i Exploring Awareness and Healthy Lifestyle Behaviours for the Prevention of Hypertension in Rural Communities in Central Uganda Mary Namuguzi - @00538815 Supervisors: Dr Joy Probyn Professor Heather Iles-Smith Co-supervisors: Dr Karen Higginbotham Dr Ahmed Sarki University of Salford Submitted in Partial Fulfilment of the Requirements of the Degree of Doctor of Philosophy School of Health and Society May 2024 ii Table of Contents Acknowledgements .................................................................................................................... xiii Dedication ................................................................................................................................... xiv Declaration................................................................................................................................... xv Abstract ....................................................................................................................................... xvi 1 Chapter One: Introduction and Background ............................................................... 1 1.1 Chapter Overview .................................................................................................................... 1 1.1.1 Introduction ............................................................................................................... 1 1.1.2 Background ............................................................................................................... 4 1.2 Statement of the problem ................................................................................................... 21 1.3 Significance of the Study ................................................................................................... 23 1.4 Justification for the Study .................................................................................................. 24 1.5 Motivation for the Study .................................................................................................... 24 1.6 Healthcare System in Uganda ............................................................................................ 26 1.7 Chapter Summary .............................................................................................................. 27 2 Chapter Two: Theoretical Dimensions Related to this Study ......................................... 28 2.1 Potential Models and Theories Related to this Study ........................................................ 28 2.2 Theory of Planned Behaviour (TPB) ................................................................................. 28 2.3 Stages of Change (Transtheoretical Model) ...................................................................... 29 2.4 The Health Belief Model ................................................................................................... 30 2.4.1 Reasons for Selecting the Health Belief Model ...................................................... 33 2.4.2 Implications of Health Belief Model to Prevention of Hypertension ..................... 35 2.4.3 Chapter Summary ................................................................................................... 35 3 Chapter Three: Scoping Review of the Literature ........................................................... 37 3.1 Introduction to the Scoping Review .................................................................................. 37 3.2 Review Questions .............................................................................................................. 38 iii 3.3 Types of Evidence.............................................................................................................. 38 3.4 Search strategy ................................................................................................................... 39 3.5 Evidence for screening and selection ................................................................................. 39 3.5.1 Introduction to the PRISMA-ScR figure ................................................................ 43 3.6 Review Findings ................................................................................................................ 45 3.6.1 Definition of Hypertension in Low- and Middle-Income Countries ...................... 45 3.6.2 Clinical practice protocols/policies ......................................................................... 46 3.6.3 Awareness and Knowledge about Prevention of Hypertension in Low- and Middle- Income Countries ................................................................................................................... 46 3.6.4 Prevalence of Hypertension in Low- and Middle-Income Countries ..................... 50 3.6.5 Non-Modifiable Risk Factors for Hypertension ..................................................... 52 3.6.6 Modifiable Risk Factors for Hypertension ............................................................. 53 3.6.7 Individual Healthy Lifestyle Behaviours that Influence the Prevalence of Hypertension .......................................................................................................................... 54 3.6.8 Methodologies used in studies included in the scoping review .............................. 63 3.6.9 Distribution of Studies by Study Country ............................................................... 64 3.7 Chapter Summary .............................................................................................................. 64 4 Chapter Four: Methods ...................................................................................................... 67 4.1 Research Questions ............................................................................................................ 67 4.2 Research Paradigm or Philosophical Worldview .............................................................. 67 4.2.1 Research Paradigm and Philosophical World View Used in this Study ................. 67 4.2.2 Mixed methods and the pragmatic paradigm .......................................................... 72 4.2.3 Linking the Theoretical Model and Research Paradigm ......................................... 73 4.3 Mixed Methods Methodology............................................................................................ 74 4.3.1 Sampling for Mixed Methods Research ................................................................. 77 4.3.2 Phase One: Quantitative study ................................................................................ 77 iv 4.3.3 Phase Two: Qualitative Method.............................................................................. 95 4.3.4 Phase 3: Data Integration Procedure ..................................................................... 105 4.4 Ethical Issues ................................................................................................................... 107 4.5 Risk Management During Data Collection in the COVID-19 Pandemic Period ............. 108 4.6 Budget for the Research ................................................................................................... 109 4.7 Chapter Summary ............................................................................................................ 109 5 Chapter Five: Findings ..................................................................................................... 111 5.1 Part I: Quantitative Results .............................................................................................. 111 5.1.1 Characteristics of the Study Cohort ...................................................................... 111 5.1.2 Participants’ Socioeconomic Characteristics ........................................................ 114 5.1.3 Knowledge about hypertension prevention .......................................................... 116 5.1.4 Healthy Lifestyle behaviours ................................................................................ 122 5.1.5 Prevalence of Hypertension .................................................................................. 131 5.1.6 Comparison of Sociodemographic Characteristics by Hypertension Status ......... 135 5.1.7 Comparison of Knowledge about the Prevention of Hypertension-by-Hypertension Status 138 5.1.8 Association Between Physical Activity and Hypertension Status ........................ 140 5.1.9 Dietary Behaviours and their Association with Hypertension Status ................... 144 5.1.10 Relationship Between Tobacco Use and Hypertension Status ............................. 147 5.1.11 Relationship Between Alcohol Consumption and Hypertension Status ............... 148 5.1.12 Crude Estimates from the Bivariate Regression Analysis .................................... 149 5.1.13 Knowledge and awareness of hypertension prevention and its association with hypertension status .............................................................................................................. 152 5.1.14 Association Between Physical Activity and Hypertension ................................... 154 5.1.15 Associations between Dietary Factors and Hypertension ..................................... 158 5.1.16 Smoking and its association with hypertension .................................................... 161 v 5.1.17 Association between alcohol consumption and hypertension .............................. 163 5.1.18 Health-seeking behaviour for hypertension and BMI ........................................... 164 5.1.19 Multivariable Regression Analysis ....................................................................... 166 5.1.20 Logistic Regression Model ................................................................................... 168 5.1.21 Summary of the Key Quantitative Findings ......................................................... 168 5.2 Part II: Qualitative Findings............................................................................................. 170 5.2.1 Introduction of the Qualitative Sample ................................................................. 170 5.2.2 Theme 1: Sociocultural factors related to hypertension ....................................... 172 5.2.3 Theme Two: Socioeconomic Factors Related to Hypertension ............................ 181 5.2.4 Theme Three: Knowledge and Perceptions about Hypertension .......................... 188 5.2.5 Theme Four: Proposed Interventions for Hypertension Prevention ..................... 194 5.2.6 Overall summary of the qualitative findings ........................................................ 200 5.3 Part III: Integration of the Quantitative and Qualitative Findings ................................... 202 5.3.1 Healthy Lifestyle Behaviours for Prevention of Hypertension............................. 203 5.3.2 Knowledge about Hypertension and its Prevention .............................................. 206 5.3.3 Sociodemographic Risk Factors that Influenced the Prevalence of Hypertension 207 5.3.4 Summary of the data integration ........................................................................... 208 5.4 Summary of the findings .................................................................................................. 209 6 Chapter Six: Discussion of the Findings .......................................................................... 210 6.1 Introduction ...................................................................................................................... 210 6.2 Key Finding 1: Perceived knowledge was associated with a reduced risk for hypertension 211 6.3 Key finding 2: Dietary Modification and its Association with Hypertension Prevention 213 6.4 Key finding 3: Moderate-Intensity Activities Reduced the Risk for Developing Hypertension ............................................................................................................................... 214 vi 6.5 Key finding 4: Prevalence of hypertension was higher among women compared with men 217 6.6 Key finding 5: Cultural issues related to cooking practices ............................................ 