A Study of the Relationship Between Practice Of

A STUDY OF THE RELATIONSHIP BETWEEN PRACTICE OF CARDIOVASCULAR RISK REDUCTION MEASURES AND CARDIOVASCULAR DISEASE RISK AMONG URBAN AND RURAL PRIMARY SCHOOL TEACHERS OF ANAMBRA STATE

Cosmas Chiedozie OFOEGBU

MBBS, MPH

SUBMITTED TO NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA

IN PART FULFILMENT FOR AWARD OF FELLOWSHIP IN PUBLIC HEALTH

NOVEMBER, 2015

DECLARATION

I hereby declare that this work titled “A study of the relationship between practice of Cardiovascular risk reduction measures and Cardiovascular disease risk among urban and rural primary school teachers of Anambra State” was done by me under supervision and that it has not been submitted in part or in full for any other examination or any journal for publication.

……………………………………………………………………………………

Dr. OFOEGBU Cosmas Chiedozie

CERTIFICATION

We certify that we supervised this work titled “A study on the relationship between practice of Cardiovascular risk reduction measures and Cardiovascular disease risk in urban and rural primary school teachers of Anambra State” carried out by Dr. OFOEGBU Cosmas Chiedozie in the department of

Community Medicine, Nnamdi Azikiwe University Teaching Hospital Nnewi,

Anambra State, Nigeria.

…………………………………………………………………………………… Prof Amobi Linus Ilika

Department of Community Medicine and Primary Health Care,

Nnamdi Azikiwe University Teaching Hospital,

Nnewi, Nigeria.

……………………………………………………………………………………

Dr Ifeadike Chigozie

Department of Community Medicine and Primary Health Care,

Nnamdi Azikiwe University Teaching Hospital,

Nnewi, Nigeria.

iii

I certify that Dr Cosmas Chiedozie OFOEGBU has undergone training in this department and is eligible to sit for the part 2 (final) examinations of the Faculty of Public Health, National Postgraduate College of Nigeria.

……………………………………………………………………………………

Dr Echendu Adinma

Department of Community Medicine and Primary Health Care,

Nnamdi Azikiwe University Teaching Hospital,

Nnewi, Nigeria.

DEDICATION

This book is dedicated to Almighty God who in his infinite mercies have brought me this far.

ACKNOWLEDGEMENTS

I am very thankful for the innumerable contributions of my supervisors Prof Linus Amobi Ilika and Dr Chigozie Ifeadike for their encouragements and constant prompting towards the completion of this work and for painstakingly going through this work. God bless you both.

I also appreciate the contributions of Prof Christian Ibe, Dr Echendu Adinma my indefatigable head of department, Dr Ifeoma Modebe, Dr Prosper Adogu, Dr Obiageli Emelumadu, Dr Chika Ubajaka, Dr Achunam Nwabueze, Dr Uzo Ebenebe, Dr Alphonsus Obi-Okaro, Dr Nonso Nnebue, Dr Ifeoma Udigwe, Dr Ifeoma Njelita and Dr Nkiru Ezeama. Thank you all for teaching me the act of medical research.

I also want to thank all the residents in my department many of whom have encouraged me in many ways.

For my research assistants am glad you didn’t disappoint me especially Emeka Ikeabbah for helping with data entry.

My special thanks goes to my mum Lolo Kate Ofoegbu for her inspiring words.

For all the staffs in the various schools were this research was carried out in thank you for making this work possible .

Lastly am grateful for all those who have contributed to the success of this work in one way or the other especially the staffs of Anambra state universal basic education board. Thank you all.

TABLE OF CONTENTS Page

DECLARATION i

CERTIFICATION ii

DEDICATION iii

ACKNOWLEDGEMENTS iv

TABLE OF CONTENTS v

LIST OF TABLES x

LIST OF FIGURES xii

LIST OF ABBREVIATIONS xiii

ABSTRACT xiv

CHAPTER ONE: INTRODUCTION

1.1 Background information 1

1.2 Statement of research problem 4

1.3. Rationale for the study 6

1.4 Objectives 7

1.4.1 General Objectives 7

1.4.2 Specific Objectives 8

CHAPTER TWO: LITERATURE REVIEW

2.1 Knowledge of cardiovascular risk reduction measures 9

2.2 Practice of cardiovascular risk reduction measures 12

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2.3 Risk for cardiovascular disease 13

2.4 Relationship between the practice of cardiovascular risk reduction measures and the risk of cardiovascular disease 17

CHAPTER THREE: METHODOLOGY

3.1 Study area 19

3.2 Study population 20

3.3 Study design 20

3.4 Sample size estimation 21

3.5 Sampling technique 22

3.5.1 Urban area 24

3.5.2 Onitsha North Local Government Area 25

3.5.3 Rural area 25

3.6 Sampling Procedure 25

3.6.1 Urban Area: 25

3.6.2 Rural Area: 26

3.7 Inclusion criteria 27

3.8 Exclusion criteria 27

3.9 Data collection Instruments 28

3.9.1 Questionnaire 28

3.9.2 Other data collection instruments 28

3.10 Validation of Questionnaire and Pretesting 29

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3.10.1 Questionnaire: 29

3.10.2 Pretesting 29

3.11 Validation of instruments of measurements 30

3.11.1 Mercury sphygmomanometer 30

3.11.2 Stadiometer 30

3.11.3 Beam balance: 30

3.11.4 Laboratory equipment: 31

3.12 Focus group discussion 31

3.13 Measurement procedure and standardization 31

3.13.1. Blood pressure measurement 31

3.13.2 Waist circumference 32

3.13.3 Height measurement 32

3.13.4 Weight measurement 32

3.13.5 Body mass index (BMI) 33

3.13.6 Blood cholesterol measurement 33

3.14 Training of the research assistant 33

3.15 Data analysis 33

3.16 Ethical consideration 34

3.17 Confounding variables. 34

3.18 Limitations 35

CHAPTER FOUR

4.0 Results 36

4.1 Quantitative findings 37

4.1.1 Section A: Biodata (Socio demographic factors) 37

4.1.2 Section B: Awareness of cardiovascular disease risk and risk reduction measures 39

4.1.3 Section C: Practice of cardiovascular disease risk reduction measure 47

4.1.4 Section D: Anthropometric/laboratory measurements for urban and rural primary school teachers in Anambra State. 51 4.1.5 Section E: Relationship between awareness and practice of cardiovascular disease risk/reduction measures and the risk for cardiovascular diseases 70 4.2 Qualitative findings 73

