial hypertension (systolic blood pressure 140 mmHg or more and/or diastolic blood pressure 90 mmHg or more) and/ or self-reported for medication [6]. We classified hypertension based on the seventh report of the Joint National Committee, and the American College of Cardiology [25, 26]. Accordingly, systolic or diastolic blood pressure measurement < 120/80 mmHg is normal, 120-139/80-89 mmHg is pre-hypertension or elevated blood pressure, 140-159/90-99 mmHg is stage 1 hypertension, and ≥ 160/100 mmHg is stage 2 hypertension [25, 26].

Hyperglycemia

Defined based upon the American Diabetes Association definition (persons with FBS level 7.0 mmol/l or above) and/ or self-reported for medication based on the prescription made by health personnel working in a licensed health institution [27].

Nutritional status

BMI values of < 18.5 kg/m2: underweight, 18.5–24.9 kg/m2: normal, 25–29.9 kg/m2: overweight and ≥ 30 kg/m2: obese were used to classify the nutritional status of adults [28, 29].

High total cholesterol level

Total cholesterol level 5.2 mmol/l (200 mg/dl) or more [30].

Alcohol drinking

Defined based on the self-reported consumption of a standard alcoholic drink such as 285 ml of beer, 120 ml of wine, and 30 ml of spirits of five or more for men or four or more for women in a single drinking occasion within the past 30 days [21].

Current smokers

Self-reported current use of smoked tobacco or smokeless tobacco products.

Khat chewing

Defined based on the self-reported current chewing of khat.

Low level of physical activity

If the study subject performed vigorous or moderate physical activity less than 600 METs-minutes/week [21, 22].

Data quality management

Data collectors and immediate supervisors were trained for one week on the data collection instrument, key variables, and their measurements. A pre-test was conducted on 5% of the total sample size, with a population having the same socio-economic characteristics as the study population. The data collection team was offered retraining based on the problems identified and experiences gained during the pre-test. Laboratory technicians received training on standard operating procedures of blood sample collections. The principal investigator and field supervisors provided supportive supervision, daily throughout the data collection time. Incomplete and inconsistent data were returned to data collectors for corrections.

Data entry and analysis

Data were entered into the Epi-Data version 3.1 (EpiData Association, Odense, Denmark) using the double-entry system and cleaned for inconsistency. The data were analyzed using STATA version 15 software (StataCorp LLC College Station Texas, U.S.A.). The wealth index was constructed using 40 variables for rural and 28 variables for urban areas related to the ownership of household assets using a principal component analysis. During the analysis, in each study setting eleven components with factor loading > 0.4 (house lighting, ceiling type, bedroom, cooking place, ox, electricity, radio, mobile, chair, table and mattress for a rural area, and floor type, wall type, ceiling type, bedroom, house ownership, toilet, television, mobile, table, mattress, and injera stove for an urban area) were identified and retained. The wealth index values were calculated by summing up the scores of eleven components in each study setting. Finally, the three socioeconomic categories were generated by splitting the wealth index values into three equal classes. Descriptive summaries were analyzed to determine the frequency and proportion of categorical variables. All the independent variables satisfied the assumption for the multicollinearity test with the Variance Inflation Factor (VIF) less than 10 or tolerance greater than 0.1.

Prevalence of pre-hypertension and hypertension was computed based on the European Society of Hypertension (ESH) Guideline [6]. To generate a weight for the two-stage cluster sampling, first, we computed finite population corrections for the two stages independently. Then to get our survey weight, we multiplied and inverted the two finite population corrections. We determined the weighted prevalence, after declaring the data set as a two-stage survey, using the primary sampling unit identifier, the weight of the cluster, finite population correction of the first stage sampling, secondary sampling unit identifier, and finite population correction of the second stage sampling.

Factors associated with hypertension were analyzed using logistic regression. Binary categorical explanatory variables were coded in the same way as that of the outcome variable. Variables with P values less than 0.20 in the bivariate analysis, and those with socio-demographic and public health importance were selected for multivariate analysis. The number of cases that represent observation in the rarer of the two binary levels of the outcome variable was considered to fix the number of candidate variables that entered into the final multivariate logistic regression model. Accordingly, twelve variables were selected for multivariate analysis to control overfitting. The multivariate logistic regression analysis was started after declaring the data set as survey data to account for the effect of clustering in the estimated standard errors. AOR with 95% CI, and P value less than 0.05 were used to ascertain the significance of the association.

Ethical consideration

Ethical clearance was obtained from the Institutional Review Board at Hawassa University (IRB/005/10) and the Regional Ethical Committee of Western Norway (2017/2248/REK nord). A support letter was obtained from Wolaita Sodo University and submitted to the concerned zonal and district offices. Written informed consent was obtained from all the study subjects; after introducing the purpose of the research using information sheets. Participation was based on voluntary. The identities of the study participants were kept confidential. Persons with FBS level 7.0 mmol/l (126 mg/dl) or above, high blood pressure, and other serious ailments were linked to the nearest health service facilities.

Results

Socio-demographic profiles of the participants

A total of 2483 respondents participated in the study with a response rate of 99.9%. The study participants were from two districts, namely Wolaita Sodo town (1243 (50.1%)) and Ofa rural district (1240 (49.9%)). The male to female ratio of the participants was 1.1. One thousand four hundred twenty-one (57.2%) study participants were between 25 and 39 years of age, with the median age of 35 ranging from 25–64 years. Of the total study participants, 676 (27.2%) were educated at the level of college or more. Most of the participants (2322 (93.5%)) were married or in relation (See Table 1).

Table 1

Distribution of socio-demographic and economic characteristics by hypertension among adults aged 25–64 years in Wolaita, southern Ethiopia 2018 (n = 2483).

