Zanzibar has a population around 1.3 million with average growth rate of 3.1% (Census, 2009). Life expectancy at birth for Zanzibar was estimated in 2002 to be 57 years (NBS, 2005). Administratively, Zanzibar has five regions and ten districts. Each district is subdivided into several constituencies and Shehias. A shehia is the lowest government administrative structure at the community level. It is composed of several communities and usually represents between 1,000 – 21,000 people.
Health care is provided at three levels to the public. The first level is the Primary level with three types of health facilities (1st line PHCU, 2nd line PHCU and Cottage hospitals) located in or near to the community. The Secondary level is composed of district hospitals and tertiary level which comprised of referral hospital.
In recent years the growing importance of NCD diseases has been recognized. The situation in Zanzibar reflects that of other countries with an increase number of cases particularly in hypertension as being seen in health facilities (MOHSW, 2007).
Figure 1: Map of Zanzibar with the two main islands (Courtesy of the University of Texas Libraries, The University of Texas at Austin)
1.2 Situation analysis
The global burden of hypertension estimated that 7.6 million premature deaths which are about 13.5% of the global total and 92 million DALYs which is 6.0 % of the global total were attributed to hypertension; unfortunately about 80% of the attributable burden is occurred in developing countries (Lawes M et al., 2008). In Tanzania mainland deaths from non-communicable disease including hypertension are remarkably higher at the age of 15-59 years than in UK (Bovet P et al., 2008).
Zanzibar has experienced the burden of non-communicable disease and regarded being a significant health problem (MOHSW, 2007). It has been identified as a major public health problem in the islands. Hypertension and related diseases occupy the second position among top ten leading causes of mortality, according to HMIS data 2007 case fatality rate reported due to hypertension among inpatients was 8.8%.
Hypertension disease also known as “silent killer” has affected many people especially adults between the age of 40 years and above. Aging population between 60 and above are most at risk of getting the disease. Hypertension can cause other health problem such as cardiac complications, sexual dysfunction, and loss of vision and kidney failure.
Literature review factors influencing hypertension
A limited number of population based surveys for hypertension in Sub-Saharan has been conducted. Therefore information on prevalence, incidence and associated risk factors is not sufficient to get a clear picture.
Most recently literatures have shown that for the next coming years, non communicable diseases related with lifestyle such as hypertension and diabetes mellitus was estimated to comprise an increasing proportion of the total disease burden in low income communities in the developing countries especially in Sub-Saharan Africa. In urban societies the prevalence of hypertension is high in many developing countries (WHO, 2003).
Between 2006 and 2015 deaths due to non-communicable disease are expected to increase by 17% half of which will be due to cardiovascular disease (WHO, 2007). Worldwide hypertension is seen to be highly prevalent risk factor for cardiovascular due to increasing longevity.
The risk factors that might be associated with hypertension or increase chance of getting the disease are: age,Â ethnicity, family history, stress,Â obesity,Â diabetes,Â smoking andÂ excessive drinking.
Zanzibar has recognized non communicable disease including hypertension as a major public health problem. A base line and prevalence data has not been done to know the exact magnitude of the problem.
Control and treatment of hypertension remain less than optimal worldwide and awareness is still a major problem in the communities. It is not yet known if the existing structure of the primary level gives proper health education to their clients. The assessment of what kind of services at the primary level based on NCD guideline should be looked upon. Health promotion unit of the Ministry of health has to be assessed if they are conducting regular programs or mass campaign on awareness of the disease. Knowledge and understanding of the disease among patients and the community as whole is less. We are aware of people’s shallow knowledge on high blood pressure or stroke but these should more explored in details in terms of contributing factors and challenges faced to improve prevention strategies to combat the disease.
The Ministry of Health and Social Welfare in Zanzibar has stressed the need to integrate prevention and management of the most common NCD including hypertension at all level by the end of 2010, and one among the main core interventions is to sensitize health personnel on relevant research findings (MOHSW, 2007). Our main hope is that the findings of this research will be the starting point to develop and improve the preventive measures of hypertension in the communities.
To explore factors influencing hypertension preventive behaviour among adults above 40 years in Zanzibar Islands in order to make informed recommendations to improve health promoting strategies to combat the disease.
To determine the magnitude of hypertension among adults above 40 years based on HMIS records.
To explore knowledge, attitude and practice about causes and consequences of hypertension among adults above 40 years of age.
To make informed recommendations to improve health promoting strategies to combat the disease.
3.1 Study type
In order to achieve the study objectives, a qualitative exploratory study will be conducted so as to get a clear picture what preventive strategies should be carried out to combat the disease among the adults above 40 years. Our main study population are adults above 40 years. Study unit is a person male or female above 40 years of age with or without hypertension.