4.2.1 Cardiovascular disease and risk factors 73

4.2.2 Cardiovascular disease risk factor reduction 74

4.2.3 Practice of Cardiovascular disease risk reduction 74

4.2.4 Relationship with weight and Cardiovascular disease 75

4.2.5 Impact of Cardiovascular disease risk reduction effort 75

CHAPTER FIVE: DISCUSSION 76

CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS

6.1 Conclusion 89

6.2 Recommendations 89

References 91

Appendices 99-117

LIST OF TABLES

Table 3.1: Instruments and tools for data collection and their manufacturers. 29 Table 1: Socio demographic characteristics of respondents (Categorical variables) 37 Table 2 Awareness of Cardiovascular disease risk factors 39 Table 3: Awareness of cardiovascular disease risk reduction measures 43 Table 4: Overall awareness of cardiovascular diseases risk/reduction measures in urban and rural primary school teachers in Anambra State 46 Table 5 Practice of cardiovascular disease risk reduction measure 47 Table 6: Overall practice of cardiovascular diseases risk/reduction measures in urban and rural primary school teachers in Anambra State 50 Table 7: Numerical measurements for anthropometric and laboratory data 51 Table 8: Categorized Body Mass Index for urban and rural primary school teacher in teachers in Anambra State 52 Table 9: Categorized Waist circumference of urban and rural primary school teachers in Anambra state 53 Table 10 Categorized Systolic blood pressure for urban and rural primary school teachers in Anambra State 55 Table 11 – Categorized Diastolic Blood Pressure for primary school teachers in urban and rural areas in Anambra state. 55 Table 12 – Categorized cholesterol level for urban and rural primary school teachers in Anambra State 56 Table 13: Risk Factor of Cardiovascular Disease For Urban and Rural primary school teachers in Anambra state. 57 Table 14: Cross tabulation of Body mass index (BMI) with systolic blood pressure, cholesterol, Diastolic blood pressure. 59 Table 15: Cross tabulation of waist circumference with Systolic blood pressure, Diastolic blood pressure and cholesterol 60

Table 16: Cross tabulation of Systolic blood pressure with BMI, Cholesterol, Diastolic Blood pressure and Waist circumference 61 Table 17: Cross tabulation of Diastolic blood pressure with Body mass index, Cholesterol, waist circumference and systolic blood pressure 63 Table 18: Cross tabulation of Cholesterol with Body mass index, diastolic blood pressure, waist circumference and systolic blood pressure 64 Table 19: Cross tabulation of categorized age of respondents with cholesterol, body mass index, diastolic blood pressure, systolic blood pressure and waist circumference and risk for Cardiovascular disease. 65 Table 20: Cross tabulation of gender with body mass index, waist circumference, systolic blood pressure, diastolic blood pressure and cholesterol 67 Table 21: Logistic regression showing adjusted odds ratio for predictors of risk for cardiovascular diseases 68 Table 22: Distribution of overall risk for cardiovascular disease in urban and rural primary school teachers in Anambra state 69 Table 23: Relationship of awareness of cardiovascular disease risk/reduction measures and practice of cardiovascular disease risk reduction measures 70 Table 24: Relationship of awareness of cardiovascular disease risk reduction measures and risk for cardiovascular diseases 71 Table 25 Relationship of overall practice of cardiovascular disease risk reduction measures and risk for cardiovascular diseases 72

xii

LIST OF ABBREVIATIONS

BMI Body Mass Index

BP Blood Pressure

CVD Cardio Vascular Disease

ISH International Society for Hypertension

LGA Local Government Area

WHO World Health Organisation

xiii

ABSTRACT

Introduction

Cardiovascular diseases are a group of diseases that affect the heart and blood vessels. They are the leading course of deaths globally.

Methods

The study was a cross sectional comparative study to assess the relationship between the awareness and practice of cardiovascular disease risk reduction measures and the risk for cardiovascular diseases among urban and rural primary school teachers in Anambra State. Data was collected from teachers between 38 to 59 years using both quantitative and qualitative methods. A pretested and semi-structured interviewer administered questionnaire was used, anthropometric and laboratory measurements of cholesterol level was done. Qualitative data was analysed using Institute for Business Management- Statistical Packages for Social Sciences (IBM-SPSS) version 22.

Test of associations were done using chi-square and logistics regressions. Level of significance set was at 5%. Focus group discussions were done and analysed using coding and thematic content analysis.

Result

A total of 320 respondents were surveyed. The mean age was 50.78±5.13 and a significant variation exist in age with older teachers being more in the rural areas p<0.01. Respondents were mainly females (97.81%) and most respondents have postgraduate degree (71.56%). Over 90% were married and nearly 60% of respondents were Catholics.

Awareness of cardiovascular disease was high 82.81%. Commonest source of information was the media.

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Awareness varied in urban and rural respondents. Whereas urban respondents were more aware of cardiovascular disease, rural respondents had better awareness of exercise as a risk reduction measures and had better practice (p<0.05). Obesity was more among urban respondents but blood pressure rise was more in the rural respondents while no variation existed in their cholesterol levels. A significant association was recorded between rise in blood pressure and obesity. Cholesterol levels, BMI, systolic blood pressure, diastolic blood pressure and risk score for developing cardiovascular diseases all increased with increasing age. Multivariate analysis revealed predictors of risk for cardiovascular disease as age [OR:11.4(95% (1:6.0-21.7], systolic blood pressure [OR: 0.3(95%(1:0.1-0.6) and cholesterol [OR:0.3(95%(1:01-0.7).

CONCLUSION AND RECOMMENDATION

The risk of developing cardiovascular disease increased with increasing age and since older teachers were in the rural areas the risk was higher amongst rural respondents. No association was found between the awareness of cardiovascular disease and/or practice of cardiovascular disease. Efforts should be made to improve on the diets and exercise of primary school teachers inorder to modify the increasing risk from aging.

Keywords: Cardiovascular disease risk, risk reduction, primary school teachers.