Variables	Categories (n)	Prehypertension		Hypertension
		Number of cases	Weighted prevalence % (95% CI)	Number of cases	Weighted prevalence % (95% CI)
Age	25–39 years (1421)	747	51.5 (46.7, 56.3)	366	25.9 (21.9, 30.4)
	40–64 years (1062)	408	39.7 (35.6, 44.1)	452	38.5 (33.3, 44.0)
Sex	Female (1170)	552	46.5 (42.1, 50.8)	340	28.8 (24.4, 33.6)
	Male (1313)	603	46.4 (42.3, 50.6)	478	33.4 (29.3, 37.9)
Residence	Rural (1240)	575	46.3 (42.9, 50.0)	356	28.7 (25.8, 31.8)
	Urban (1243)	580	46.7 (38.3, 55.2)	462	37.2 (28.3, 47.0)
Educational status	Primary & below (1410)	611	44.6 (41.0, 48.2)	445	29.9 (26.5, 33.6)
	High school (397)	203	50.2 (45.0, 55.5)	130	32.3 (27.1, 37.8)
	College+ (676)	341	50.1 (40.7, 60.0)	243	35.6 (26.7, 45.5)
Ethnicity	Wolaita (2372)	1124	47.0 (43.5, 50.5)	757	30.6 (27.3, 34.1)
	Others (111)	31	27.6 (17.9, 40.0)	61	55.5 (42.6, 67.7)
Marital status	Single (161)	86	55.2 (48.6, 61.6)	43	25.8 (20.5, 31.8)
	Married/ in relation (2322)	1069	45.9 (42.1, 50.0)	775	31.7 (28.0, 35.6)
Occupation	Employee (637)	318	49.8 (39.1, 60.4)	236	37.3 (27.3, 48.5)
	Merchant (332)	164	49.4 (43.8, 55.1)	102	29.4 (24.5, 34.9)
	Farmer (740)	337	46.1 (41.6, 50.8)	213	27.7 (24.7, 31.0)
	Housewife (509)	219	42.9 (37.3, 48.7)	160	31.0 (24.9, 37.8)
	Retiree (133)	50	37.2 (29.6, 45.6)	63	48.0 (40.7, 55.4)
	Students (74)	43	55.7 (43.6, 67.2)	17	24.8 (15.0, 38.2)
	Others (58)	24	47.4 (33.7, 61.4)	27	39.4 (24.4, 56.6)
Wealth index	Poor (784)	321	42.4 (37.1, 47.8)	288	34.4 (27.8, 41.7)
	Medium (793)	364	46.8 (42.4, 51.2)	263	30.5 (25.8, 35.6)
	Rich (906)	470	49.8 (44.0, 55.5)	267	29.3 (25.4, 33.4)

Weighted prevalence: weighted for sampling.

Prevalence of prehypertension and hypertension

The overall weighted prevalence of hypertension and prehypertension in the Wolaita area was 31.3% (27.7%-35.1%) and 46.4% (42.9%-50.0%) respectively. The weighted prevalence of hypertension of those who were not aware of their hypertension until the time of the survey was 29.8%% (26.5%-33.3%). Where the weighted prevalence of self-reported cases of hypertension was 2.2% (1.2%-3.8%). The weighted prevalence of hypertension in urban was 37.2% (28.3%-47.0%), while 28.7% (25.8%-31.8%) in the rural (See Table 1).

A remarkably higher weighted prevalence of hypertension was noted among participants with obesity (55.7% (45.3%-65.6%)) compared to the people with the normal nutritional status (29.6% (26.4%-33.0%)). The weighted prevalence of hypertension among participants who consumed sugar-sweetened food was 33.8% (29.5%-38.3%), while it was 23.6% (19.4%-28.4%) among people who did not consume sugar-sweetened food (See Table 2).

Table 2

Behavioral and anthropometric characteristics by hypertension among adults aged 25–64 years in Wolaita, southern Ethiopia 2018 (n = 2483).

Variables	Categories (n)	Prehypertension		Hypertension
		Number of cases	Weighted prevalence % (95% CI)	Number of cases	Weighted prevalence % (95% CI)
Physical activity	Low (1311)	626	46.5 (40.9, 52.2)	451	34.5 (28.9, 40.5)
	Moderate/high (1172)	529	46.4 (43.2, 49.6)	367	28.8 (25.3, 32.5)
Fruit consumption	Not daily (60)	22	36.3 (23.2, 51.8)	21	33.0 (21.5, 47.0)
	Daily (2423)	1133	46.6 (43.0, 50.2)	797	31.3 (27.7, 35.1)
Vegetable consumption	Not daily (131)	46	38.0 (24.3, 54.0)	59	42.8 (30.6, 56.0)
	Daily (2352)	1109	46.8 (43.1, 50.5)	759	30.8 (27.3, 34.6)
Sugar sweetened beverage intake	No (1743)	833	47.9 (44.4, 51.4)	543	29.7 (26.3, 33.4)
	Yes (740)	322	42.0 (35.0, 49.3)	275	36.1 (29.8, 42.8)
Sugar-sweetened food intake	No (545)	289	53.4 (48.4, 58.3)	153	23.6 (19.4, 28.4)
	Yes (1938)	866	44.2 (40.2, 48.3)	685	33.8 (29.5, 38.3)
Smoking	No (2466)	1150	46.6 (43.0, 50.2)	812	31.4 (27.8, 35.2)
	Yes (18)	5	29.2 (11.9, 55.8)	6	24.8 (12.8, 42.5)
Alcohol drinking	No (2435)	1142	46.7 (43.1, 50.4)	790	31.0 (27.5, 34.7)
	Yes (48)	13	29.3 (15.8, 47.9)	28	50.4 (29.0, 71.7)
BMI	Underweight (411)	170	41.2 (35.4, 47.3)	117	27.9 (23.1, 33.2)
	Normal (1548)	741	48.4 (45.4, 51.4)	477	29.6 (26.4, 33.0)
	Overweight (415)	208	48.6 (36.7, 60.7)	163	41.2 (28.6, 55.1)
	Obese (109)	36	31.6 (23.2, 41.3)	61	55.7 (45.3, 65.6)
Hyperglycemia	No (2373)	1122	47.1 (43.5, 50.7)	757	30.6 (27.0, 34.3)
	Yes (110)	33	29.5 (19.3, 42.2)	61	50.6 (39.9, 61.3)

Weighted prevalence: weighted for sampling.

Factors associated with hypertension

Participants who developed obesity were significantly associated with hypertension [AOR = 2.5; 95% CI: 1.4–4.5] as compared to their counterparts. Similarly, there was a greater chance of developing hypertension among participants who consumed sweet food at least once a month [AOR = 1.6; 95% CI: 1.3–2.1] as compared to those who did not. Likewise, male participants had a greater chance of getting hypertension [AOR = 1.4; 95% CI: 1.1–1.7] compared to the female participants.