221 6.7 Key finding 6: Healthy food is costly for low-income earners ........................................ 222 6.8 Men’s perception of women’s emancipation as a stressor among women ...................... 224 6.9 Key finding 7: Smoking and BMI are associated with the risk for hypertension ............ 224 6.9.1 Smoking ................................................................................................................ 224 6.9.2 BMI ....................................................................................................................... 225 6.10 Key finding 8: Family-centered care approach enhances acceptance and adherence to interventions for the prevention of hypertension ........................................................................ 226 6.11 Key Finding 9: Age and Genetics are Non-modifiable Risk Factors for Hypertension .. 226 6.12 Chapter Summary ............................................................................................................ 227 7 Chapter Seven: Conclusions and Implications of the Findings ..................................... 229 7.1 Introduction to the chapter ............................................................................................... 229 7.2 Reflexivity........................................................................................................................ 229 7.3 Strengths and Limitations ................................................................................................ 231 7.4 Innovative Mixed Methods .............................................................................................. 232 7.5 Contribution to Knowledge.............................................................................................. 232 7.6 Implications of the Results for Further Research ............................................................ 233 7.7 Implications for Practice and Policy ................................................................................ 235 7.8 Conclusions ...................................................................................................................... 237 7.9 Future Research Directions .............................................................................................. 238 7.10 Dissemination of the Findings ......................................................................................... 238 7.11 Reflection on this PhD Journey ....................................................................................... 239 8 References ........................................................................................................................... 241 9 Appendices ......................................................................................................................... 289 vii 9.1 Appendix A: Protocol for the scoping review ................................................................. 289 9.2 Appendix B: Search Strategy ........................................................................................... 295 9.3 Appendix C: Data Extraction Form for the Scoping Review .......................................... 296 9.4 Appendix D: District in Central Uganda ......................................................................... 362 9.5 Appendix E: Participant Information Sheet for the Survey ............................................ 363 9.6 Appendix F: Olupapula lw’Omwetabi oluliko obubaka obukwata ku Kunoonyereza .... 367 9.7 Appendix G: Certificate of Translation ........................................................................... 371 9.8 Appendix H: Consent Form for the Survey ..................................................................... 372 9.9 Appendix I: Foomu y’okukkiriza ey’Okunoonyereza ................................................... 374 9.10 Appendix J: Survey Tool ................................................................................................. 376 9.11 Appendix K: Okunoonyereza kw’Obubaka obw’ebibalo ................................................ 386 9.12 Appendix L: Codebook for Prevention of Hypertension Data ........................................ 394 9.13 Appendix M: Resumption of Research Activities During the Covid-19 Pandemic ........ 407 9.14 Appendix N: Focus Group Discussion Interview Guide ................................................. 409 9.15 Appendix O: Participant Information Sheet for the Focus Group Discussion................. 410 9.16 Appendix P: Olupapula lw’Omwetabi olw’okukubanyirizaako ebirowoozo mu Bibinja 414 9.17 Appendix Q: Consent Form for the Focus Group Discussion ......................................... 419 9.18 Appendix R: Foomu y’Okukkiriza ey’okukubaganya ebirowoozo mu bibinja ............... 421 9.19 Appendix S: Memo during the focus group discussion ................................................... 423 9.20 Appendix T: Field Notes ................................................................................................. 424 9.21 Appendix U: Administrative Clearance from Wakiso District ........................................ 427 9.22 Appendix V: Ethics Approval from the University of Salford ........................................ 428 9.23 Appendix W: Ethics Approval from TASO Research and Ethics Committee ................ 429 9.24 Appendix X: Administrative Clearance from DHO to the General Secretary Uganda National Council for Science and Technology ........................................................................... 430 viii 9.25 Appendix X: Ethics Approval from UNCST ................................................................... 431 9.26 Appendix Z: Budget ......................................................................................................... 433 9.27 Appendix ZA: Gantt Chart............................................................................................... 434 9.28 Appendix ZB: List of Training Undertaken ..................................................................... 436 9.29 Appendix ZC: Research Supervision Record .................................................................. 467 9.30 Appendix ZC: English Editor’s Confirmation ................................................................. 470 9.31 Appendix ZD: Training Schedule for Research Assistants ............................................. 471 ix List of Tables Table 1: Classification of blood pressure levels of the British Hypertension Society.................... 8 Table 2: Search Strategy and Number of Articles Retrieved ....................................................... 40 Table 3: Advantages and disadvantages of the positivist, postpositivist, interpretivist, and pragmatic paradigms ..................................................................................................................... 71 Table 4: Summary of the analysis process for the study variables ............................................... 92 Table 5: Sample for the Plan for Familiarization and Coding Table .......................................... 104 Table 6: Demographic Characteristics of the Study Cohort (N=562) ........................................ 112 Table 7: Participants’ Socioeconomic Characteristics (N=562) ................................................. 115 Table 8: Knowledge about Hypertension Prevention ................................................................. 117 Table 9: Individual Healthy Lifestyle Behaviours that Influence the Prevalence of Hypertension (N=562) ....................................................................................................................................... 123 Table 10: Frequency of Vigorous Sports Activities (N=562) ..................................................... 125 Table 11: Frequency of smoking in the study cohort (N=562) ................................................... 126 Table 12: Frequency of Alcohol Consumption in the Study Cohort (N=562) ........................... 127 Table 13: Frequency of Dietary Patterns .................................................................................... 129 Table 14: Prevalence of Hypertension (N=562) ......................................................................... 132 Table 15: Frequency distribution of weight, height, and body mass index of the study cohort (N=562) ....................................................................................................................................... 134 Table 16: Comparison of weight, height, and BMI with hypertension status ............................ 135 Table 17: Comparison of Sociodemographic Characteristics by Hypertension Status (N=562) 136 Table 18: Comparison of Knowledge about Hypertension Prevention and Hypertension Status (N=562) ....................................................................................................................................... 139 Table 19: Physical Activity and Hypertension Status (N=562) .................................................. 141 Table 20: Dietary Behaviours and their Association with Hypertension Status ......................... 145 Table 21: Tobacco Use and Hypertension Status (N=562) ........................................................ 147 Table 22: Relationship Between Alcohol Consumption and Hypertension Status..................... 148 Table 23: Demographic Characteristics and Associations with Hypertension (N=562) ............ 150 Table 24: Knowledge and awareness of hypertension prevention and its association with hypertension status (N=562) ....................................................................................................... 153 Table 25: Physical Activities and their Association with Hypertension (N=562) ...................... 156 x Table 26: Usual diet and associations with hypertension (N=562) ............................................ 159 Table 27: Smoking and its association with hypertension (N=562) ........................................... 162 Table 28: Association of alcohol consumption with hypertension (N=562) .............................. 163 Table 29: Health-seeking behaviour for hypertension and body mass index (N=562) .............. 165 Table 30: Multivariable Regression Analysis ............................................................................. 167 Table 31: Logistic Model for Hypertension Category and Goodness-of-fit Test ....................... 168 Table 32: Participants in Focus Group Discussion 1 (FGD1) .................................................... 170 Table 33: Participants in Focus Group Discussion 2 (FGD2) .................................................... 170 Table 34: Participants in Focus Group Discussion 3 (FGD3) .................................................... 171 Table 35: Participants in Focus Group Discussion 4 (FGD4) .................................................... 171 xi List of Figures Figure 1: The Health Belief Model ............................................................................................... 32 Figure 2: PRISMA-ScR Flow Diagram for the Scoping Review .................................................. 44 Figure 3: Visual Model for Mixed Methods Sequential Explanatory Design Procedure for Exploring Awareness and Lifestyle Behaviours in the Prevention of Hypertension (HTN) ........ 76 Figure 4: Illustration of the Sampling Procedure used in this Study ............................................ 81 Figure 5: Process of Data Integration Using the Narrative Approach by Applying the Contiguous Technique .................................................................................................................................... 107 Figure 6: Thematic Map for Theme One .................................................................................... 174 Figure 7: Thematic map for theme two....................................................................................... 183 Figure 8: Theme Three: Knowledge and Perceptions about Hypertension ............................... 