CHAPTER ONE

INTRODUCTION

1.1 Background information

Cardiovascular diseases affect the cardiovascular system and it comprise cardiac diseases, vascular diseases of the brain and kidneys, and peripheral arterial diseases.1 Coronary heart disease (angina and heart attack) and stroke are also included in cardiovascular diseases.3

Cardiovascular diseases are a class of diseases that involves the heart and blood vessels

(arteries, capillaries and veins)1-6 Cardiovascular diseases are caused by diverse factors which can play singly or in combination. The commonest among these factors is atherosclerosis that results in hypertension.4 Ageing presents a challenge in that it leads to physiological and morphological changes that alter the functions of the cardiovascular system, leading to increased risk of cardiovascular diseases.4 Prominent among these changes is atherosclerosis which denotes narrowing of arteries due to fats (atheroma) clogging the walls of the vessels and preventing them from supplying oxygen rich blood to the organs.3

A number of risk factors have been noted as leading to increased chances of cardiovascular diseases. These include cigarette smoking, hypertension, physical inactivity, overweight and obesity, family history of heart disease, ethnicity, sex and age, high blood cholesterol.1, 2, 3

This denotes a blood cholesterol level greater than 200ml/dl, and beyond this level, cholesterol settles in the inner walls of vessels leading to atherosclerosis.7, 8 Most risk factors increase with age and these increase levels up at age 45-50 years in males and 60-65 years in females.5, 6, 9 Women generally have the same cardiovascular diseases risk factors as men.

However, some risk factors may affect women differently than men. For example, diabetes raises the risk of cardiovascular diseases more in women. Also, some risk factors, such as birth control pills and menopause, only affect women.9 It is therefore not surprising that

1 cardiovascular disease rate increases with age in all races of the world. These risks cannot be ignored as that will lead to dire consequences for the individuals, families, communities and the entire health system. It can also affect all aspects of health; (physical, social and psychological) leading to frustration, anger, confusion and depression.5, 10, 11 The practice of cardiovascular risk reduction measures can significantly reduce the risk of cardiovascular diseases and it must be encouraged.5, 6 Cardiovascular disease risk factors cannot be ignored without worsening the health indices of Nigeria, rather these risks should be well researched and its preventive strategies well understood. The risk reduction mechanisms should be taught in schools and early enough before the lifestyle posing risk to cardiovascular diseases are developed,12 this is because lifestyle modifications are often difficult to implement. The risk reduction practices include the avoidance of smoking, exercise, healthy eating, avoidance or moderation of alcohol, regular medical check-up and risk assessment scoring.13-22 Smoking doubles the risk of developing this disease as numerous chemicals in cigarette damages arteries and increases the risk of stroke.14,15,22 Smoking avoidance is singly the most significant cardiovascular risk reduction practice that reduces the risk of cardiovascular diseases. The link between physical inactivity and obesity has been noted since antiquity.

Singly and in combination, both increase the risk of cardiovascular disease.16, 17 While physical inactivity cannot be categorically defined, it is noted that at least thirty minutes of moderate physical activity like brisk walking, jogging, swimming and cycling on most days of the week reduces ones risk of obesity and subsequently cardiovascular episodes.13-17

Obesity which can be either truncal or central is defined by a body mass index

(weight/height2) greater than 25. Obesity significantly increases the risk of developing cardiovascular diseases. This is calculated by using body mass index (BMI) which is dividing an individual’s weight in kilograms by his/her height in meters squared (kg/m2). Different categories of obesity exist and are classified as shown in appendix VI23. The increased risk of

2 obesity is marked when it is central (excess fat deposition in the abdomen). A waist circumference of greater than 102cm and 88cm for males and females respectively is a significant risk of cardiovascular disease.15

Healthy nutrition is one factor that does not only link with obesity but reduces the blood cholesterol level. Foods rich in fruits and vegetables and replacing of red meat with fish and/or lean meat reduce the risk of developing cardiovascular diseases.15-21 It is advisable for a person to consume at least five portions of food per day.13, 15-22 An adequate portion is demonstrated quantitatively using different sizes in our environment. A portion of meal rich in carbohydrate should be the size of the fist, a portion of meat is the size of a match box, a portion of fish is the size of a cheque book or palm and a portion of margarine is the size of a dice.20 Avoidance of fatty foods, minimal salt consumption (less than 2400mg/day), preference of lean meat (poultry) and avoidance of pastries, sweets and commercially packaged foods is a healthy practice.13, 15-19 A Mediterranean diet rich in olive oil, nuts, fish, fruit, legumes and wine reduces the risk of heart attacks and strokes by 30%.13, 24 High consumption of noodles and paracetamol leads to hypertension due to their high sodium content and thus increases the risk of cardiovascular diseases.25 Moderate use of alcohol (less than 21 unit per week or 4 units per day for males and less than 14 units per week or 3 units per day for females) reduces one’s risk of cardiovascular events.17-20 The gains of regular medical check-ups as a risk reduction practice cannot be overemphasized as some cardiovascular diseases show no symptom, hypertension for instance. Every adult should get a blood pressure check at least every three years and the older the adult, the higher the need, as hypertension increases with age from one in ten people in their twenties and thirties to five in ten people in their fifties.24

Medical check-ups help to identify diabetes mellitus, a condition that leads to premature cardiovascular complications in a setting of chronic hyperglycaemia.27 Also cholesterol

3 estimations are best done every five years.27, 28, 29 To identify people at high risk of developing cardiovascular disease, a risk assessment score is calculated using age, blood pressure, blood cholesterol, cigarette smoking, and weight. A risk assessment score of greater than 20% (2 in 10 chances) is a high risk and such an individual needs immediate cardiovascular risk reduction practices. Existing cardiovascular disease, kidney diseases and diabetes mellitus also entails urgency in instituting cardiovascular disease reduction in the individual.15, 28, 30, 31 Hypertension as defined by World Health Organization (WHO) is denoted as a blood pressure reading of up to or more than 140/90. For the purpose of this study all participants that have a blood pressure reading of 140/90 and above and not on anti hypertensive and not previously diagnosed as hypertensive was classified as having hypertension. For grading of hypertension by World Health Organization see Appendix VII 32

1.2 Statement of research problem

According to WHO, cardiovascular diseases are the leading cause of death, globally accounting for 30% of all deaths recorded in 2008.33 More worrisome is that these deaths are more in the low and middle income countries which account for 80% of all global deaths due to cardiovascular diseases.34 Africa has not been spared this global tide as cardiovascular diseases are now the second most common cause of deaths in most African countries.34-37 In fact, recent documentations claim that cardiovascular diseases have reached near epidemic proportions in Africa.35,36 The World Health report of 2002 showed that 9.2% of all deaths in