Moreover, hypertension increased with the increasing total cholesterol level [AOR = 1.2; 95% CI: 1.1–1.3] after adjusting the other factors. Hypertension was also increased with the increased blood sugar level [AOR = 1.1; 95% CI: 1.01–1.2] after adjusting the other factors. We observed a higher chance of developing hypertension with the advancing age [AOR = 1.03; 95% CI: 1.01–1.04] (Table 3).

Table 3

A multivariate logistic regression using survey data analysis of factors with hypertension among the adult population aged 25–64 years in Wolaita, southern Ethiopia.

Variables (n = 2483)	Categories	Hypertension		Crude OR (95% CI)	Adjusted OR (95% CI)
		No N (%)	Yes N (%)
Age				1.03 (1.02, 1.05)	1.03 (1.01, 1.04)
Sex	Female	830 (70.9)	340 (29.1)	1.0	1.0
	Male	835 (63.6)	478 (36.4)	1.4 (1.1, 1.7)	1.4 (1.1, 1.7)
Residence	Rural	884 (71.3)	356 (28.7)	1.0	1.0
	Urban	781 (62.8)	462 (37.2)	1.5 (0.9, 2.4)	1.2 (0.8, 1.9)
Educational status	Primary & below	965 (68.4)	445 (31.6)	1.0	1.0
	High school	267 (67.2)	130 (32.8)	1.1 (0.8, 1.4)	1.0 (0.7, 1.3)
	College+	433 (64.0)	243 (36.0)	1.2 (0.8, 1.9)	0.9 (0.7, 1.2)
Marital status	Single	118 (73.3)	43 (26.7)	1.0	1.0
	Married/ in relation	1547 (66.6)	775 (33.4)	1.4 (1.0, 1.9)	1.0 (0.7, 1.4)
Vegetable consumption	Not daily	72 (55.0)	59 (45.0)	1.0	1.0
	Daily	1593 (67.7)	759 (32.3)	0.6 (0.3, 0.9)	0.6 (0.4, 1.1)
Physical activity	Low	860 (65.6)	451 (34.4)	1.0	1.0
	Normal	805 (68.7)	367 (31.3)	0.9 (0.6, 1.2)	1.0 (0.7, 1.4)
Sugar sweetened food intake	No	412 (75.6)	133 (25.4)	1.0	1.0
	Yes	1253 (64.7)	685 (35.4)	1.7 (1.4, 2.1)	1.6 (1.3, 2.1)
Obesity	No	1617 (68.1)	757 (31.9)	1.0	1.0
	Yes	48 (44.0)	61 (56.0)	2.7 (1.7, 4.2)	2.5 (1.4, 4.5)
Alcohol drinking	No	1645 (67.6)	790 (32.4)	1.0	1.0
	Yes	20 (41.7)	28 (58.3)	2.9 (1.3, 6.7)	2.1 (0.9, 4.9)
Total cholesterol	Mmol/ l			1.3 (1.2, 1.4)	1.2 (1.1, 1.3)
Blood sugar	Mmol/ l			1.1 (1.1, 1.2)	1.1 (1.01, 1.2)

Discussion

The prevalence of hypertension among adults in Wolaita was high, with a weighted prevalence of 31.3%. A small proportion of the affected people are aware of their high blood pressure. This study reported a high prevalence of prehypertension; which indicates a high percentage of people at risk of hypertension. Obesity, sugar-sweetened food consumption, male sex, elevated total cholesterol, raised fasting blood sugar, and advancing age were positively associated with hypertension.

The overall prevalence of hypertension reported in this study is in agreement with the findings reported from other studies [11, 13], while it is higher than the results indicated elsewhere in Ethiopia [14, 17], and other countries in Africa [12, 31]. The observed difference might be because of the socio-demographic and cultural variations among the study populations. The present study reported a higher prevalence of prehypertension compared to similar studies conducted in other African countries [11, 31]. It also reported a higher proportion of people who were not aware of their hypertension until the time of the survey compared to another study conducted in northwest Ethiopia [17]. This shows the presence of a high proportion of people that are at high risk of hypertension.

Participants who developed obesity were more likely to develop hypertension as compared to their counterparts. This is comparable with the findings from other studies [13, 16]. There is an established link between obesity and hypertension. The accumulation of excess fatty tissue instigates a cascade of events that give rise to increased blood pressure [32, 33]. Similarly, sugar-sweetened food consumption was also positively associated with hypertension, which is consistent with the finding from another study [14]. Excessive energy consumption might result in overweight and obesity and be linked to hypertension [34]. Furthermore, sex as a non-modifiable factor showed a positive association with hypertension, as has been found in another study [13, 17]. In this study, hypertension was more prevalent among male participants as compared to females.

Moreover, hypertension increased with elevated total cholesterol levels. This is in line with the finding reported by another community-based study [15]. This might be due to increased deposition and accumulation of lipids in the blood vessels. Similarly, there was a positive association between fasting blood sugar level and hypertension. A study elsewhere reported a similar finding [17]. This might be partially explained by the sharing of common risk factors [35, 36]. Advancing age was associated with hypertension as has been found in other studies [16-18]. The decreasing energy expenditure with advancing age may lead to the accumulation of adipose tissue and this may give rise to the development of obesity and high blood pressure [32, 37].

Strengths and limitations

The magnitude of confounding was assessed using the level of variation between the crude and adjusted estimates. The absence of difference between the two estimates indicates the observed exposure-outcome effect was not confounded by the potential confounding variable. The study, being a cross-sectional survey, lacks a temporal relationship. Since Wolaita is a predominantly religious society, we expect a social desirability bias for responses related to behavioral questions such as smoking, alcohol, and khat chewing. In this study, the distribution of sex across the age groups was not as expected. Age was measured based on the birth date estimation using the study participants’ recall memory, which was supported by main public events that occurred around the participants’ birth date.

Conclusion

The prevalence of hypertension among adults in Wolaita was high. A small proportion of the affected people are aware of their high blood pressure. This study reported a high prevalence of prehypertension; which indicates a high percentage of people at risk of hypertension. Obesity, sugar-sweetened food consumption, male sex, elevated total cholesterol level, raised fasting blood sugar level, and advancing age were positively associated with hypertension. We identified modifiable risk factors with public health importance that includes obesity, sugar-sweetened food consumption, elevated total cholesterol, and raised fasting blood sugar level. The findings of this study can be used for immediate public health practice. Therefore, it is essential to develop periodic screening programs, and primary intervention strategies such as the prevention of obesity, and reduction of sugar-sweetened food consumption as has been shown in this study.