189 Figure 9: Proposed interventions for Hypertension Prevention .................................................. 195 Figure 10: Overall summary of the qualitative findings ............................................................. 202 xii Table of Charts Chart 1: Methodologies Used in Studies Included in the Scoping Review .................................. 63 Chart 2: Distribution of the Countries Included in the Scoping Review ...................................... 64 Chart 3: Knowledge about the prevention of hypertension ........................................................ 119 xiii Acknowledgements I wish to thank everyone who contributed to the success of this thesis by giving their time, support, encouragement, and mentorship. Above all, I would like to thank my supervisors, Dr Joy Probyn, Professor Heather Iles- Smith, Dr Karen Higginbotham, and Dr Ahmed Sarki, for their endless support and guidance throughout this PhD journey. You were a wonderful supervision team that I will always cherish. My sincere appreciation goes to the management of the Aga Khan University (AKU) School of Nursing and Midwifery for giving me time, financial support, and an enabling environment to pursue this degree. To my AKU family and all my PhD friends at AKU who have guided and supported me, the library, and the ICT team, I am very grateful. You were always a source of encouragement and support throughout this PhD journey. I thank all the people in Wakiso District (Kasengejje and Mende Parishes) and the Wakiso District Leadership (DHO, CAO, LC III, LCI and the VHTs) for granting me the necessary support to access the study participants. My sincere appreciation goes to all participants in this study for their cooperation and willingness to be a part of this study. I would also like to thank my husband (Mr. Rumunya Samuel) and children (Matthew, Shadrach, Martha, and Simeon) who have endured my absence during this PhD journey. To my siblings, in-laws, relatives, and friends, I am forever grateful to you because you have always been a source of inspiration and encouragement, even when things seemed very tough. xiv Dedication I would like to dedicate this PhD to my husband (Mr. Rumunya Samuel) and children (Matthew, Shadrach, Martha, and Simeon) for their wonderful support and patience. I would also like to dedicate this work to my brother (Ssuna Samuel) and my sister (Betty Nyanzi) who passed away in May 2021 and April 2020, respectively for their support, love, and motivation. I also dedicate this PhD to the people of Wakiso District who are passionate about the prevention of hypertension as well as the district health officers for having allowed me to conduct this research. xv Declaration I attest that the regulations and code of conduct for PhD degree programs at the University of Salford were followed when completing the work in this thesis. To the best of my knowledge and belief, this study does not include any previously published or written work by another individual unless specifically referenced in the text, nor does it contain any material previously submitted for any other academic award at any university. This thesis is the candidate’s original work. The author’s opinions are the only ones that are expressed in this dissertation. Signed: Date: 27th May 2024 xvi Abstract Background Globally, hypertension is a major risk factor for mortality and most deaths occur in low- and middle-income countries. The prevalence of hypertension is highest in the rural communities of Central Uganda where awareness is lowest. There is limited evidence about the primary prevention of hypertension in Uganda, yet most of risk factors are preventable. This study aims to explore awareness and individual healthy lifestyle behaviours for the prevention of hypertension in rural communities of Central Uganda. Methods A sequential explanatory mixed methods research study was conducted. A multistage sampling technique was used to identify study sites and participants. A survey and focus group guide were used to collect quantitative and qualitative data respectively. Data were analyzed using descriptive statistics, bivariate analysis, and logistic regression models. Results are presented in frequencies, percentages, and Odds ratios (OR). The statistical analysis was carried out using Stata version 13. Qualitative data was analyzed using framework analysis and a narrative contiguous approach was used for data integration. Results Overall, 562 participants were included in the quantitative study, and of these 66.73% were female, 54.27% were aged 18-37 years, and only 7.12% had completed a tertiary level of education. Approximately 60% knew their hypertension status. Only 5% of participants were able to mention 3-4 types of foods that prevent hypertension. Bivariate analysis indicates that the risk of being hypertensive increases with one’s age; being educated to at least the primary level was found to be associated with a reduced risk of being hypertensive when compared to having no education at all; OR=0.48 (95% CI: 0.26-0.89) for primary, 0.20 (95% CI: 0.10-0.39) for secondary, and 0.33 (0.14-0.81) for tertiary level education. Not performing moderate physical intensity activities were found to have a significantly increased likelihood of being hypertensive compared to participants whose usual work involved moderate physical intensity (OR = 0.51; 95% CI: 0.34-0.76). Moreover, the risk of acquiring hypertension reduces with the increasing number of hours of performing moderate intensity activities (3-4 hours OR = 0.61; 95% CI: 0.41-0.90 ** and 5-10 hours OR = 0.26; 95% CI: 0.14-0.48 ***). xvii The qualitative study included 32 participants. Four themes emerged from the framework analysis: (i) socio-cultural issues related to hypertension, (ii) socio-economic factors related to hypertension, (iii) knowledge and perception about hypertension, and (iv) proposed interventions for the prevention of hypertension. The consumption of bitter berries, a family-centered care approach, and cultural practices for food preparation were perceived to be key in the prevention of hypertension. Conclusion The findings from this research have significant policy implications particularly targeted interventions focusing on a family-centered approach care for the prevention of hypertension in rural communities of Uganda and across low- and middle-income countries with similar settings. This study has uncovered traditional practices for the prevention of hypertension in the communities surveyed. A key example is the use of bitter berries in the prevention of hypertension. However, clinical trials are required to further examine the effectiveness of bitter berries in the regulation of blood pressure in the adult population. Key words Hypertension, healthy lifestyle behaviours, prevention Key * = p-value = ≤ 0.01 to ≤ 0.05 ** = p-value = <0.01 to ≤ 0.009 *** = p-value = < 0.009 1 1 Chapter One: Introduction and Background 1.1 Chapter Overview This chapter presents an introduction to this thesis, which explored awareness and lifestyle behaviours for the prevention of hypertension in rural communities in Uganda. Statistics for the prevalence of hypertension globally and in low- and middle-income countries, including Uganda, are presented. The chapter then discusses current knowledge about the prevention of hypertension, healthy lifestyle behaviours that influence the prevalence of hypertension and effective interventions for the prevention of hypertension. The chapter also describes the research problem and significance of this study and elucidates the theoretical dimensions and motivation underpinning the study. 1.1.1 Introduction Globally, hypertension is the leading cause of premature death and cardiovascular diseases (CVDs). Furthermore, global estimates indicated that the number of people with hypertension increased from 594 million in 1975 to 1.13 billion in 2015 (WHO, 2019), and is likely to exceed 1.6 billion by 2025 (Fuchs & Whelton, 2020; Mills et al., 2016; Wang et al., 2020; WHO, 2019). A recent global study that included 195 countries reported that the number of hypertensive cases had more than doubled from 7.7 million in 1990 to 17.1 million in 2017, and the number of hypertensive fatalities and disability-adjusted life years had also increased significantly, reaching 925,675 cases and 16.5 million, respectively (Dai et al., 2021). The prevalence of hypertension in low- and middle-income countries has been estimated at 32.3%, with the highest estimates coming from the Latin America and Caribbean region (39.1%, 95% confidence interval [CI]: 33.1%–45.2%) (Sandelowski, 2000). Furthermore, the African region had the highest prevalence of hypertension among adults aged 25 years and above (46%) and the Americas had the lowest (35%) (Mills et al., 2016; WHO, 2013). However, many risk factors for hypertension are preventable. The World Health Organization (WHO) regions demonstrated disparities in the distribution of the prevalence of hypertension, with the highest prevalence in the African WHO region (27%) and lowest in the American region (17%), which supported earlier estimates (WHO, 2019). This is further supported by a study that was conducted in East and West Africa in seven communities. Results showed that 25% of participants had high blood pressure, 40% were ignorant of it, 50% of those who were aware received treatment, and 2 only 50% of those who received treatment had regulated blood pressure (Okello et al., 2020). However, according to a more recent survey conducted by the World Hypertension League, Africa currently seems to have the greatest prevalence of hypertension globally, with rates for both sexes combined among those over 25 years old approaching 46% (Parati et al., 2022). Although the prevalence of hypertension is Africa is high, the diagnosis, treatment, and management of hypertension face several obstacles in Africa, including inadequate patient knowledge, restricted access to healthcare services, overworked healthcare systems, issues with the health staff, shortage of inexpensive medication, and noncompliance with medication schedules (WHO, 2023b). A study conducted across six different Sub-Saharan African regions reported that there was a significant difference in the prevalence and awareness of hypertension across these regions and recommended the need for country-specific awareness programs (Gómez-Olivé et al., 2017). In that study, the South African sites showed the highest prevalence (ranging from 41.6% to 54.1%), and Burkina Faso showed the lowest prevalence (15%). Analysis of the prevalence stratified by sex showed that in Agincourt, Dikgale, and Nairobi, women had higher rates of hypertension than men, whereas men had significantly higher rates than women in Nanoro (Burkina Faso). However, the prevalence of hypertension increased with age in both sexes (Gómez-Olivé et al., 2017). An epidemiological study conducted in Uganda showed that the overall prevalence of hypertension was 26.4%, with the highest prevalence (28.5%) in Central Uganda and the lowest (23.3%) in the Northern region (Guwatudde et al., 2015). Overall, the prevalence of hypertension in Uganda is high compared with the WHO 2000–2025 age-standardized prevalence of 19.5% (Ahmad et al., 2001). Moreover, the age-standardized prevalence rates in Uganda were reported to range from 19.8% to 30.50% in earlier investigations (Kotwani et al., 2013; Maher, Waswa, Baisley, Karabarinde, & Unwin, 2011; Mondo, Otim, Musoke, Orem, & Akol, 2016; Morgan, 1998; Musinguzi & Nuwaha, 2013; Wamala, Karyabakabo, Ndungutse, & Guwatudde, 2009). Based on this previous literature, it was evident that the prevalence of hypertension in Uganda was established approximately eight years prior to the current study. In addition, most of these studies used a quantitative approach to establish the prevalence and none attempted to explore the reasons as why the prevalence has consistently remained high. This then highlighted the need to determine the current prevalence of hypertension in the Central Region of Uganda. The prevalence statistic was then used to explore why the prevalence remained high, as well as propose preventive measures to the prevention of hypertension by using a qualitative approach. 