African region were accounted for by cardiovascular diseases.35. In the world health statistics, the African region of WHO recorded the highest prevalence of raised blood pressure in both males and females at 38.1% and 35.5% respectively.38 Also, Nigeria when compared to most other countries has a higher prevalence of risk factors to cardiovascular disease.38

In addition, available statistics stated the number of disability adjusted life years lost to cardiovascular diseases in Sub-Saharan Africa rose from 5.3 million for men and 6.3 million for women in 1990 to 6.5 million and 6.9 million for males and females respectively in

2004.35

This perceived epidemic of cardiovascular disease in Sub-Saharan Africa is driven by multiple factors working collectively such as diet, smoking, obesity, poor infrastructure for health care, urbanization, poverty and lack of government programs.27, 39-43 Presently in

Nigeria, cardiovascular diseases are on the increase and constitute bulk of admissions in the hospitals.34 More worrisome is that 20% of Nigerians suffering from these diseases are unaware that they suffer from it34. Globally in 2004, most countries recorded high mortality as a result of cardiovascular diseases.44 In the same year, about 150 billion dollars is believed to be spent globally in direct cost for addressing hypertension34. In its bid to reflect the magnitude of the problems posed by cardiovascular diseases like hypertension and lack of its reduction practices, the WHO after the world hypertension day of 2012, adopted the 2013 theme of world health day as “Healthy Blood Pressure” with the slogan ‘’Healthy Hearts

Beat, Healthy Blood Pressure’’.34 Researches have shown increased incidence of hypertension amongst teachers than other occupations (designers and researchers) with the relative risk of developing arterial hypertension of 1.5 and a prevalence of 31% amongst teachers studied. It is evident therefore that the lack of cardiovascular risk reduction practices in most part of the world, particularly Nigeria has in enumerable ways led to increase in morbidity and mortality due to cardiovascular diseases.35, 44 It is expedient that studies on cardiovascular risk reduction be carried out to give the public health practitioners evidence based information on this area34 and teachers should be the target of public health interventions towards this problem as educating them will translate in educating the young mind.

1.3. Rationale for the study

Overwhelming evidence showed that while the developed countries are witnessing a decline in the rate of cardiovascular disease, developing countries including Nigeria, are recording a high increase.33, 45 There are also more deaths in the developing countries from cardiovascular diseases than the developed countries.27, 46 While the problem ravages developing countries, it is worrisome that facts and figures to curb it are obtained from developed worlds. The need for local research studies on this ravaging problem cannot be over emphasized for it is indeed with knowledge that the public health professionals can tackle this problem and anticipate success. Cardiovascular disease rates are rising rapidly in

Nigeria especially in cities with unplanned urbanization.34 Anambra state, which is fast becoming an urban state, is one of such cities with the demerits of unplanned urbanization.

To further worsen the situation, there is dearth of data on cardiovascular disease and its reduction practices in Anambra state. It is therefore expedient that research of this type be carried out in Anambra state on teachers which constitutes a larger part of its working force and a major link to the entire society particularly the young ones.

Classroom discussion is shown to be an excellent tool to teach students the interaction between stress, emotions and cardiovascular health.12 It is also a fact that, though cardiovascular diseases are evident in adulthood, the risk factors starts in early life.46 In view of these, we call to mind that apart from the health workers, teachers are the next occupational group that must be involved if we are to rid the society of this deadly scourge.

This occupational group interacts with the pupils who are yet to develop the attitude posing risk to developing cardiovascular disease and thus, can make our primordial prevention efforts successful.12 This they will do so if they are aware of the cardiovascular risk reduction measures and practice them. This study will provide information that will help in reduction of risk for cardiovascular diseases particularly in the study area and its result can be extrapolated

6 and applied in similar settings in Anambra state. This study can also provide a basis for formulating a cardiovascular health program and incorporating such programs into the health system of the state as part of its school health program. Awareness of teachers on high blood pressure will equip them to teach their pupils about it. Teachers are wide spread in every community and are seen as role models, and most of the time they are the resource persons in most events especially in rural settings. Therefore, their awareness and practice will affect the entire community. When teachers are affected or develop these diseases, there was high level of absenteeism and this will lead to a huge impact on the efficiency and effectiveness in schools especially in primary schools where there are single core teachers for each class.

From available literatures not much work has been done on school teachers especially as regards non-communicable diseases. The research done in urban secondary school teachers did not explore the teachers in the rural areas and those in primary schools. The choice of primary school teachers for the rural-urban comparism proposed is because primary school teachers are almost evenly distributed in both urban and rural areas unlike other occupational groups that are mainly seen in urban settings. Similar studies previously conducted did not look at teachers in the rural areas.

1.4 Objectives

1.4.1 General Objectives

To determine the relationship between awareness and practice of cardiovascular risk reduction measures and risk of developing cardiovascular disease amongst primary school teachers in urban and rural areas of Anambra state.

1.4.2 Specific Objectives

(1) To assess the level of awareness of cardiovascular risk reduction measures among

primary school teachers in rural and urban local governments areas in Anambra state.

(2) To assess the practice of cardiovascular risk reduction measures among primary school

teachers in rural and urban local governments areas in Anambra state.

(3) To measure (body mass index, waist circumference, blood cholesterol, blood sugar and

blood pressure) and assess the risk of cardiovascular disease present in primary school

teachers in urban and rural areas in Anambra state.

(4) To determine the relationship if any between the awareness and practice of cardiovascular

risk reduction measures and the risk for cardiovascular disease among primary school

teachers in rural and urban local government areas in Anambra state.

CHAPTER TWO

LITERATURE REVIEW

2.1 Knowledge of cardiovascular risk reduction measures

Knowledge is an important pre-requisite for implementing both primary and secondary preventive strategies for cardiovascular diseases.47,48,49,50 Developing nations continue to be ill equipped to handle the burden of cardiovascular diseases as inspite of the rise in morbidity and mortality indices from cardiovascular diseases risk factor reduction knowledge remains low.47,48,49,50 In a study to assess the knowledge of teachers on cardiovascular disease in Oyo state using 386 secondary school teachers, hypertension and heart attack was the most common correctly identified cardiovascular disease. It was concluded that general knowledge of the teachers is inadequate about cardiovascular disease and it’s risk factors.51 A survey in

Ibadan, Nigeria in 2012 further showed that more than 99% of the 2000 respondents were unaware that excess weight around the waist line increases the risk of cardiovascular event.