Knowledge gap on factors associated with systolic and diastolic blood pressures and comparison of mean systolic and diastolic blood pressures considering residence as a primary exposure variable in Ethiopia.

(RAR)

Click here for additional data file.

English questionnaire and consent.

(RAR)

Click here for additional data file.

Amharic questionnaire and consent.

(RAR)

Click here for additional data file.

Wolaita language questionnaire version and consent.

(RAR)

Click here for additional data file.

16 Apr 2021

PONE-D-21-02507

Hypertension in southern Ethiopia: a community-based cross-sectional study from in Wolaita

PLOS ONE

Dear Dr. Kumma,

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.

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Reviewer #1: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: I Don't Know

**********

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Reviewer #1: Yes

Reviewer #2: No

**********

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Reviewer #2: Yes

**********

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Reviewer #1: Thank you very much for giving me opportunity to revise this paper.

Hypertension in southern Ethiopia: a community-based cross-sectional study from in

Wolaita

The title, introduction, discussion are all on hypertension straight away. However, the objective and statistics, methods and results are on the level of systolic and diastolic blood pressure. This is confusing because these are two different issues. Thus the paper is on tow different objectives. Authors wrongly cited articles on hypertension as if these are on systolic and diastolic blood pressure. I have gone through your references, non of them is on systolic and diastolic blood pressure.

Reviewer #2: Title ----I think community based cross-sectional study is enough delete from in Wolita

Abstract: objective

Line 23---if your aim was to assess factors associated with systolic and diastolic blood pressure, best study design is case control but you use cross-sectional why?

--You assessed systolic and diastolic blood pressure or systolic and diastolic high blood pressure?

Line 32---In your result you start about prevalence of hypertension, but your objective was systolic and diastolic blood pressure, if it is not about high blood pressure how you could talk about hypertension??? Is this consistent?

Line/no 33-34----your mean systolic BP was 130.5 with CI of 129.8-131.3mmHg; is this hypertension?? Because as my understanding and as your category this is under prehypertension. What you say on this??

You calculate mean systolic and diastolic blood pressure from over all but it is good if you calculate from those above 140(systolic) or high blood pressure and similarly to diastolic above 90.

Your document lacks consistency ---for example in objective you said to compare systolic and diastolic blood pressure among urban and rural but in your method section you said to assess variation of prevalence of hypertension among urban and rural. Which one is your focus?

154---Data collection----narrating all issue is I think boring, so try to minimize it

186------not suitable for ht measurement was excluded—what is not suitable and suitable??? Please clearly mention it.

157---I think you adapt your survey questions from WHO steps survey not prepared, are you prepared or adapt?

Result section—

Mean systolic and mean diastolic blood pressure—what is the importance of assessing the mean systolic and diastolic blood pressure? What is the public health importance of the mean value of systolic and diastolic blood pressure?

337---Those not aware of their hypertension were 30.9% and self-report was 3%: according to your operational definition it was 33.9% but yours is 32.9%; what makes this difference?

Line 317---table 3 demonstrates…..participants.—rather it is good you simply write issues you put under table 3 and at last or end of paragraph refer to table 3 or put in bracket like(see table 3)

Line 318-320---In your operational definition you put normal value and what hyper…means. I think it is not necessary to write this issue in this part.

Almost in all your result you include or write exact value of participant and total sample size. Example in line 321 589 0f 2483; but the sample size or your study participant are known or you tell us at the beginning of your result so it is good you put number and percent with out your total sample size or participant.

-line 329-331

Factors associated with…… and table 4 and 5 heading is not shows us associated factors please revise it.

Line 356 or table 4 you show us distribution of systolic and diastolic blood pressure or hypertension and in urban ---for stage I HTN=9.7 and stage II=6.8 totally ===16.5

For rural---stage I=10.2 and stage II=4.2 totally===14.4 according to your operational definition prevalence of hypertension is 16.5% newly diagnosed plus self report 5.2=21.7% for urban and 14.4% new plus 0.8% self report =15.2% for rural. But your prevalence is different from this, how you calculate this? Are you include pre-hypertension?? If so is this right?

Additionally you reported self report 3% but in your table it is 6%(0.8% rural and 5.2% urban) what makes this difference?

Again on residence variable both urban and rural row there is summation error please see and revise it.

Line 374---Similar comment as line 317

Starting from line 396----- you tell us about factors associated with systolic as well as diastolic blood pressure that is including normal blood pressure, so what is public health importance and what you recommend based on this??

Factors associated with mean systolic and mean diastolic blood pressure including normal why?

I didn’t see any discussion issue about isolated systolic hypertension and isolated diastolic hypertension why?

Table 7 ---editorial issue, it is mean diastolic blood pressure

Strength and limitation

Starting from line 509----please try to minimize it. Avoid unnecessary issue, some you included under strength are not strength and it is your sampling technique and others are about method, so please revise it.

Line 534---advancing age or advanced age

Finally---your title is about Hypertension in southern Ethiopia, your objective is to assess factors associated with systolic and diastolic blood pressure and compare the mean systolic and diastolic blood pressures among rural and urban populations and you conclude as prevalence of hypertension in Wolita was high. How you see these?? Your objective was not about high blood pressure but simply systolic and diastolic blood pressure and through out your document you tell us about this issue, so how it could be about hypertension??

**********

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19 May 2021

PONE-D-21-02507

Hypertension in southern Ethiopia: a community-based cross-sectional study

Dear Dr. Dario Ummarino,

We would like to thank you and the reviewers for considering our paper for the next level. We have carefully worked on the comments provided by the academic editor as well as the reviewers. We have uploaded the following items during our submission: responses to the reviewers, Revised Manuscript with Track Changes, and Revised Paper without Track Changes (Manuscript). Please see below our one by one responses and explanations to questions and comments. Our responses and explanations to the questions and comments are indicated in bullet points.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

• Thank you so much, we have worked according to the PLOS ONE requirement.

2. Thank you for stating the following financial disclosure: "No: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

At this time, please address the following queries:

a. Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

• South Ethiopia Network of Universities in Public Health (SENUPH) funded the research; which in turn is funded by the Norwegian Program for Capacity Development in Higher Education and Research for Development (NORHED).

• Wolaita Sodo University provided logistics and technical support.

b. State what role the funders took on the study. If the funders had no role in your study, please state: “

• The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

c. If any authors received a salary from any of your funders, please state which authors and which funders.