3 Concerningly, the overall rate of awareness of hypertension in Uganda was reported to be very low at 7.7%, with awareness being significantly lower among rural communities compared with urban communities (12.1%) (unadjusted p=0.001) (Guwatudde et al., 2015). In that study, body mass index (BMI) and age were significantly associated with the prevalence of hypertension. Bloch (2016) revealed that between 2000 and 2010, high-income countries were able to show substantial improvements in awareness about hypertension (58.2%–67.0%) compared with low- income countries, which reported considerably lower rates of awareness (32.3%–37.9%). It is therefore imperative to pay serious attention to the significant and growing differences in the global burden of incorrectly treated hypertension, and potentially adjust the approaches used to raise awareness and help prevent hypertension. The World Heart Federation indicated that by 2025, the global rate of hypertension control is expected to have increased by 25% (Adler et al., 2015). However, achieving this objective requires a significant decrease in the burden of hypertension across the world. It is therefore important to focus on achieving controlled blood pressure for people with hypertension, which is a challenge in low- and middle-income countries as their healthcare systems are challenged by limited resources. Therefore, the prevalence of hypertension in low- and middle-income nations could be reduced by population-based changes in healthy behaviours such as sodium intake, exercise routines, and weight management (Bloch, 2016). This highlighted a need to assess people’s knowledge and awareness about hypertension in rural communities, which may inform policymakers about implementing effective awareness programmes and reducing the high rates of hypertension in these areas. Hypertension is described as a silent killer (WHO, 2019). The best approach to address hypertension is via prevention before it manifests (Zheng, Li, & Cai, 2014). In the Framingham study conducted in Massachusetts in the US, the risk for developing hypertension was associated with blood pressure history, BMI, parental history, and smoking habits (Parikh et al., 2008). Therefore, because hypertension and its impacts disproportionately affect neglected and underprivileged communities, public health interventions for hypertension have potential to reduce CVDs across a range of groups at risk (Ferdinand et al., 2012). Moreover, evidence has shown that public health approaches have greatly reduced the morbidity and mortality associated with hypertension in high-income countries (Bloch, 2016). This implies that when people are informed about their blood pressure status and associated risk factors, the incidence of hypertension may be reduced. 4 In Uganda, a nationwide epidemiological survey was conducted across rural and urban communities using the WHO stepwise (STEPS) approach for the surveillance of non- communicable diseases (Guwatudde et al., 2015). This survey instrument has three steps: a questionnaire, physical measurements, and biometric measurements. The STEPS approach is an important framework for obtaining data on risk factors for non-communicable diseases. The tool is flexible and can be modified to accommodate country-specific interests (Guthold et al., 2011; Riley et al., 2016; WHO, 2020). Guwatudde et al. (2015) established that many participants in their study had heard of and even seen people with hypertension, but their understanding of the disease remained limited. Another study conducted in Eastern Uganda among people aged 35–60 years found that hypertension was associated with increasing age and being overweight (Wamala et al., 2009). In addition, people who lived in rural areas were more likely to be hypertensive compared with those in peri-urban areas (p=0.013) (Wamala et al., 2009). However, Guwatudde et al. (2015) did not find any significant difference in the prevalence of hypertension between rural and urban communities. Most people with hypertension are not aware of their status, which calls for the reinforcement of existing efforts to prevent hypertension (WHO, 2014). This also highlights the need to focus on the high prevalence of hypertension and the low rates of hypertension awareness in Uganda. Any opportunity that may inform efforts to prevent the disease must be considered. For this reason, this study sought to explore awareness and healthy lifestyle behaviours for the prevention of hypertension in rural communities in Central Uganda. 1.1.2 Background Hypertension is the leading preventable risk factor for mortality in both developed and developing countries worldwide (Bloch, 2016; Ferdinand et al., 2012; Krousel-Wood, Muntner, He, & Whelton, 2004). Furthermore, hypertension contributes to 45% of deaths due to heart diseases, with 51% of this mortality attributable to stroke (WHO, 2013). African Caribbean-born people have a 50% higher prevalence and incidence of hypertension than American people. However, the African Caribbean has a lower rate of awareness of hypertension compared with America (Kumar, 2013). Moreover, hypertension accounts for more than 10 million preventable deaths globally each year (Patel et al., 2016), and about 75% of people with hypertension (1.04 billion) live in low- and middle-income countries (Mills, Stefanescu, & He, 2020). A person is supposed to start taking antihypertensive medication when their blood pressure is ≥140/90 mmHg. 5 However, antihypertensive medications are costly, and adherence is a challenge, especially in poorly resourced settings. Importantly, many of the predisposing factors for hypertension can be prevented (Unger et al., 2020). Based on this evidence, the need to explore healthy lifestyle behaviours for the prevention of hypertension has become imperative in Uganda, which is a resource-limited country (Owor, 2020). Globally, the burden of hypertension is high, with four in every 10 adults over age 25 years being at risk for premature death and disability (Khalsa et al., 2014; Lane et al., 2012; Lim et al., 2012). Prevention of hypertension is essential to reduce CVDs and improve the quality of life of individuals. The risk factors associated with CVDs include smoking, poor diet, lack of exercise, and excessive alcohol intake (Adrega, Ribeiro, Santos, & Santos, 2018; Lee, Kim, & Kang, 2019). Aging is a long-term risk factor for developing hypertension. In high-income countries, older age groups (≥60 years) are most affected by hypertension (Mills et al., 2016) and this was also evident in the US (Nwankwo, Yoon, & Burt, 2013). In contrast, the most affected age group in low- and middle-income countries is those aged 40–59 years (Mills et al., 2016). In addition, males in both high-income and low- and middle-income countries tend to have a higher prevalence of hypertension than females (Mills et al., 2016). These findings have been further supported by a systematic review and meta-analysis conducted in Cameroon, which reported that the hypertension prevalence was 34.3% among men and 31.3% among women (Mbanya et al., 2019). Guwatudde et al. (2015) reported that aging and BMI were the only significant non-modifiable and modifiable risk factors, respectively, that were associated with the risk for developing hypertension. Although other risk factors were not statistically significant in that study, other potential confounding factors may explain those findings (Vernon, Laville, & Jackson, 1990). Therefore, it is important to consider both modifiable and non-modifiable risk factors for hypertension prevention. Guwatudde et al. (2015) found that many people were not aware that they were hypertensive. Lack of awareness is therefore a public health threat that may eventually increase a country’s healthcare burden (Guwatudde et al., 2015). This highlights the importance of exploring knowledge about hypertension, healthy lifestyle behaviours, and the prevalence of hypertension to establish context- specific recommendations for preventive measures. Other studies also identified the need for blood pressure surveillance, information regarding prevalence, and improved knowledge about the 6 diagnosis, treatment, and management of hypertension in their respective nations (Khalsa et al., 2014; Lane et al., 2012). Approximately 80% of CVD-related mortality occurs in low- and middle-income countries. Evidence shows that public health strategies and policies, such as promoting healthy living, evidence-based clinical practice, and community preventive practices, can help to prevent hypertension (Ferdinand et al., 2012). The World Hypertension League (WHL) developed a needs assessment tool to support the development of hypertension prevention and control programs. Findings from that assessment indicated that among the societies assessed, developing educational resources was ranked among the most important (10 of 14) actions (Khalsa et al., 2014). In addition, a need for customized guidelines was identified because of differences in economic status, ethnicity, and language across the studied countries. Furthermore, the WHL study identified a need for developing national programs involving hypertension prevention, screening, and control, with an emphasis on education for the public and healthcare professionals (Khalsa et al., 2014). Evidence from the WHL study highlighted the need for every country or community to assess and identify appropriate preventive measures for hypertension. However, a study conducted in Nepal reported an increasing burden of non-communicable diseases, mainly because their healthcare system was focused on the curative instead of the preventive and promotive aspects of health (Oli, Vaidya, Subedi, & Krettek, 2014). Hypertension is a public health issue because of the morbidity and associated costs for society (Gaziano, Bitton, Anand, & Weinstein, 2009). To reduce the occurrence of hypertension, healthcare professionals should detect hypertensive individuals early and encourage preventative actions. The targeted method is used to treat patients with hypertension, but it has also successfully been employed to prevent hypertension in people who are at high risk for the disease (Whelton, Carey, & Aronow, 2018). A study from China reported that implementing a community intervention program that included lifestyle changes and hypertension education for rural communities was a potent strategy to lower the prevalence of hypertension and enhance long-term health outcomes (Huang et al., 2011b). Similarly, a study conducted in Uganda identified the need for sustainable interventions to assist in reducing the burden of hypertension in Ugandan communities (Guwatudde et al., 2015). 