Fifty six percent of the respondents could not identify a single risk factor and only 10.5% of respondents knew that hypertension is life threatening, only 1.5% could identify an abnormally high blood pressure reading while 0.8% had an idea of their current blood pressure reading52

In a study carried out in 2012 in Kano, Nigeria, using the members of the Nigerian armed forces, this cross sectional study was carried out among 82 members of the Nigerian Arm

Forces within the ages of 30 to 60 years. Each eligible and will participant was administered a CVD risk factor knowledge and attitude assessment questionnaire. The outcome of the study showed 75.6% of the respondents were aware of CVD while 70.6% of the study population identified smoking as a risk factor for cardiovascular disease, 87% identified stress as a cardiovascular disease risk factor while 41.6% identified obesity. Sedentary

9 lifestyle and poor dietary habit were the least identified at 16.6% and 6.4% of respondents respectively identified it. Over fifty percent (51.2%) admitted taking alcohol, 93.9 engaged in exercise, 52.4 take vegetables and fruit on a regular basis while 34.5 check their weight regularly. Only 5% of the respondent practice regular medical checkup.53

While the scientific community decry the poor knowledge of cardiovascular disease risk reduction in the population, it is mind blowing that this poor knowledge is even amongst the health care providers54. A study in United States in 2006 involving 1200 family physicians and general internists to assess knowledge of cardiovascular risk reduction practices among the health care providers. Responses from 888 physicians who see up to 60 patients a week were analyzed. The result showed that only 28% of family physicians and 38% of general internists made right choices of treatment for low risk patients and only 59% of family physicians and 56% of general internists identified the correct guideline based goal for serum fasting LDL level (less than 100mg/dl) for high risk patients. It was deduced that poor knowledge (47.8%) and skills to recommend dietary changes amongst physicians is a significant barrier to cardiovascular disease risk management.54

In a similar study, 500 randomly selected physicians (300 primary care physicians, 100 obstetricians and gynecologists and 100 cardiologists) were studied using a standard questionnaire to assess awareness of, adoption of, and barriers to national cardiovascular disease prevention guidelines.55 At the end, it was observed that perception of risk was the primary factor associated with the doctor’s recommendation for cardiovascular disease prevention rather than evidence.55 It can therefore be concluded that education intervention for care physicians are needed to improve the quality of cardiovascular disease prevention and also lower morbidity and mortality from cardiovascular diseases in both men and women.

A descriptive study in Croatia discovered that graduating medical students had poor knowledge of cardiovascular risk reduction. The survey involved 442 medical students (228

10 freshmen and 214 graduating class) assessing their awareness of dyslipidemia, arterial hypertension, metabolic syndrome and lipid lowering drugs. Although knowledge of cardiovascular disease reduction was significantly better among graduating students, it was still not sufficient as only 66% had good knowledge56. If medical students could record low knowledge of cardiovascular disease then primary school teachers knowledge is expected to be low as they lack medical knowledge.

People of Asian descent have one of the highest risks of cardiovascular diseases yet poor knowledge of cardiovascular risk reduction50. An institute based study in Karachi, Pakistan; used 720 patients with first Acute Myocardial Infarction (AMI) were interviewed on the knowledge of four modifiable risk factors of heart disease: fatty food consumption, smoking, obesity and exercise. Out of the 720 study subjects, 92% had good level of knowledge about the association of fatty food consumption with heart disease, 83% identified the association of smoking with heart disease, 42% were knowledgeable about the association of obesity with heart disease and only 25% knew about the protective effect of exercise. The participants knowing three out of four risk factors were regarded as having a good level of knowledge of cardiovascular disease. After constructing a multiple logistic regression model to identify the determinants of good level of knowledge, only 42% of the study population had a good knowledge of the risk factors of heart disease. The findings proved lack of good level of knowledge of modifiable risk factors of heart disease among the Pakistan population.48, 50

Considering the rapid increase in the prevalence rates of cardiovascular disease risk across the globe, a research study was conducted in Mongolia, based on the National Non- communicable disease knowledge, awareness and practices survey it was gathered that as many as one in two Mongolians have never heard of the term “diabetes”. This low baseline of

11 health knowledge, crucial to developing population health literacy, may hinder public health interventions.57, 58,59

2.2 Practice of cardiovascular risk reduction measures

An innovative approach on cardiovascular disease risk reduction is needed because a focus on cardiovascular risk reduction in children and adolescents addresses a disease process atherosclerosis in which the chemical endpoint of cardiovascular disease is remote. The recommendation for the cardiovascular risk reduction practice is needed to address the prevention of risk factor development, primordial prevention, and the prevention of future cardiovascular disease by effective management of identified risk factors.31 A study conducted among 358 secondary school teachers in Oyo state showed that 12.3% were current smokers, 32.1% drank alcohol. More than 80% of the teachers performed exercise regularly.51

An assessment of practice of cardiovascular risk factor reduction among the Nigerian armed forces (male) in 2012 in Kano state showed that: 51.2% consumed alcohol excessively,

93.9% engaged in exercise, mostly running, 52.4% took vegetable and fruits on a regular basis, 34.5% checked their body weight regularly, but only 5% visited a hospital for routine medical checkup52

In a German study, chefs were found to have low cardiovascular risk reduction practice when compared with office workers matched for age and sex. The study groups consists of 45 chefs and 48 office workers, using male individuals between the age groups of 30-45 years to determine which occupational groups has higher cardiovascular risk.60 The subjects were required to compile a 7-day-dietary record and to collect their urine 24 hrs in advance to the medical checkup.60 It was hypothesized that due to their working conditions, Chefs indulge in a nutritional state and behavior that were not beneficial for cardiovascular health. However, according to the answers given in the food frequency questionnaires in the study, the Chefs