• The principal author is the academic staff of Wolaita Sodo University, Ethiopia. Therefore, I receive a salary from the Wolaita Sodo University, Ethiopia. However, the university had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Currently, I am on study leave for a PhD study. I am doing my PhD study in a joint PhD program at Hawassa University and the University of Bergen. And this study is part of my PhD work, where the Wolaita Sodo University has no direct role in this study.

d. If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

• The authors received no specific funding for this work.

3. 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.

• Thank you, we will provide the relevant accession numbers or DOIs necessary to access our data.

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

• Thank you for the feedback; we have used all our effort to satisfy the reviewers regarding the comment.

________________________________________

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

Reviewer #1: No

Reviewer #2: I Don't Know

• Thank you for the feedback, we have worked to answer the comments provided by the reviewers. Depending upon the comments provided by the academic editor and the reviewers; we have modified the title, and objective of the study. We have also worked on the introduction and discussion section based upon the modifications made to the title and the objective. Primarily, we did a linear regression analysis to assess factors associated with systolic and diastolic blood pressure in Wolaita, southern Ethiopia. In line with the modifications made to the title and the objective, we added some points in the statistical analysis to address the prevalence of hypertension.

________________________________________

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: No

• Thank you for the comment; we will deposit the data to a public repository on the acceptance of the manuscript for publication.

________________________________________

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

• Thank you for the feedback.

________________________________________

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: Thank you very much for giving me opportunity to revise this paper.

Hypertension in southern Ethiopia: a community-based cross-sectional study from in

Wolaita. The title, introduction, discussion are all on hypertension straight away. However, the objective and statistics, methods and results are on the level of systolic and diastolic blood pressure. This is confusing because these are two different issues. Thus the paper is on two different objectives. Authors wrongly cited articles on hypertension as if these are on systolic and diastolic blood pressure. I have gone through your references, none of them is on systolic and diastolic blood pressure.

• Thank you, we accepted the comment. Accordingly, we have modified the title, and objective of the study. That is, the title now has both hypertension and blood pressure. And in line with it, we have incorporated additional points in the introduction and discussion section of the paper. We have also used additional literatures while making changes to the introduction and discussing our findings. Therefore, the reference section of our paper is reorganized in line with the modifications.

Reviewer #2: Title ----I think community based cross-sectional study is enough delete from in Wolaita

• Thank you, we have accepted the comment, and rewrote the title as suggested.

Abstract: objective

Line 23---if your aim was to assess factors associated with systolic and diastolic blood pressure, best study design is case control but you use cross-sectional why?

• We appreciate your concern. Our explanation to the question is, it is possible to use either of the two designs depending upon the research question or the purpose of the study. In retrospective studies, which start with the case (disease/ outcome) and then possible exposure, a case-control study design is a commonly used study design. Whereas, a cross-sectional study design can also be used to assess the association of different factors with an outcome variable for the data collected at a point in time. In our case, we collected primary data on blood pressure and other variables at a point in time, which is cross-sectional. And we are aware that the temporality of the association between the exposure and the outcome variable remains in question except for some biological exposures like sex. We took this into consideration while interpreting the results.

You assessed systolic and diastolic blood pressure or systolic and diastolic high blood pressure?

• We assessed systolic and diastolic blood pressure, and we categorized according to the operational definition of high blood pressure for the sake of reporting the burden of hypertension.

Line 32---In your result you start about prevalence of hypertension, but your objective was systolic and diastolic blood pressure, if it is not about high blood pressure how you could talk about hypertension??? Is this consistent?

• Thank you for raising such an important point, which is similar to the question raised by the first reviewer. As we responded to the question raised by the first reviewer; taking our important findings and consistency of information starting from the title to discussion into consideration, we have modified our title, and the objective. Accordingly, we have also incorporated additional points to the introduction, methods, and discussion. In line with it, we have used additional literatures.

Line/no 33-34----your mean systolic BP was 130.5 with CI of 129.8-131.3mmHg; is this hypertension?? Because, as my understanding and as your category this is under prehypertension. What you say on this??

• Thank you for the question and for providing this opportunity to clarify our research work. As you know blood pressure data is continuous data. Therefore, it is possible to compute the mean with its confidence interval from the overall systolic as well diastolic blood pressure data. The mean does not provide categorical information; it gives aggregate information on the average blood pressure within the study population.

In order to address the prevalence of pre-hypertension and hypertension, we have modified our title and objective. And analyzed the blood pressure data by classifying it into different categories according to the European Society of Hypertension (ESH) Guidelines. Using this we presented results on pre-hypertension and hypertension with its stages.

You calculate mean systolic and diastolic blood pressure from overall, but it is good if you calculate from those above 140(systolic) or high blood pressure and similarly to diastolic above 90.

• Thanks for this question also. One of the advantages of continuous data analysis of the overall observations is to avoid loss of information. An important property of the mean is that it includes every value in your data set as part of the calculation, and its purpose is to indicate the central location of our data since the mean is a measure of central tendency. If we start to compute the mean of systolic and diastolic blood pressure from above 140 and 90 mmHg, respectively, then it will be the mean of blood pressure for the hypertensive category only and may not be as such valuable information considering the overall aim or context of our study. Because of this reason we computed mean from the overall data.

Your document lacks consistency ---for example in objective you said to compare systolic and diastolic blood pressure among urban and rural but in your method section you said to assess variation of prevalence of hypertension among urban and rural. Which one is your focus?

• Thank you so much for indicating such a discrepancy. We have made corrections based upon your comment. Please, see the correction in the revised paper without track change in line number 130, and 131.

154---Data collection----narrating all issue is I think boring, so try to minimize it

• Thank you, we have deleted some waste words from the document. Please, see deletions in the revised paper with track change in line number 146, 147, 160, and 277.

186------not suitable for ht measurement was excluded—what is not suitable and suitable??? Please clearly mention it.

• Thank you so much, we have now mentioned the condition which was not suitable for height measurement. Please, see the correction in the revised paper without track change in line number 188.

157---I think you adapt your survey questions from WHO steps survey not prepared, are you prepared or adapt?

• Thank you so much for the comment. We have paraphrased the statement as per the comment. Please, see the correction in the revised paper without track change in line number 157.

Result section—

Mean systolic and mean diastolic blood pressure—what is the importance of assessing the mean systolic and diastolic blood pressure? What is the public health importance of the mean value of systolic and diastolic blood pressure?