7 1.1.1.1 Definition of hypertension Hypertension is also known as raised blood pressure or high blood pressure, and is usually asymptomatic (Zhou et al., 2021). Blood pressure represents the amount of force applied to the main arteries by circulating blood (WHO, 2019). For many people, hypertension is a silent disease with no symptoms. It is often only detected when a person visits their local primary healthcare center or hospital for an unrelated condition and their blood pressure is checked (WHO, 2019). If not diagnosed and treated early, hypertension causes damage to the arteries supplying major organs in the body, such as the heart, kidney, brain, and eyes. It may also increase the risks for stroke, ischemic heart disease, and renal failure (WHO, 2019). The focus of the present study was the primary prevention of hypertension. In primary prevention, a susceptible population or person is the target of primary preventative strategies. Primary prevention aims to stop a disease before it ever starts. Consequently, its intended audience is healthy people. Conversely, secondary prevention targets healthy-appearing people with subclinical disease and emphasizes early disease identification (Kisling & Das, 2021). The definition of hypertension used in this study was adopted from the American College of Cardiology/American Heart Association and National Institute for Health and Care Excellence (NICE) guidelines (Jones, McCormack, Constanti, & McManus, 2020). Hypertension is defined as a systolic blood pressure of ≥140 mmHg and diastolic blood pressure of ≥90 mmHg (Armstrong & Bull, 2006; Flack & Adekola, 2020; Jones et al., 2020; Unger et al., 2020; Whelton et al., 2017; Whelton et al., 2022). NICE further defines hypertension in three stages based on blood pressure measurement and severity (Table 1): grade one is blood pressure ≥140/90 mmHg; grade two is blood pressure ≥160/100 mmHg; and grade three is a systolic blood pressure of ≥180 mmHg or a diastolic blood pressure of ≥110 mmHg (Jones et al., 2020). However, the NICE NG136 of 2019 recommends that the blood pressure measurement should be <140/90 mmHg in all adults younger than 80 years and <150/90 mmHg for people older than 80 years (Jones et al., 2020). It is important that before making a diagnosis of hypertension, the blood pressure is taken in both arms and if the difference in blood pressure is greater than 15 mmHg, the blood pressure in the arm with a higher blood pressure is repeated (Muntner et al., 2019; NICE, 2023). When the blood pressure remains ≥140/90 mmHg, another blood pressure is taken and then the last two blood pressures are recorded (NICE, 2023). On the other hand, a persistent clinic blood pressure of ≥140/90 mmHg suggests the need for an ambulatory blood pressure monitoring (ABPM). An 8 average ABPM or home blood pressure monitoring (HBPM) average of ≥135/85 mmHg confirms a diagnosis of hypertension. Once using the ABPM, is important to note that the blood pressure is taken twice every hour and an average of fourteen readings is taken to confirm the diagnosis of hypertension (NICE, 2023). On the other hand, when using the HBPM, the person has to be seated and two blood pressure measurements are taken with an interval of one minute and this is repeated for seven days and thereafter, although the average blood pressure readings of the last six days is considered for the diagnosis to be confirmed, and it is preferably done in the morning and evening (NICE, 2023). Previous studies have defined hypertension differently where they took an average of the last two blood pressures if a participant had done three blood pressures and an average of two if they had a record of two blood pressures (Geldsetzer et al., 2019). Although (Ntaganda et al., 2022) used the average of three blood pressure measures in their study, they used a one-minute interval between measurements. This implies that if the NICE guidelines of 2023 are applied in the different studies, the prevalence rates would most likely be higher then what they are now. Table 1: Classification of blood pressure levels of the British Hypertension Society Category Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Blood pressure Optimal <120 <80 Normal <130 <85 High normal 130–139 85–89 Hypertension Grade 1 (mild) 140–159 90–99 Grade 2 (moderate) 160–179 100–109 Grade 3 (severe) ≥180 ≥110 Isolate systolic hypertension Grade 1 140–159 <90 Grade 2 ≥160 <90 (Williams et al., 2018) 9 1.1.1.2 Knowledge about hypertension prevention Prevention of hypertension in primary care is important and helps to avert the complications and costs associated with later hypertension management (Whelton et al., 2002). For populations to be able to implement preventive measures and achieve prevention, they need to know about hypertension and the correct interventions to employ. This was supported by a study conducted by the National High Blood Pressure Education Program Coordinating Committee that focused on the primary prevention of hypertension (Whelton et al., 2002). That study identified a need for individuals to gain more knowledge on the effectiveness of dietary and lifestyle modifications to prevent hypertension and therefore made recommendations for further research (Whelton et al., 2002). Furthermore, knowledge about hypertension and its prevention has an important role to play in the prevention of hypertension (Sengwana & Puoane, 2004; Williams, Baker, Parker, & Nurss, 1998). Knowledge about diseases or illnesses increases with increasing education levels and socioeconomic status, and is not related to the age of an individual (Kasl & Cobb, 1966). A mixed methods study conducted in Ghana revealed that there was an association between participants’ level of education and knowledge about hypertension, with a high level of knowledge found among educated participants (Agyei-Baffour, Tetteh, Quansah, & Boateng, 2018). Furthermore, a systematic review and meta-analysis from Africa found that hypertension was common among people with no formal education (Kaze, Schutte, Erqou, Kengne, & Echouffo-Tcheugui, 2017). Another study conducted among hypertensive and non-hypertensive people in rural areas of China revealed that the hypertension knowledge score among those diagnosed with hypertension was approximately 26% compared with 20% among non-hypertensive participants (Wang, Kong, Wu, Bai, & Burton, 2005). This implied that when a person suffers from a disease or condition, it is likely that they will have more knowledge about that disease/condition compared with someone who does not have the disease. In addition to education level, other factors that influence individuals’ levels of knowledge about hypertension include marital status, health status, reading health-related materials regularly, history of blood pressure checks, and joining hypertension workshops facilitated by health workers (Wang et al., 2005). A significant finding in another study was that participants who had a high school education level were able to tell the difference between systolic and diastolic blood pressure and had received information about hypertension from their 10 medical team compared with who had no high school education (Oliveria, Chen, McCarthy, Davis, & Hill, 2005). Place of residence has also been associated with the risk for developing hypertension. A study conducted across high-, middle-, and low-income countries in five continents (17 countries including three high-income countries, seven upper-middle-income countries, three low- and middle-income countries, and four low-income countries) examined baseline participant characteristics for the Prospective Urban Rural Epidemiology (PURE) project to determine the prevalence, awareness, treatment, and control of hypertension (Chow et al., 2013). The findings showed that awareness of hypertension was similar in rural and urban communities in high-income countries. However, awareness was considerably lower in rural communities versus urban communities in low-income countries (Chow et al., 2013). Shaikh et al. (2011) assessed knowledge about risk factors for hypertension among medical students at the Gulf Medical University Ajman, in the United Arab Emirates (UAE) and showed that the majority (70%) of participants knew some risk factors for hypertension such as stress, high BMI, and high cholesterol levels. However, approximately 86% of participants did not know that low physical activity levels and use of oral contraceptives were risk factors for developing hypertension. In addition, almost 50% of the participants did not know that old age, genetic predisposition, and male gender were non-modifiable risk factors for hypertension (Shaikh et al., 2011). This suggested that an individual’s educational background determines how much they know about preventing hypertension. Spencer, Phillips, and Ogedegbe (2005) conducted a study in rural communities of Ghana that revealed there were statistically significant relationships between being normotensive and age and employment status. Participants with normal blood pressure were younger (42 vs. 61 years), had a lower BMI (24 kg/m2 vs. 27 kg/m2), and were more likely to be employed (74% vs. 64%) than participants with hypertension (all values significant at p<0.05). Moreover, ideas that emerged when participants were asked what they believed to be the causes of high blood pressure included stressors from daily living, traumatic life events, coexisting medical disorders, and behavioural elements (Spencer et al., 2005). Based on the evidence provided, most available studies focused on knowledge about secondary prevention of hypertension and factors that influenced the knowledge that individuals may have. Furthermore, those studies indicated that low knowledge levels were more common in 11 rural than urban communities (Chow et al., 2013). However, few studies have concentrated on the knowledge that people held pertaining to primary prevention of hypertension. 1.1.1.3 Healthy lifestyle behaviours that influence the prevalence of hypertension Most approaches to the prevention of hypertension have largely focused on early diagnosis, treatment, and rehabilitation. However, this leaves the management cycle for hypertension incomplete without primary prevention of the disease, despite three-quarters of all CVDs being preventable using lifestyle modifications (Perk et al., 2012; Perk et al., 2013). Moreover, with the increasing prevalence of hypertension and projected 60% prevalence globally by 2025, the prevention of hypertension is a major public health concern (Kearney et al., 2005). Several lines of evidence suggest there are different lifestyle behaviours that influence the prevalence of hypertension. These include modifiable lifestyle factors such as physical activity, alcohol consumption, smoking, and nutrition patterns (Alsinani et al., 2018; National High Blood Pressure Education Program: Working Group on Primary Prevention of Hypertension, 1993; Perk et al., 2013). Many studies have emphasized that hypertension is preventable through lifestyle modifications (Alsinani et al., 2018; Perk et al., 2012). Lifestyle is defined as an individual’s healthy and unhealthy behaviours that can impact their health status (Shafieyan et al., 2016). Previous studies showed that the most important risk factors in an individual’s lifestyle were low physical activity, smoking, poor diet (Wang et al., 2005; WHO, 2002), and alcohol consumption (Defo et al., 2017; Zheng et al., 2014). In addition, low socioeconomic status has been associated with an increased number of risk factors that an individual may have and therefore an increased predisposition for hypertension (Khan et al., 2013). This was demonstrated in a study conducted among public-sector workers in Angola that showed that people in low socioeconomic areas had higher incidences of hypertension (Capingana et al., 2013), which was possibly attributable to their inability to afford healthy foods. Details of specific lifestyle behaviours are discussed in the following sections. 