12 consumed more fish in comparison to office workers. Office workers either smoked less or only occasionally, moreover, they consumed more vegetables and fruits in comparison to chefs.60 In conclusion, the chefs involved in the study carried a higher risk of cardiovascular disease than the comparison group of office workers.60-64 There were more smokers in the chef group. Chefs have a stronger work-related dedication which is displayed by a significant higher effort at achieving perfection, more willingness to perform strenuous work and an increased occupational aspiration.60-64 These factors can lead to psychological stress, which is strongly associated with a high risk of cardiovascular disease.61 The office workers have a lower risk of cardiovascular disease than the comparison group of chefs.60 In a research involving police officers in India, it was noted that there was poor cardiovascular risk reduction practices with significant alcohol use and cigarette smoking in up to 50% of respondents.65, 66, 67

In a research using two different locations in Borno state, Nigeria, the urban setting was

Maiduguri while the rural setting was an unspecified remote village approximately 200km from the capital city, the total number of respondents was 224, 102 from the urban residents and 122 from the rural residents. Smoking of cigarettes and alcohol usage were uncommon in both populations (3 people from the urban respondents and none from the rural). Seventy five percent of the urban respondents versus 91.8% of the rural respondents reported that they were involved in some form of exercises. 68

2.3 Risk for cardiovascular disease

In a study in Enugu Nigeria, which involved 858 adults aged 40-70 years selected randomly, subjects with hypertension consisted of 274 (68.8%) females and 124 (31.2%) males. Among the hypertensive subjects, hypercholesterolemia was seen in 13 (3.3%) subjects while blood glucose profile was observed in 19 (4.8%) subjects. Central Obesity was present in 141

(35.4%) subjects. The prevalence of hypertension as found in this study was high (46%).

Obesity is a common cardiovascular disease risk factor driven that ageing and obesity are one of the significant predictors of cardiovascular disease among rural dwellers. In view of the increasing trend in prevalence of cardiovascular disease, it was recommended that there was the need to institute educational programmes to guard against possible cardiovascular disease among these rural dwellers.40, 41, 42

Another study in Enugu South Eastern Nigeria showed higher prevalence of hypertension and dysglycaemia in men while all other risk factors like generalized obesity, abdominal obesity, and hyperglycemia were higher in women; hypercholesterolemia did not reveal significant association with gender.69

In a study among urban black population in South Africa, it was reported that 66% of the study population had high body mass index and 40% were severely overweight, about 33% had a rise in at least one component of the blood pressure and 13% had raised blood cholesterol70. It was identified that overweight was significantly associated with elevated blood pressure, raised serum glucose and cholesterol level.70

A research was conducted in Sofia, among 168 female teachers between 25 and 55 years of age with the aim to investigate the age related changes of Blood Pressure (BP) and prevalence of Arterial Hypertension (AH). A group of 103 female employees (designers, researchers) served as controls. The research showed that the age-related changes of systolic and diastolic blood pressure were more pronounced in the teachers’ group. The elevation of the diastolic blood pressure with age was more expressed among the teachers than the controls. The estimated relative risk for arterial hypertension among teachers in total was 1.5 and the prevalence of arterial hypertension among teachers over 40 years old was 31%, which can classify this occupation as high risk for arterial hypertension.71 A study was conducted in

Basrah city, Iraq on 403 secondary school female teachers with the aim of determining the

14 prevalence of hypertension among them and identifying lifestyle related risk factors. Result showed the prevalence of hypertension among the study population was 21.3%, about 20.3% of them were pre-hypertensive. The prevalence of lifestyle risk factors among them were as follows; physical inactivity (67%), overweight (40.9%), obesity (37.7%), contraceptive pills use (18.6%), salty diet (18.1%), fatty diet (15.4%), drugs intake (12.4%), coffee intake

(6.5%), and smoking (0.5%). A significant association was found between some lifestyle risk factors and hypertension, those were drug intake, and body mass index. In this research, early detection of hypertension and educational health programs regarding lifestyle behavior was highly recommended.72

The risk factors for cardiovascular diseases can be classified as;

(i) Major Risk Factors: these are the factors that research has significantly shown to

increase the risk of cardiovascular diseases, that is; age, sex, heredity/race.

(ii) Contributing Risk Factors: these ones are associated with increased risk of

cardiovascular diseases but their significance and prevalence are not precisely

determined, that is; stress, alcohol, and diet.

(iii) Modifiable Risk Factors: some of the risk factors can be modified, treated or

controlled and they are said to be modifiable risk factors, that is; cigarette

smoking, physical inactivity, obesity.

The more risk factors one has, the greater the chances of developing coronary heart disease.

Also the greater the level of each risk factor, the greater the risk. It is essential to measure the risk of heart disease and make plan for how to prevent it in the near future. A risk assessment tool can be used by anyone aged twenty or older who does not already have heart disease or diabetes. In order to use this tool, a person must know his/her blood pressure, cholesterol levels, height, weight, and waist circumference. See section D of the questionnaire for risk assessment scoring in Appendix II.73

In a study amongst students in Isfahannt to establish any relationship between Body mass index, blood pressure and red blood cells indices among new entering students of University of Isfahannt, the study subjects were made up of 514 males and 1161 females with mean age of 20.7 + years. High systolic blood pressure was more common in the students with BMI >

25kg/m2 (P< 0.001).74

In a study among urban and rural residents in Ethiopia, Vietnam and Indonesia to establish any association between body mass index and blood pressure across three populations in

Africa and Asia. The study subjects were 8014 with 52.5% of them female systolic BP and

Diastolic BP increased along with BMI quintiles75.

In a study conducted at lady Reading hospital, Peshawar, Pakistan among random individuals to check if BMI affects cholesterol, sugar and blood pressure. The study subjects were 2270,

1798 male and 472 females, with mean age of 38.47+ 12.66. Cholesterol level was higher in both overweight (BMI>25) and obese individuals (BMI>30) than in normal weight subjects

(BMI 18.5-24.9) (P=0.000). Systolic and Diastolic BP was also higher in both overweight

(BMI > 25) and obese individuals (BMI>30) than in normal weight subjects (BMI 18.5-24.9)

(P=0.000) Here also, there was a significant difference in the cholesterol level between male and female subjects (P=0.000). There was also a significant difference in the systolic BP between male and female subjects (P=0.000). However, there was no significant difference in the diastolic BP of male and female subjects (P=0.706).76

In a study conducted in Switzerland to establish any relationship between BMI, blood pressure and serum cholesterol in 56,784 swiss army conscripts with mean age 19.7 + 1.0, systolic BP was highest among those with BMI>40, (P<0.001). diastolic BP was also highest among those with BMI > 40 (P< 0.001). Cholesterol level was also higher among those with

BMI > 40.77

In Australia, mortality rates for coronary heart diseases are higher outside the capital cities.