• Thank you for raising such an important concern. We think that computing the mean values provides the overall picture of blood pressure in the studied community without any loss of information due to groupings into high and low. Meanwhile, we have also provided categorical information on levels of blood pressure, including the magnitude of hypertension considering the public health importance of such information. And we believe that reporting in both ways is an advantage.

337---Those not aware of their hypertension were 30.9% and self-report was 3%: according to your operational definition it was 33.9% but yours is 32.9%; what makes this difference?

• Thank you so much for allowing us to explain this, as you saw in the text in line 337, the prevalence of hypertension of those who were not aware of their hypertension until the time of the survey, meaning the prevalence of undiagnosed hypertension was 30.9% (743 of 2408 persons; 95% CI: 29.0% - 32.7%). Here the prevalence of hypertension was calculated from the newly diagnosed participants meaning we excluded the self-reported cases who had an awareness of their previous hypertension status from the analysis. That means the denominator, in this case, is 2408 as indicated in the text. Whereas, the denominator for the self-reported cases of hypertension was 2483 (3.0% (75 of 2483 persons; 95% CI: 2.4%-3.8%)). Because of the difference in the denominator, we did not add the two proportions. Taking 2483 as the denominator for both, it is possible to obtain 32.9%. There is also an overlap of hypertension cases between previously undiagnosed cases and self-reported cases of medication as shown in Table 1, which is prepared for the sake of clarifying this question.

Table 1. Distribution of hypertension with high blood pressure (high systolic and diastolic blood pressures) and self-reported cases of medication, Wolaita, Southern Ethiopia (n = 2483).

Category Self-reported cases Total

No yes

HBP No 0 (0.0) 16 (0.6) 16 (0.6)

Yes 743 (29.9) 59 (2.4) 802 (32.3)

Total 743 (29.9) 75 (3.0) 818 (32.9)

Line 317---table 3 demonstrates…..participants.—rather it is good you simply write issues you put under table 3 and at last or end of paragraph refer to table 3 or put in bracket like(see table 3)

• Thank you, we accepted your comment and corrected it accordingly. Please, see such types of corrections in the revised paper without track change in line number 317, 328, 336, 356, 361, 399, 405, 412, 424, 432, and we have omitted the statements mentioned at the beginning of the paragraphs.

Line 318-320---In your operational definition you put normal value and what hyper…means. I think it is not necessary to write this issue in this part.

• We also thank you for this comment, we have deleted the redundancies. Please, see the changes in the revised paper without track change in line number 332, and 333.

Almost in all your result you include or write exact value of participant and total sample size. Example in line 321 589 0f 2483; but the sample size or your study participant are known or you tell us at the beginning of your result so it is good you put number and percent with out your total sample size or participant.

• Thank you, we have made corrections on it. Please, see an example of the corrections in the revised paper without track change from line number 332 to 336. Accordingly, we have made such types of corrections throughout the paper, except for conditions where there is a difference in the denominator as indicated in line number 345.

-line 329-331 Factors associated with…… and table 4 and 5 heading is not shows us associated factors please revise it.

• Thanks, we have rewritten the headings of Tables 4 and 5. Please, see the corrections in the revised paper without track change in line number 362, 363, 366, and 367.

Line 356 or table 4 you show us distribution of systolic and diastolic blood pressure or hypertension and in urban ---for stage I HTN=9.7 and stage II=6.8 totally ===16.5

For rural---stage I=10.2 and stage II=4.2 totally===14.4 according to your operational definition prevalence of hypertension is 16.5% newly diagnosed plus self report 5.2=21.7% for urban and 14.4% new plus 0.8% self report =15.2% for rural. But your prevalence is different from this, how you calculate this? Are you include pre-hypertension?? If so is this right?

• We appreciate your comment on Table 4. Based upon your comment we have revised table four, and made some changes on the denominators. Now, the denominator became the row total for all the categories to simplify comparison between categories of variables. Because of the difference in the denominator of the two categories (Column 8 & 9), the addition of prevalence rates cannot provide the same result. We did not mix pre-hypertension with hypertension cases. Please, see the changes made in the revised paper without track change on line number 364 or Table 4.

Additionally you reported self report 3% but in your table it is 6% (0.8% rural and 5.2% urban) what makes this difference?

• Thank you, as we have explained above the denominators are different, therefore the summation does not provide 3%. Please, see the revised paper without track change in line number 364 or Table 4.

Again on residence variable both urban and rural, row there is summation error please see and revise it.

• Thank you for the comment, we have cross-checked the summation. The row total for rural and urban excluding the rows in column 7, table 4 is 1240 and 1243 respectively. The results in column 7 are the summation of row results from columns 1 - 6. Please, see the revised paper without track change in line number 364 or Table 4.

Line 374---Similar comment as line 317

• Thank you, we have accepted the comment and made the correction accordingly. Please, see the correction in the revised paper without track change in line number 399, and we have omitted the statement which was written at the beginning of the paragraph.

Starting from line 396----- you tell us about factors associated with systolic as well as diastolic blood pressure that is including normal blood pressure, so what is public health importance and what you recommend based on this??

• Thank you so much for the question. Our explanation of this question is similar to other questions related to it. Systolic and diastolic blood pressure data are continuous data. We can analyze systolic and diastolic blood pressure as the dependent variables using linear regression, which does not require dropping values or systematically categorize them. The advantage of analyzing such data using linear regression is to identify factors that contribute either to the increase or decrease of a blood pressure level in the study population. Therefore, using the information obtained from this study public health measures can be taken to control modifiable risk factors that contribute to the increase of blood pressure, and factors decreasing blood pressure in the community can be promoted. Analyzing continuous data using linear regression avoids loss of information.

Factors associated with mean systolic and mean diastolic blood pressure including normal why?

• We analyzed factors associated with systolic and diastolic blood pressure. Our explanation is, with linear regression using the overall data; one can observe the relationship between the explanatory and an outcome variable. Whether there is a linear increase in the outcome variable with the increasing explanatory variable or a linear decrease in the outcome variable with the decreasing explanatory variable.

I didn’t see any discussion issue about isolated systolic hypertension and isolated diastolic hypertension why?

• Thank you, we have now included it in the discussion. Please, see the discussion made on the isolated systolic, and diastolic hypertension in the revised paper without track change from line number 456 to 462.