1.1.1.3.1 Physical activity Given the increasing prevalence of hypertension globally, physical activity has been suggested as a preventive measure for hypertension at the primary prevention level (Diaz & Shimbo, 2013), because it lowers peripheral vascular resistance (Hegde & Solomon, 2015). Physical activities involve the use of the musculoskeletal system to make movements that result in the use of energy. Physical activities include the activities that an individual performs in relation 12 to their work as well as specific activities performed for the purposes of health promotion and disease prevention (Caspersen, Powell, & Christenson, 1985). Other components of physical activity include exercise (deliberate and regular) and physical fitness, which refers to an individual’s ability to perform physical activities without experiencing fatigue (Caspersen et al., 1985). Performing adequate physical activity is important for reducing obesity, which in turn helps to prevent hypertension. A study conducted among Vietnamese individuals independently linked age, educational attainment, BMI, and physical activity to hypertension in both men and women (Do, Geleijnse, Le, Kok, & Feskens, 2015). Although adequate physical activity is associated with a reduced likelihood of developing hypertension, the population of Vietnam tends to live a relatively sedentary lifestyle because of the country’s rapid industrialization, urbanization, and modernization; people therefore had low physical activity at work, moving to and from work, and during their free time (Do et al., 2015). The Global Physical Activity Questionnaire (WHO, 2005) indicates that each week, individuals should engage in at least 150 minutes of moderate-intensity physical activity, 75 minutes of vigorous-intensity physical activity, or an equivalent combination across three domains (work, travel, and leisure). Physical activities are categorized as vigorous-intensity if they cause a significant increase in breathing or heart rate, and as moderate-intensity if they cause a smaller increase in breathing or heart rate. In both categories, physical activities should be performed continuously for at least 10 minutes (Armstrong & Bull, 2006). However, a study conducted in Bangladesh rated physical exercise as low for performing housework, medium for walking and swimming, and adequate/high when performing sports, heavy lifting, or jogging (Ali, Mohanto, Nurunnabi, Haque, & Islam, 2022). Studies from China and Vietnam classified physical activity as low, moderate, and high based on the self-report Global Physical Activity Questionnaire Analysis Guide and using metabolic equivalent (MET) minutes per week (Cai, Liu, Zhang, Li, & Wang, 2012). The number of days (per week) and minutes (per day) that participants spent engaging in moderately intense sports activity, walking, moderately intense household activity, and moderately intense farming were recorded. Physical activity duration was multiplied by the MET values for each activity. The low, moderate, and high categories were obtained if participants engaged in any combination of 13 walking, moderate-intensity, or vigorous-intensity activities for at least 600 MET minutes each week, 600–3,000 MET minutes each week, and ≥3,000 MET minutes each week, respectively (Do et al., 2015). Similarly, a study from Iran categorized physical activity as low, moderate, and high using the International Physical Activity Questionnaire-Short Form. This tool uses self-reported physical activities performed to estimate MET minutes and number of days/weeks spent performing physical activities (Mirzaei, Mirzaei, Gholami, & Abolhosseini, 2021). That study revealed that 50% of adults had low physical activity and 75% were overweight or obese. Moreover, people with higher levels of education, more physical activity, and lower BMI had a lower prevalence of hypertension (p<0.0001) than those with low education, less physical activity and higher BMI (Mirzaei, Mirzaei, Gholami, & Abolhosseini, 2021). Performing adequate physical activity is important for reducing obesity, which in turn helps to prevent hypertension. Vuillemin et al. (2005) investigated the relationship between meeting public health recommendations for moderate and vigorous physical activity in adults (aged ≥35 years) and health-related quality of life. That study found there was a significant relationship between leisure-time physical activity and health-related quality of life among both men and women. This was consistent with the Physical Activity Guidelines for Americans Health and Services (2008), which asserted that health-related outcomes increased with increasing physical activities, intensity, and longer performance duration. This suggested that sufficient physical activity reduced a person’s chances of developing hypertension, which was supported by a systematic review and meta-analysis involving randomized clinical trials (more than 5000 participants) focused on exercise training for blood pressure (Cornelissen & Smart, 2013). The findings of that study showed that exercise training substantially reduced both systolic and diastolic blood pressure. Similarly, the WHO recommends that adults aged 18–64 years engage in 150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous aerobic physical activity per week (WHO, 2011). In addition, it is recommended that adults increase their moderate aerobic physical activities to 300 minutes (or 150 minutes of vigorous aerobic activities) to maximize the health benefits (WHO, 2010). This highlights the positive relationship between increased physical activity and health benefits, including the primary prevention of hypertension. This was further supported by a study conducted in rural and urban communities of Cameroon that found a reduction in BMI and blood pressure with increased physical activity, although that study could not show a dose-response relationship between physical activity and health benefits 14 (Sobngwi et al., 2002). Furthermore, a recent systematic review and meta-analysis (Wamba, Takah, & Johnman, 2019) found a reduction in diastolic blood pressure for one study, but failed to draw conclusions for another study that did not have a follow-up of participants. Moreover, a study conducted in urban Uganda to establish the determinants of raised blood pressure showed a statistically significant difference in the odds ratio (OR) between raised blood pressure and moderate-to-vigorous intensity activities for more than 4 hours a week (Chin et al., 2017). Although that study was conducted in urban Uganda and yielded significant findings, there is no evidence of similar findings in rural communities. Therefore, it is necessary to clarify the status of healthy lifestyle behaviours (e.g., physical activity) for the prevention of hypertension in rural communities in Uganda. 1.1.1.3.2 Alcohol consumption Previous research from developed countries established that a reduction in alcohol consumption reduced blood pressure in both hypertensive and normotensive individuals (Klatsky, 1996; Skliros et al., 2012; Ueshima et al., 1993). This was confirmed in several randomized controlled trials involving people from different geographical locations and cultural backgrounds that showed a positive relationship between a reduction in alcohol consumption and reduced blood pressure (Cushman et al., 1996; Cushman, 2001; Cushman et al., 1994). Various factors play roles in determining the effects of alcohol on blood pressure (Potter & Beevers, 1985). Alcohol intake immediately results in vasodilation, and continuous intake of alcohol leads to increased blood alcohol levels (Potter & Beevers, 1985). However, blood pressure changes are normally seen around 24 hours after alcohol intake, which suggests that the effect of alcohol on blood pressure is not influenced by long-term structural damage (Moreira, Fuchs, Moraes, Bredemeier, & Duncan, 1998). Therefore, studying alcohol consumption among normotensive populations may contribute to efforts for primary prevention of hypertension. In addition, a meta-analysis involving 15 randomized control trials (total of 2234 participants) that were published before June 1999 aimed to evaluate the impact of alcohol reduction on blood pressure (Xu & Ragain, 2005). That analysis revealed that the general pooled estimates of the effect of alcohol decrease on systolic and diastolic blood pressure were −3.31 (95% CI: −2.52 to −4.10) mmHg and −2.04 (95% CI: −1.49 to −2.58) mm Hg, respectively (p=0.0001 for both). The association between alcohol and hypertension has also been studied in 15 urban communities in Accra Ghana, and high levels of alcohol consumption were linked with hypertension (Afrifa–Anane, Agyemang, Codjoe, Ogedegbe, & de-Graft Aikins, 2015). Similarly, a cross-sectional study conducted in Rukungiri (South-Western Uganda) reported that factors that were significantly associated with hypertension included high consumption of alcohol (OR=2.28, 95% CI: 1.42–3.64), tertiary education (OR=1.91, 95% CI: 1.03–3.56), older age (OR=1.42, 95% CI: 1.27–1.59), and high BMI (overweight: OR=1.95, 95% CI: 1.37–2.79; obesity: OR=5.07, 95% CI: 2.79–9.21). Those authors also found a high prevalence of hypertension in the investigated rural district, which later guided their recommendation for further research to determine the distribution and determinants of hypertension in other parts of the country (Wamala et al., 2009). However, most research to date has focused on secondary prevention of hypertension rather than primary prevention; a reduction in the prevalence of hypertension and effective management would yield better results if primary prevention is given due consideration (Diaz & Shimbo, 2013). 1.1.1.3.3 Smoking Buttar, Li, and Ravi (2005) found that 80% of heart diseases could be prevented by modifying risk factors. Smoking is thought to be one such factor. A systematic review of studies conducted in low- and middle-come countries revealed the prevalence of hypertension was significantly higher in non-smokers compared with smokers in most countries (Sarki, Nduka, Stranges, Kandala, & Uthman, 2015). This was further supported by Green, Jucha, and Luz (1986), and it was later concluded that the role of smoking in hypertension was unclear. In contrast, Sarki et al. (2015) found that in Asia, smoking was an independent risk factor for hypertension and there was a higher prevalence of hypertension among smokers compared with non-smokers. However, the proportion of hypertension among non-smokers was thought to be attributable to smokers reporting themselves as non-smokers (Sarki et al., 2015). In the US, less than 50% of the population is protected from secondary smoking because anti-smoking laws have not been reinforced in most public places, such as bars, restaurants, and workstations (Bauer, Briss, Goodman, & Bowman, 2014). However, this issue could be overcome by programs that focused on communities, schools, workplaces, and restaurants as well as high- risk populations (Burt et al., 1995). It is important to note that smoking cessation alone may not prevent hypertension among individuals. For example, a study from China found that ageing was a major non-modifiable risk that lead to an increased prevalence of chronic diseases, for which hypertension was the main risk factor (Wang et al., 2005). Moreover, it was estimated that between 16 2000 and 2040, death due to CVDs in China would increase by 200% (Wang et al., 2005), which calls for the development of appropriate measures to curb the situation. Furthermore, a study conducted in Korea considered the effects of different types of smokers, including hidden smokers, and evaluated the association between smoking and hypertension using innovative variables and a population-based sample (Kim & Lee, 2019). The results of their multivariate logistic regression analysis revealed that current and former smoking were not associated with hypertension (OR=1.25, 95% CI: 0.99–1.57 and OR=1.20, CI: 0.90–1.60, respectively). Although there was no connection between smoking and hypertension, when gender was not considered, regarding the cotinine-verified smoking status and smoking cessation services (SCS), the adjusted ORs in the relationship between smoking and hypertension in female smokers were 1.44 (95% CI: 1.02–2.04) and 1.46 (95% CI: 1.05–2.02), respectively (Kim & Lee, 2019). This evidence emphasized that as there are numerous risks for hypertension, prevention of hypertension requires a comprehensive exploration of the role of different healthy lifestyle behaviours, including smoking. 