The difference between rural and urban areas accounts for approximately 5000 excess death per year. Rural areas have a disproportionably high and increasing percentage of elderly patients who are more likely to have cardiovascular disease and other medical problems.

Rural patients also face higher costs accessing medical care, though their income tends to be lower than those of urban dwellers. Report also revealed that rural patients are actually more compliant than their city peers, but many stop taking drugs because of adverse effects or lack of understanding about their treatments. Drugs and some interventions for cardiovascular disease were poorly utilised in rural areas.59

2.4 Relationship between the practice of cardiovascular risk reduction measures and the risk of cardiovascular disease

Several researches in the United States have shown that the knowledge of cardiovascular risk reduction is poor in the population, particularly among women and adolescents. A study of women in United States showed low awareness of cardiovascular disease and high prevalence of risk factors. The study is a six months pre/post longitudinal education intervention for high risk women (n= 1310). The intervention consisted of education/awareness, screening/risk assessment, diagnostic testing/treatment, lifestyle modification/ rehabilitation, and treatment/evaluation. At the end of the study, there was statistically significant improvement in the level of knowledge, risk awareness/ reduction and clinical outcomes.78

A research was conducted on 205 children from Scott County, Mississippi to determine their risk of obesity and overweight. This study involved measurement and assessments of height, weight, BMI, waist circumference, dietary intake, and physical activity level using pedometers.73 Out of the 205 children, 54% were overweight, saturated fat and sodium intake exceeded recommended level, calcium, fruits and vegetable intake were inadequate.73 It was

17 recommended that cardiovascular risk reduction built on a comprehensive heart care model program is effective in improving knowledge and practice of cardiovascular risk reduction and attainment of healthy society.54, 73 Though this research was amongst children but one can expect similar prevalence of obesity amongst adults.

Since the 1950’s, it was noted that the consumption of food containing high amount of saturated fatty acid (including meat fats, milk fats, butter, coconut oil, palm oil and palm kernel oil) can lead to cardiovascular disease.73 The above listed food are best substituted with higher proportion of unsaturated fatty acid like olive oil, peanut oil, safflower, sunflower, corn, soy and cotton seed oil. A research in United States in 2011 showed that reducing saturated fats in diet reduces the risk of cardiovascular event by 14%.73 A similar research in 2009, also in America, showed that there is an increased incidence of ischemic heart disease with the consumption of low dietary poly-unsaturated fatty acid.73, 78 The research was carried out on people aged 30-44 years with a relative risk of 1.05. It was concluded that replacing saturated fatty acid with poly-unsaturated fatty acid or carbohydrate reduces cardiovascular event.78 A research study involving police officers, noted that there was poor cardiovascular risk reduction and also an increased risk of cardiovascular diseases with hypertriglyceridemia and high blood pressure as the commonest abnormalities.

Hypertension constituted 37.7% of the study population of 900 officers, diabetes 70%, smoking 10%, and alcohol use 48%. It can be inferred that low cardiovascular risk reduction practices leads to increased risk of cardiovascular disease.61, 65, 66

CHAPTER THREE

METHODOLOGY

3.1 Study area

Anambra state is one of the 36 states in Nigeria that is located in the southeast geopolitical zone. Anambra state is bounded by Delta state to the west, Imo state to the south, Enugu state to the east and Kogi state to the north79. The original Anambra was created in 1976 when the then East central state was divided into Anambra and Imo states respectively. Then, it comprised the present Anambra state and Enugu state including the Abakaliki part of Ebonyi state, with Enugu as its capital.79, 80 After further states creation in 1991, Enugu state with

Abakalilki was excised, leaving Anambra with Awka as its capital.79, 80 Anambra state is situated on a generally low elevation on the eastern side of the river Niger, has a total land area of 4,416 sq.km.79, 80 The climate of Anambra state is typical tropic with mean rainfall of

2000mm and a mean temperature of about 30 degrees centigrade.79, 80

There are 21 local government areas and about 177 autonomous communities in Anambra state, with a total population of 4,182,032 people in the 2006 national census.81 Of the twenty one local governments, five are urban; five are semi-urban while eleven are rural 82. The indigenous ethnic group in Anambra state is Igbo which comprises of about 98% of the population and about 2% of Igala who lives in the north western part of the state.83

Christianity is the dominant religion in Anambra state, with few adherents to traditional religion and Muslims who mostly are non-indigenes. The pre-dominant occupation of the people includes farming (mostly in rural areas), trading, office work, manufacturing and artisanry.83

3.2 Study population

The study population included teachers in the registered primary schools in Anambra state.

There are 1043 registered primary schools in the state.

The local governments are divided into urban (Onitsha north, Onitsha south, Nnewi north,

Awka south, and Idemili north), semi urban (Ihiala, Idemili south, Aguata ,Anaocha and

Njikoka local governments) and the rural local governments(Anambra east, Anambra west,

Awka north, Ayamelum, Dunukofia, Ekwusigo, Nnewi south, Ogbaru, Orumba north,

Orumba south and Oyi).83

The total number of teachers in Anambra state is 10,319 in the 21 local government areas.

Teachers in the five urban local government areas (Onitsha north, Onitsha south, Awka south,

Nnewi north, Idemili north) are 3,453. The number of teachers in rural local government areas is 4,133. The average number of teachers in an urban local government area is 691 while that of a rural local government is 375. There are a total of 227 schools in the urban local government, giving an average number of teachers per school as 16 (total number of teachers/ number of schools i.e. 3453/227). In the rural local governments, there are a total of

511 schools, giving an average of 8 teachers per school (total number of teachers/ number of schools, i.e.4133/511).

3.3 Study design

This was a comparative cross sectional study. Two teaching hospitals and two mission hospitals were used for the study. The mission hospitals were those with different departments and were comparable with the teaching hospitals. Satisfaction with services were measured with respect to waiting time, doctors services, nurses services, health record

20 services, pharmacy services, laboratory services, radiological services, paypoint services, physical environment and cost of services.

Comparison and differences in the clients similarities and differences in the clients level of satisfaction with services.