3.2 Study issues
Prevention measures of the disease is still a challenge as the exactly what factors influencing preventive behaviour of the disease are not well known among adults. The aim is to learn from their knowledge, attitude and practice and how they think could be preventive measures to control the disease among them. Information that will be provided during the study will be easier to make people to participate fully in prevention and control of hypertension. Study issues are:
Magnitude of hypertension among adults above 40 years
Knowledge and cause of the disease
Symptoms of hypertension
Awareness of the disease
Health seeking behaviour
Risk factors such as obesity, smoking and alcohol intake, Ageing and family history
3.3 Data collection techniques
In order to describe the magnitude of hypertension among adults above 40 years in Zanzibar Islands, HMIS records for patients above 40 years with hypertension attending clinics will be carried out.
Focus Group Discussion
Focus group discussion will be carried out in two Shehias. A criterion will be set for the FGD to consider the following group of people:
Men group (head of households, different marital status, employment, age from 40 and above, religion,10 people with hypertension)
Women group (different marital status, employment, age from 40 and above, religion, 10 with hypertension)
Each FGD group will have a maximum of 10 participants. FGDs will be consented by signing of the consent forms (see annex 3). Two research assistants are going to moderate each FGD using topic guide, whereby one will be taking notes with the help of digital recorder. A total of 4 FGDs will be conducted in Urban district. Duration for FGD will be 3 hours per group including refreshments.
Semi-structured interview will be conducted to 6 adults above 40 years. 3 will be patients with hypertension at the clinic and 3 are adults without hypertension at the Shehia level.
Semi-structured interviews with health workers
2 health staff from hypertension clinic and 2 in charges of PHCUs will be asked to respond to structured interview designed specifically to ascertain their knowledge and practice of hypertension disease offered by their facilities.
Semi-structured interview with Head of Hypertension clinic
Structured interview with Head of Hypertension clinic at Mnazi Mmoja Hospital in Urban district will be conducted. Snow ball technique could be used to obtain names of people to include in the interview.
3.4 Sampling and recruitment of the study
The study population will be adults between the age of 40 and above in Urban district of Zanzibar. Urban district will be purposively selected due to its cultural diversity and accommodate people from different backgrounds from Unguja and Pemba Islands.
Purposeful sampling with maximum variation will be used in selection of the study sample. 40 adults, 20 each from two shehias in Urban district will be recruited. By informing Shehia Health Committees a criteria for selection will be employed. Among the criteria 20 adults should be people with hypertension and between male and female with age differences (40-45,46-50,51-65,66-70,71-75,76-80+). Those with hypertension will be selected from the health facility of their respective Shehias. 4 FGDs will be conducted for adults. Men and Women will be separated during discussions. 6 adults above 40 years will be recruited from study population for semi structured interviews.
For the purpose of triangulation, 2 staff from hypertension clinics and Head of hypertension clinic will be interviewed as key informants. 2 in charges of Primary Health Care Units in Urban district will also be interviewed.
3.5 Data Collection
One of the first activities is for principal investigator to consult with Technical Working Group (TWG) for Quality Assurance in the Ministry of health to describe the whole research process for final decision. Together with TWG selection of 8 research assistants will be done. Review of consent form will be discussed, it should be noted that FGD participants may not be literate, and therefore verbal consent will be sought at the outset following introduction of the study and the purpose of the FGD.
A request letter for ethical clearence will be forwarded to the Zanzibar Medical Research (ZMRC), attached with reseach proposal,topic guide, questionnaires and consent form. Principal investigator together with 8 reseach assistants will conduct FGD and interviews.
3.5 Analysis and data processing
Qualitative data template by Using excel sheets will be used to enter interview transcripts daily.
3.6 Ethical Consideration
Before the start of the study permission will be obtain from (ZMRC). Apart from that, letters explaining the purpose, aim and objectives of the study are going to be written to the Urban District Commissioner as well as heads of local communities (Shehas) and head of the health facilities. Informed consent will be obtained from all respondents (see annex 3). For confidentiality interviews will be conducted in privacy.
3.7 Quality assurance
A group of 8 research assistants will be trained for a period of 5 days. The research assistants will be chosen according to their background and experience of research. The research assistants will review the research tools and will be instructed on the main objective of each research tool to be used in the field. The tools will be the topic guide, semi-structured and in depth interview questionnaires.
The actual training days will be 3 and the remaining 2 days will be used for pre-testing the tools and making final corrections and edition. The principal investigator of the study will lead the role during training of research assistants to ensure that they get a clear idea of what the study aimed to achieve. After training, research assistants will be taken to the field for two days to pilot the tools and topic guide and final after pre-testing the tools and guide will be printed.
Work Plan Schedule
See annex 2
Dissemination of results
A stakeholder’s meeting will be conducted at the Ministry of Health and Social Welfare Zanzibar headquarters for the final results of the study. The results will be used to improve preventive measures for hypertension among adults population. The results will be shared with health promotion unit of the Ministry in order to draw public awareness strategies.