1.1.1.3.4 Nutrition patterns Zheng et al. (2014) described the estimation of hypertension risk from lifestyle factors using a case study from Pizhou City, Jiangsu Province, China. That study aimed to create a combined model that replicated the illness grade of an individual patient based on lifestyle factors and a simple health profile using the surrogate signature model. Although fasting blood sugar was a significant indicator of hypertension, other indicators could be created with minimal errors. Zheng et al. (2014) noted that a surrogate signature was made up of health profile and lifestyle features used in risk screening. The identified risk factors for developing hypertension were: age; arterial pulse; fasting plasma glucose; BMI; sleep quality; intake of salt, oil, and alcohol; and stress. When fasting plasma glucose data were absent, diet-related factors were considered, such as the amount of food consumed, money spent on food, and type of meats eaten. Importantly, the surrogate model did not require full knowledge of the individual’s health. That study reported several interesting findings. The use of animal fats was found to reduce the risk of developing hypertension, whereas divorce increased the chance of developing hypertension; these factors may offer good indicators to consider in the prevention of hypertension. However, the surrogate model had limitations because its lifestyle pattern comprised compound behaviours related to multiple 17 historical, geological, economic, cultural, and ethnic influences. Therefore, further studies were recommended to compare the different parameters (Zheng et al., 2014). A large and growing body of literature has investigated sodium consumption and its relationship with blood pressure. Sodium intake is regulated by the nervous system and must therefore be maintained within a normal range (i.e., 136–146 mEq/L) (Pohl, Wheeler, & Murray, 2013) as too much or too little intake may cause damage to body tissues (Grillo, Salvi, Coruzzi, Salvi, & Parati, 2019). Intake of excess amounts of sodium causes fluid retention, which in turn increases blood volume and blood pressure (Grillo et al., 2019; Guyton, 1991; Wenstedt et al., 2022). Evidence from a systematic review and meta-analysis of randomized trials revealed that a modest reduction in salt intake significantly reduced blood pressure in both normotensive and hypertensive individuals, irrespective of their sex and ethnic background (He, Li, & MacGregor, 2013). Similarly, a more recent systematic review and meta-analysis that included studies from six Sub-Saharan African countries found that salt-limiting interventions were effective in reducing blood pressure (Wamba et al., 2019). However, those findings may not be representative of the general Sub-Saharan African population, and there is a need for a larger-scale study. Furthermore, a study that was conducted to establish the salt content in instant noodle formulations in 10 countries found that the sodium levels were high but differed across countries; noodles in China had the highest amount of sodium (1944 mg/100 g; range: 397–3678 mg/100 g) compared with New Zealand (798 mg/100 g; range: 249–2380 mg/100 g) (Farrand et al., 2017). That study found that on average, a noodle packet accounted for 35%–95% of the daily salt consumption (<5 g) recommended by the WHO; 37% of the instant noodles were within limits of South African targets, 45% satisfied Pacific Island region targets, and 62% met the 2017 United Kingdom targets (Farrand et al., 2017). These findings indicated a need to monitor the salt content in noodles worldwide to prevent some incidences of hypertension given that they are an increasingly popular food choice (Wang & Labarthe, 2011). Interestingly, a study conducted in West Africa that compared salt intake between rural and urban communities revealed that rural communities consumed more salt compared with urban communities (Kerry et al., 2005). This finding was one of the motivations for the present researcher to conduct this study in rural communities in Uganda and explore their practices regarding salt intake and its association with blood pressure. Nabatanzi et al. (2022) studied the micronutrients in wild edible berries (Basella alba, Termitomyces microcarpus, Cucurbita pepo, and Solum anguivi) that grow in Mabira forest in 18 Uganda. These berries were referred to as wild edible berries because they grew on their own in the forest without being subjected to pesticides and contaminated water for irrigation. The findings of that study showed that wild edible berries were associated with the prevention of pre-eclampsia (hypertension in pregnancy) and obesity among children aged 6–12 years. B. alba, T. microcarpus, C. pepo, and S. anguivi (commonly known as “katunkuma” in Central Uganda) were reported to contain sodium, potassium, calcium, phosphorus, magnesium, and some trace minerals, such as manganese, copper, and iron. The content of these minerals varied across the different species. Because potassium and sodium are the primary electrolytes and significant cations in body cells, the high potassium content in contrast to the low amounts of sodium in these wild edible berries was a crucial nutritional characteristic (Nabatanzi et al., 2022). Potassium and sodium are necessary for osmotic pressure and blood volume maintenance (Neal et al., 2021). However, in both pregnant women and school-age children, potassium and sodium must be taken in regulated amounts to prevent hypertension (Nabatanzi et al., 2022). Although the population in the study by Nabatanzi et al. (2022) differed from that in the present study, the findings offered some direction regarding the association between wild edible berries and the prevention of hypertension that could be explored further. However, limited literature is currently available regarding the consumption of edible berries grown on farmland and people’s experiences with the prevention of hypertension. The findings reported by Nabatanzi et al. (2022) regarding the role of wild edible berries in regulating blood pressure appeared to be similar to those of Vendrame, Adekeye, and Klimis- Zacas (2022), who studied different types of berries and the role of berry consumption in regulating blood pressure. Anthocyanins, condensed tannins, and ellagic acid are three kinds of polyphenols that may contribute to the potential of these berries for lowering blood pressure (Grosso et al., 2022). The name “polyphenols” refers to a vast class of naturally occurring plant secondary metabolites, which include four main classes: phenolic acids, flavonoids, stilbenes, and lignans. Many of these compounds are known to have vascular, anti-inflammatory, anti-thrombotic, and antioxidant properties that make them highly protective against CVDs (Durazzo et al., 2019). The ability to modulate blood pressure to treat and prevent hypertension has frequently been mentioned as one of their therapeutic benefits (Durazzo et al., 2019) (Hügel, Jackson, May, Zhang, & Xue, 2016). However, there is varying evidence about the role of berry consumption and its association with blood pressure regulation. Current knowledge indicates that although eating berries frequently is advised because of their multiple health benefits, blood pressure regulation does not 19 appear to be the main reason for doing so (Vendrame et al., 2022). This necessitates the exploration of people’s experiences with the use of berries and their role in the prevention of hypertension in the general adult population. Saturated fats consumed in large amounts are stored in various body tissues, including the blood vessels. This eventually causes the narrowing of arteries, which then requires the heart to pump blood at a higher pressure (DiNicolantonio, Lucan, & O’Keefe, 2016; Hu, 2007). A study that investigated the effects of dietary saturated and monounsaturated fatty acids found that consumption of monounsaturated fats reduced both diastolic and systolic blood pressure compared with the intake of saturated fats (Rasmussen et al., 2006). These findings implied that a reduction in saturated fat intake yielded positive results in reducing blood pressure. However, limited studies have investigated the types and quantities of fats that people in rural communities consume. 1.1.1.4 Prevalence of hypertension globally Hypertension has increasingly been seen as a serious public health problem throughout the world (Kearney et al., 2005; Salem et al., 2018; Wamala et al., 2009). Globally, the prevalence of hypertension ranges from 4% to 78%, with the highest prevalence in low- and middle-income countries (Salem et al., 2018). A systematic review and meta-analysis conducted in Africa reported that the prevalence of hypertension was 55.2% in 2017 (Kaze et al., 2017). In Uganda, a study that assessed geographical differences in the prevalence of hypertension reported an overall prevalence of 31.5% (Lunyera et al., 2018). In the same study, demographic characteristics such as education, monthly income and occupation were not significant in explaining the lower prevalence of hypertension in West Nile and the Northern region, and further studies were recommended to explore the impact of epidemiological shifts (e.g., dietary and lifestyle changes) on the development of hypertension. However, urbanization was thought to contribute to the high prevalence of hypertension in the Central Region of Uganda (Lunyera et al., 2018). Chin et al. (2017) asserted that BMI was the major contributing factor to the high prevalence of hypertension, although other studies associated hypertension prevalence with other factors such as random blood sugar, increased alcohol intake, waste-to-hip ratio, and education level (Maher et al., 2011; Nakibuuka et al., 2015). Sarki et al. (2015) reported that the prevalence of hypertension was higher among non- educated populations compared with educated populations in low- and middle-income countries. 20 These findings were consistent with a study conducted in Buikwe District in Uganda, which found that the prevalence of hypertension among uneducated people was three times higher than that among educated people (i.e., tertiary or high school education) (Musinguzi & Nuwaha, 2013). Existing literature from the region on the prevalence of hypertension is extensive and covers different regions in Uganda. However, few studies have focused on the prevalence of hypertension in rural communities of Central Uganda to try and identify possible risk factors for the increasing prevalence of hypertension in that region. 1.1.1.5 Individuals’ experiences in hypertension prevention A qualitative study was conducted among 27 patients with hypertension who were referred to health centres affiliated with the Tehran University of Medical Sciences in Iran to explore their experiences before they became hypertensive (Shamsi, Nayeri, & Esmaili, 2017). Findings from that study showed that participants were both negligent and ignorant about lifestyle modifications, such as nutrition, obesity, exercise, and smoking, which could have helped them to prevent hypertension (Shamsi et al., 2017). Furthermore, participants felt that their disease (hypertension) was a result of their experience of stressful events. Participants also believed that their family background (e.g., poor nutrition in the family, inheritance, and involvement in conflicts) exposed them to the risk for developing hypertension. Other participants believed that job stress, poverty, urbanization, and chemical agents might have contributed to the development of the disease. Moreover, a study from Nepal among hypertensive participants revealed that they believed that implementing and maintaining lifestyle modifications was difficult because their knowledge about the disease was low and people never thought about hypertension until they acquired the disease (Oli et al., 2014). In addition, Chang et al. (2019) conducted a qualitative study to explore challenges to hypertension and diabetes management in rural Uganda; their participants reported that they only went to the hospital when they were too sick to perform their usual routine activities. In addition, participants associated hypertension with stress and a genetic predisposition, and some believed the disease could be acquired at random without specific associated factors. The belief that stress causes hypertension led participants to make sedentary lifestyle choices (e.g., watching television) as a means of blood pressure management (Chang et al., 2019). Barriers to the prevention of hypertension may include: cultural norms; failure to follow health education instructions; lack of funding for health education services, space