Table 7 ---editorial issue, it is mean diastolic blood pressure

• Thank you; it is diastolic blood pressure.

Strength and limitation

Starting from line 509----please try to minimize it. Avoid unnecessary issue, some you included under strength are not strength and it is your sampling technique and others are about method, so please revise it.

• Thank you so much, we have revised it and avoided issues related to methods. Please, see the corrections in the revised paper with track changes from line number 539 to 543.

Line 534---advancing age or advanced age

• Thank you for raising the point, some use advancing age others use advanced age. However, we used the term "advancing" to show the increasing trend or pattern of blood pressure with increasing age.

Finally---your title is about Hypertension in southern Ethiopia, your objective is to assess factors associated with systolic and diastolic blood pressure and compare the mean systolic and diastolic blood pressures among rural and urban populations and you conclude as prevalence of hypertension in Wolita was high. How you see these?? Your objective was not about high blood pressure but simply systolic and diastolic blood pressure and throughout your document you tell us about this issue, so how it could be about hypertension??

• Thank you so much for showing us this important point. Taking your comments into consideration, we have modified our objective and in line with it, we have modified our title, and incorporated additional points into the introduction of the paper. We have also incorporated additional points to the methods and discussion, and used additional articles that address the modified objective.

________________________________________

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

• No

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

29 Jun 2021

PONE-D-21-02507R1

Hypertension, and blood pressure in southern Ethiopia: a community-based cross-sectional study

PLOS ONE

Dear authors/editorial staff members/Editor in chief!

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.

Please submit your revised manuscript by Aug 13 2021 11:59PM. 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Wali Khan

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Dear authors/editorial staff members/Editor in chief!

I would like to inform you that I have reached my decision that the manuscript numbered cited in the subject above is based on scientific background and fulfil and satisfy the standard of PLOS ONE for publication. I have checked out the points of reviewers raised during revision and responses given by the author(s) against each point. I am satisfied by the response of the author(s) for the points raised. As according to the reviewers comments objectives were not similar to the title and thus the findings were not related to the objectives and lack of consistency in the paper but this is now addressed by the authors accordingly. As Academic editor of this manuscript I decided to publish this submission in PLOS ONE.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. 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: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

4. 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: No

**********

5. 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

**********

6. 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: I suggest to accept it in the current form.

Authors succeeded to response to all of the raised points

Reviewer #2: Minor comment

Result

Line 371---mean(SD) it is good if you write like 130.5 ±0.4

Discussion

Line 476-478---Why you raised this issue? Because as you told us this was not assed in your study. So it is good if you delete it.

Strength

Line 509---judgment of causality?? Your study design is cross-sectional how it could be???

As my perception it is good you minimize or summarize it and make your strength & limitation to one paragraph

Conclusion

Line 536—you write modifiable risk factors but it is good if you indicate this statement above (line 529) when you listing factors associated with blood pressure. Because this is conclusion so it is good if you show us those risk factors you identified in your study as modifiable and non-modifiable.

Reference

Line 596—reference 10—randomly I checked this reference and for this article there is authors so, it is good if you see and revise it.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Ishag Adam

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

2 Jul 2021

Dear Dr. Wali Khan,

We would like to thank you and the reviewers for your suggestions, and comments. We have worked on the comments provided by the reviewer. We have uploaded the following items during our resubmission: responses to the reviewers, Revised Manuscript with Track Changes, and Revised Paper without Track Changes (Manuscript). Please see below our one-by-one response and explanations to questions and comments. Our responses and explanations to the questions and comments are indicated in bullet points.

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

• Thank you so much, we have carefully reviewed the reference list, and all are written according to the PLOS ONE requirement.

Additional Editor Comments (if provided):

Dear authors/editorial staff members/Editor in chief!

I would like to inform you that I have reached my decision that the manuscript numbered cited in the subject above is based on scientific background and fulfil and satisfy the standard of PLOS ONE for publication. I have checked out the points of reviewers raised during revision and responses given by the author(s) against each point. I am satisfied by the response of the author(s) for the points raised. As according to the reviewers comments objectives were not similar to the title and thus the findings were not related to the objectives and lack of consistency in the paper but this is now addressed by the authors accordingly. As Academic editor of this manuscript I decided to publish this submission in PLOS ONE.

• Thank you so much for such an encouraging response.

Reviewers' comments: Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

• Thank you so much.

________________________________________

2. 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: Yes

Reviewer #2: Yes

• Thank you so much.

________________________________________

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

• Thank you so much.

________________________________________

4. 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: No

• Thank you for the comment; as we have responded previously, we will deposit the data to a public repository on the acceptance of the manuscript for publication.

________________________________________

5. 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

• Thank you so much.

________________________________________

6. 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: I suggest to accept it in the current form.

Authors succeeded to response to all of the raised points

• Thank you so much.

Reviewer #2: Minor comment

Result

Line 371---mean(SD) it is good if you write like 130.5 ±0.4

• We appreciate the comment, however, the "mean (SD)" is written in accordance with the guideline of PLoS ONE which states: "Properties of distribution. It should be clear from the text which measures of variance (standard deviation, standard error of the mean, confidence interval) and central tendency (mean, median) are being presented."

Discussion

Line 476-478---Why you raised this issue? Because as you told us this was not assed in your study. So it is good if you delete it.

• Thank you, we have deleted it.

Strength

Line 509---judgment of causality?? Your study design is cross-sectional how it could be???

As my perception it is good you minimize or summarize it and make your strength & limitation to one paragraph

• We also accepted this comment and minimized the size.

Conclusion

Line 536—you write modifiable risk factors but it is good if you indicate this statement above (line 529) when you listing factors associated with blood pressure. Because this is conclusion so it is good if you show us those risk factors you identified in your study as modifiable and non-modifiable.

• Thank you, we accepted your comment and moved the statement to the place where you suggested, and listed modifiable risk factors.

Reference

Line 596—reference 10—randomly I checked this reference and for this article there is authors so, it is good if you see and revise it.

• Thank you so much for the comment, we have revised all the references and made corrections accordingly.

________________________________________

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Ishag Adam

Reviewer #2: No

• No

Submitted filename: Responses to Reviewers.docx

Click here for additional data file.

27 Aug 2021

PONE-D-21-02507R2

Hypertension and blood pressure in southern Ethiopia: a community-based cross-sectional study

PLOS ONE

Dear Dr. Kumma:

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.

You please should make all the changes in the tables and analysis suggested.

Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

For Lab, Study and Registered Report Protocols: These article types are not expected to include results but may include pilot data.

==============================

Please submit your revised manuscript by Oct 11 2021 11:59PM. 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Rosely Sichieri

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments (if provided):

I am sorry to say that my understand is that this revised version still requires many changes.

The paper is too long, and it lacks focus.

1- There is no need of looking at levels of blood pressure and prevalence. Authors should keep only prevalence analysis. All diastolic and systolic analysis should be deleted.

2- Title should be changed - prevalence of hypertension in adults of xxxx and related factors.

3- The aim as written is to compare urban and rural areas??? This is not true.

The aim is to determine prevalence of hypertension and pre-hypertension and related factors.

4-multilevel analysis should be explained/ Was it used to account for the complex design? Are weighting included??? The ICC data is not necessary to show the intracluster? Complex surveys have specific programs called survey in SAS and Stata. They should be used.

4- Keep only the factors related to hypertension in the introduction and adjust for those factors that make sense. Multivariate analysis adjusting all for all make no sense.

5- Tables are wrong. Prevalences in the new tables by each factor should be showed. Not percentages in the column.

6- No need of table 1. Make the first the prevalence of hypertension and pre-hypertension by characteristics of the population. Weighted prevalence.

7- 7- the same for tables 2 and 3. All should be combined in one also with the prevalence by factors. Excluded all lipids and family store.

8- No need of table 4 and 5.

9- Review all the results and discussion after new analysis

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

Reviewers' comments:

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

18 Oct 2021

Dear Dr. Rosely Sichieri,

We would like to thank you for your suggestions, and comments. We have worked on the comments provided by you. We have uploaded the following items during our resubmission: Responses to the editor, Revised Manuscript with Track Changes, and Revised Paper without Track Changes (Manuscript). Please see below our one-by-one response and explanations to questions and comments. Our responses and explanations to the questions and comments are indicated in bullet points.

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.

You please should make all the changes in the tables and analysis suggested.

• Thank you so much, we have made the changes in the tables and analysis based upon your suggestion.

Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

• Thanks, we made our decisions based upon PLOS ONE's publication criteria.

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.

a. Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

• South Ethiopia Network of Universities in Public Health (SENUPH) funded the research; which in turn is funded by the Norwegian Program for Capacity Development in Higher Education and Research for Development (NORHED), the grant number of this research was ETH-13-0025.

• Wolaita Sodo University provided logistics and technical support.

b. State what role the funders took on the study. If the funders had no role in your study, please state: “

• The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

c. If any authors received a salary from any of your funders, please state which authors and which funders.

• There is no author who received a salary from South Ethiopia Network of Universities in Public Health (SENUPH) or Norwegian Program for Capacity Development in Higher Education and Research for Development (NORHED). The principal author is the academic staff of Wolaita Sodo University, Ethiopia. Therefore, I receive a salary from the Wolaita Sodo University, Ethiopia. However, the university had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Currently, I am on study leave for a PhD study. I am doing my PhD study in a joint PhD program at Hawassa University and the University of Bergen. And this study is part of my PhD work, where the Wolaita Sodo University has no direct role in this study.

d. If you did not receive any funding for this study, please state: I received funding and the financial information was given above.

Additional Editor Comments (if provided):

I am sorry to say that my understanding is that this revised version still requires many changes.

The paper is too long, and it lacks focus.

• Thank you, we appreciate your point and worked based on your comment.

1- There is no need of looking at levels of blood pressure and prevalence. Authors should keep only prevalence analysis. All diastolic and systolic analyses should be deleted.

• Thanks, we worked according to your suggestion. Therefore, we deleted diastolic and systolic analyses and analyzed only the prevalence of hypertension.

2- Title should be changed - prevalence of hypertension in adults of xxxx and related factors.

• We would also like to appreciate your comment, we have now revised the title, and wrote based upon your suggestion.

3- The aim as written is to compare urban and rural areas??? This is not true.

The aim is to determine the prevalence of hypertension and prehypertension and related factors.

• Thank you, we have also restated the aim of the study, according to your suggestion.

4- Multilevel analysis should be explained/ Was it used to account for the complex design? Are weighting included??? The ICC data is not necessary to show the intracluster? Complex surveys have specific programs called survey in SAS and Stata. They should be used.

• We accepted the comment and carried out the multivariate analysis using survey data analysis in STATA meaning after declaring the data set as survey data.

5- Keep only the factors related to hypertension in the introduction and adjust for those factors that make sense. Multivariate analysis adjusting all for all makes no sense.

• Thank you, in the introduction, we listed factors with public health importance from studies conducted in Ethiopia and elsewhere that showed association with hypertension, and from a practical point of view, we kept or adjusted for those factors in the multivariate analysis.

6- Tables are wrong. Prevalences in the new tables by each factor should be showed. Not percentages in the column.

• Thank you, we accepted the comment and worked accordingly.

7- No need of table 1. Make the first the prevalence of hypertension and prehypertension by characteristics of the population. Weighted prevalence.

• Thank you, we made the first table prevalence of hypertension and prehypertension by characteristics of the population as you suggested, and also carried out the weighted prevalence.

8- The same for tables 2 and 3. All should be combined in one also with the prevalence by factors. Excluded all lipids and family store.

• Thank you, we also made the second table as suggested above with the prevalence by the behavioral and other factors, excluding lipids and family history.

9- No need of table 4 and 5.

• Thank you, we have omitted tables 4 and 5. We have now only two descriptive tables.

10- Review all the results and discussion after new analysis

• We also appreciate all your comments. We wrote the results and discussion based upon the new analysis.

Submitted filename: Responses to reviewers_recent.docx

Click here for additional data file.

10 Nov 2021

Prevalence of hypertension, and related factors among adults in Wolaita, southern Ethiopia: a community-based cross-sectional study

PONE-D-21-02507R3

Dear Dr. Kumma,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Rosely Sichieri

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thanks for accepting all the suggestions.

Please, in the final version exclude the last column in table 3 (p-value) not needed. The CI has the same meaning. Also in this table change No- for number of participants for N.

Reviewers' comments:

6 Dec 2021

PONE-D-21-02507R3

Prevalence of hypertension, and related factors among adults in Wolaita, southern Ethiopia: a community-based cross-sectional study

Dear Dr. Kumma:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Rosely Sichieri

Academic Editor

PLOS ONE