for physical activities, healthy foods, and physical exercise programs in schools; food served in restaurants; 21 high salt content in foods; and the high cost of foods that are low in sodium and calories (Schwartz, Guwatudde, Nugent, & Kiiza, 2014). Limited studies have been published concerning the healthcare costs associated with the prevention of hypertension and other non-communicable diseases in Uganda (Schwartz et al., 2014), despite it being less costly to focus on prevention than treatment (Brouwer et al., 2015). Low levels of education and knowledge, and unavailability of cardiovascular care greatly increase CVDs and disparities. In the US, it was noted that these disparities included an increased prevalence of severe hypertension, death due to coronary heart disease, stroke, and higher mortality in black people compared with non-Hispanic white people due to CVD (Ferdinand et al., 2012). However, few studies have investigated people’s experiences with the prevention of hypertension. This was supported by Gyarfas (1996), who asserted that the worldwide experience of hypertension control and care was placed on early diagnosis and treatment as opposed to the primary prevention of hypertension. Based on the evidence provided by most of these studies, experiences about prevention of hypertension were collected from hypertensive individuals and there was scanty information of experiences among normotensive individuals, despite prevention of the disease reducing the healthcare burden due to hypertension (Huang et al., 2011b). Furthermore, a study from Ghana that explored the feasibility and acceptability of pharmacist-led prevention of hypertension in the community reported that pharmacists could promote lifestyle modifications in communities and thereby help in the prevention of hypertension (Marfo & Owusu‐Daaku, 2016). This supports the need to explore people’s experiences with primary prevention of hypertension in rural communities. 1.2 Statement of the problem Worldwide, hypertension is the most significant modifiable risk factor for both CVD and overall mortality (Roth et al., 2018; Stanaway et al., 2018). The incidence of various cardiovascular events, including stroke, myocardial infarction, sudden death, heart failure, peripheral artery disease, and end-stage renal disease, were independently correlated with office blood pressure, which is a preventive strategy if individuals measure their blood pressure regularly (Britton, Gaziano, & Djoussé, 2009; Kalaitzidis & Bakris, 2010). Interestingly, the age-standardized prevalence of hypertension fell by 2.6% in high-income countries between 2000 and 2010 but rose by 7.7% in low- and middle-income nations. During the same period, the rates of awareness about 22 hypertension were higher in high-income countries compared with low- and middle-income countries (67.0% in 2010 vs. 37.9% in 2000 and 32.3% in 2010 vs. 37.9% in 2000, respectively) (Mills et al., 2016). However, control and prevention of hypertension depend on people being aware of the disease (Musinguzi & Nuwaha, 2013). The prevalence of hypertension in Uganda is around 26.4%, with the highest prevalence reported in Central Uganda (Guwatudde et al., 2016). After accounting for demographic factors, the prevalence of hypertension was much lower in the North and West Nile than in the Central Region; therefore, it is necessary to conduct more research to ascertain the causes of this disparity (Lunyera et al., 2018). Despite being entirely preventable, hypertension is a major contributor to the global epidemic burden of non-communicable diseases (Khalsa et al., 2014). Bloch (2016) reported that many countries used public health approaches and guidelines for the prevention of hypertension in their communities. For example, the Dietary Approach to Stop Hypertension (DASH) diet was successful in decreasing blood pressure (Appel et al., 1997; Sacks et al., 2001). The DASH diet has a high concentration of fruits, vegetables, whole grains, nuts, legumes, lean protein, and low-fat dairy products, along with a significantly lower concentration of refined sugar, saturated fat, and cholesterol than regular diets (Appel et al., 1997). Compared with sodium restriction or the DASH diet alone, the combination of low sodium intake plus the DASH diet was found to significantly lower blood pressure (Juraschek, Miller, Weaver, & Appel, 2017; Sacks et al., 2001). Although awareness of hypertension is important for the uptake of prevention measures, awareness of hypertension in Uganda, particularly in the Central Region, is low (7.7%) (Guwatudde et al., 2015). Furthermore, the age-standardized prevalence was 19.8% in a rural community in Uganda (Kotwani et al., 2013). . Given the limited healthcare resources in Uganda, research must be directed to preventive measures (Zikusooka, Kyomuhang, Orem, & Tumwine, 2009). Important interventions such as health education, counseling about lifestyle behaviours, and screening for hypertension in rural communities are deemed important to prevent hypertension, especially with society or community involvement (Ofili & Ncama, 2015). These preventive measures are vital to reduce the morbidity, mortality, and disability caused by hypertension, but must be country-specific to be effective (Khalsa et al., 2014). Community-based screening programs, such as the Sustainable East Africa Research in Community Health (SEARCH), uses multi-disease prevention and treatment services that integrate human immune deficiency 23 syndrome (HIV) and non-communicable disease treatments in Uganda (Kotwani et al., 2013) . However, the prevalence of hypertension in Uganda has remained high, with rural communities having the highest prevalence and lowest awareness rates (Mustapha et al., 2022). Although the majority of people in Uganda live in rural communities (Guwatudde et al., 2015), there is limited information concerning awareness and healthy lifestyle behaviours for the prevention of hypertension in these rural communities. Previous studies in Uganda assessed the awareness and prevalence of hypertension from a quantitative perspective (Kotwani et al., 2013; Musinguzi & Nuwaha, 2013) but none explored why awareness and prevalence had persistently remained low and high, respectively. In addition, no study has explored healthy lifestyle behaviours and possible interventions that may be effective for the prevention of hypertension in rural communities in Uganda. A PhD study conducted in Central Uganda used a qualitative design to explore perceptions of the social determinants of hypertension (Busulwa, 2022). Therefore, there is need to explore awareness and healthy lifestyle behaviours to prevent hypertension in rural communities in Central Uganda. Exploring awareness and healthy lifestyle behaviours for the prevention of hypertension will provide recommendations regarding the prevention of hypertension among people in rural communities on potentially effective strategies, which may eventually reduce both the prevalence of hypertension and the associated healthcare burden. 1.3 Significance of the Study Although it is avoidable, hypertension is a hidden killer that contributes to morbidity and mortality in rural areas (WHO, 2013). Emphasis has been placed on the secondary prevention of hypertension in Uganda, although prevention of hypertension at the primary level is vital in preventing morbidity, mortality, and disability (Musinguzi & Nuwaha, 2013). The purpose of community hypertension prevention programs is to strengthen awareness, and in the long run, reduce the complications associated with hypertension. These community programs also enhance community change and reduce the risks for hypertension. However, in Sub-Saharan Africa, including Uganda, there is limited information about awareness and control of hypertension (Musinguzi & Nuwaha, 2013) despite the increasing prevalence (Mayega et al., 2012; Wamala et al., 2009). The findings from this study will inform policy on strategies to support the primary prevention of hypertension in rural communities in Central Uganda and may possibly be extended to other low- and middle-income countries with similar settings. In addition, new knowledge generated from this study will update the education sector regarding inclusion in nursing curricula, 24 which will later influence community practices. Furthermore, evidence obtained from this study will add to the body of knowledge about hypertension awareness and healthy lifestyle behaviours to prevent hypertension at the community level. The gaps identified in this study will also generate new research ideas. 1.4 Justification for the Study In Sub-Saharan Africa and Uganda, little is known about awareness of hypertension and healthy lifestyle behaviours for the prevention of hypertension (Musinguzi & Nuwaha, 2013). Moreover, the prevalence of hypertension is high and awareness is remarkably low (Guwatudde et al., 2015). Most people only learn that they have hypertension after experiencing its repercussions through experiencing related comorbid conditions (Agarwal, 2019; Balwan & Kour, 2021). Uganda’s health sector remains significantly underfunded, mainly relying on private sources of financing and the requirement for individuals to fund their healthcare. Public spending on health is considerably below the Abuja target of 15% agreed to by the Government of Uganda, coming in at 9.6% of overall government spending (Zikusooka et al., 2009). Therefore, there is a need to explore public awareness and preventative healthy lifestyle behaviours for hypertension before an individual experiences its physical impact, which will ultimately reduce the societal healthcare burden. However, few studies have explored people’s experiences regarding awareness of and healthy lifestyle behaviours for the prevention of hypertension in rural communities. This study will inform people in rural communities about the prevention of hypertension and healthy lifestyle behaviours that will reduce the prevalence of hypertension. In turn, this will inform practice about preventive interventions for hypertension in rural communities in Central Uganda. 1.5 Motivation for the Study As a nurse with a Bachelor of Science in Nursing, I spent time working in the outpatient department of a large private-for-profit hospital in Uganda. On several occasions, I admitted patients with stroke and a history of convulsions, but history revealed no positive history of hypertension. However, physical assessment showed they had blood pressure readings ranging from 160/110 mmHg to 210/130 mmHg, which were too high in comparison with a normal blood pressure (≤120/80 mmHg). When I completed my bachelor’s degree in 2010, I was employed as a clinical instructor at a university in Uganda. This involved teaching community health nursing to nursing students. As part of the teaching process, I supervised students’ community clinical 25 placements where students would perform family and community assessments, diagnoses, and interventions in people’s homes or at a community level. One of the disabling health conditions that these students and I witnessed in these communities was stroke, which is a complication of hypertension. Stroke is a serious public health concern in Uganda and leaves people with neurological impairments (WHO, 2015). As a nurse, I bought a blood pressure machine for personal use at home. To ascertain its functionality, I decided to take my blood pressure and that of the family members in my household. To my surprise, my husband’s blood pressure ranged from 178/115 mmHg to 197/120 mmHg on five different readings taken at 5-minute intervals. Even though his blood pressure was high, he did not complain of any symptoms. He had complained of a headache and fatigue, which he associated with the stressful kind of work that he does. Headache is one of the most common symptoms among people with chronic hypertension (Cirillo, Stellato, Lombardi, De Santo, & Covelli, 1999; Thomas, 2007), and mild to moderate headache (Hansson, Smith, Reeves, & Lapuerta, 2000) is consid