3.4 Sample size estimation

The minimum sample size for this study was based on 5% significance level and a power of

80%.

[2(푧훼 + 푧훽) 2 푝 (1−푝)] 84 Formula; 푛 = d2

Where: n = sample size for individual group,

Zα = standard normal deviate = 1.96 at 95% confidence interval

Zβ = statistical power at 80% = 0.884 p = arithmetic average of two proportions which is (P1 + P2) / 2 p1 = proportion of urban dwellers practicing cardiovascular risk reduction (exercise and smoking avoidance) = 0.7568 p2 = proportion of rural dwellers practicing cardiovascular risk reduction (exercise and smoking avoidance) = 0.9268

P = (0.75 + 0.92) / 2 = 0.835 d = arithmetic difference between the two population = P2 – P1

d = 0.92 -0.75 = 0.17

Zα = 1.96

Zβ = 0.8

P = 0.835

D = 0.17

Substituting into the formula; n = [2(zα + zβ) P (1 – p)] / d2 n = [2 (1.96 + 0.8)2 0.835 (1 – 0.835)] /( 0.17 )2 n = [2(7.6176) 0.835 (0.165)] / 0.0289 n = 2.0990/0.0289 n = 72.6

Therefore, the minimum sample size for each population was 73.

The total number of respondents was 146 persons.

Using an attrition rate of ten (10) percent the sample size was increased to 160

In order to increase the power of the study the sample size was doubled increased to 320 for the two groups. A total of 320 respondents were studied. One hundred and sixty from the rural areas and another 160 respondents from the urban areas were used for the study.

3.5 Sampling technique

The sampling technique that was used was a multi-stage random technique.85 In order to ascertain the feasibility of the study a preliminary survey that was carried out using records

22 from Anambra state primary education management board helped to locate the schools, determine its demographics and also to determine the sampling method suitable for the study.

SAMPLING PROCEDURE

URBAN AREA:

The urban local government area selected after a simple random sampling is Onitsha North local government area. The schools arranged in alphabetical order includes: Akpaka primary school, All saints primary school, Anyaegbunam primary school, Army children primary school 1, Army children primary school 11, Crowther primary school, Holy trinity primary school, Immaculata primary school

1, Immaculata primary school 11, Main market Unicef school, Migrant fishermen school, New Bethel primary school, Nworah Ummunna primary school, Obi Okosi primary school, Ogboli primary school, Omagba primary school 1, omagba primary school 11, Omunwegboka primary school, Oreze primary school 1, Oreze primary school 11, Ose market Unicef school, Santa Maria primary school,

St. Mary’s primary school, Woliwo primary school 1, Woliwo primary school 11. The following schools were selected using a systematic random sampling; Omagba primary school 1, Woliwo primary school 1, Holy Trinity primary school, Ogboli primary school, St. Mary’s primary school. A random start was used to select Omagba primary school 1, and a sampling interval of 8 used to select the subsequent schools as from the arrangement above.

Omagba primary school 1 has a total of 58 teachers all females, Woliwo primary school 1 has a total of 32 teachers, 31 females and 1 male, Holy trinity primary schools has a total number of 19 teachers all females, Ogboli primary school has a total of 30 teachers, 29 females and 1 male, and St. Mary’s primary school has a total of 37 teachers, 36 females and 1 male.

RURAL AREA:

The rural local government area selected after a simple random sampling is Dunukofia local government area. The schools arranged in alphabetical order includes: Aboh primary school

Umudioka, Aforigwe primary school Umudioka, Aguafor primary school Ukpo, Aguoji primary

23 school Ifitedunu, Amagu mfs Ukwulu, Central school Ifitedunu, Central school Ukpo, Central school

Ukwulu, Central school Umudioka, Central school Umunnachi, Community primary school Ifitedunu,

Community primary school Nawgu, Community primary school Umunnachi, Eziagu primary school

Umunnachi, Igwebuike mfs Umunnachi, Iruka primary school Nawgu, Obiechi primary school

Umunnachi, Obioma primary school Ukpo, Obunagu primary school Nawgu, Udodimma primary school Ukwulu, Ozalla primary school Ifitedunu, Unity primary school Ukpo. With a random start from Aforigwe primary school Umudioka, the following schools were selected; Aforigwe Umudioka,

Central Ukpo, Community Nawgu, Obiechi Umunnachi, Unity Ukpo, Amagu Ukwulu, Central

Umunnachi, Igwebuike Umunnachi, Udodimma Ukwulu, and Aguafor Ukpo.

Aforigwe primary school has a total of 27 teachers all female, Central school Ukpo has a total of 22 teachers all females, Community primary school Nawgu has a total of 7 teachers, 1 male and 6 females, Obiechi primary school has a total of 9 teachers all females, Unity primary school Ukpo has a total of 13 teachers, 12 females and 1 male, Amagu mfs Ukwulu has a total of 9 teachers, 4 males and 5 females, Central school Umunnachi has a total of 17 teachers all females, Igwebuike mfs

Umunnachi has a total of 10 teachers all females, Udodimma primary school Ukwulu has a total of 10 teachers, 1 male and 9 females, and Aguafor primary school Ukpo has a total of 11 teachers all females. The 10th school to be sampled was Community primary school Nawgu where only one teacher was selected.

3.5.1 Urban area

In the first stage, simple random sampling was used to select one local government from the five urban local government areas. After the simple random sampling, Onitsha north local government was selected.

In second stage, 10 schools were selected from the chosen local government area using simple random sampling.

In the third stage, 16 teachers were selected using stratified sampling with equal probability.

3.5.2 Onitsha North Local Government Area

Onitsha north is one of the urban local government areas in Anambra State. It is part of the

Onitsha City which is the commercial nerve centre of Anambra State. Onitsha is gateway town to South east of Nigeria. Onitsha north local government is part of Anambra north senatorial district. It is the most densely populated city in Anambra State, it is made up of high rise buildings, built up areas and little space for recreational activities and gardening.

The people are mostly traders, artisan workers, civil servants as well as teachers and few fishermen. Onitsha has a total population of 124,94280,81 of which 692 are teachers in its registered primary schools. The total number of primary schools in this local government area is 25 and the teachers are 692 (9 males and 683 females).82

3.5.3 Rural area

For the rural respondents, a local government area was selected from the 11 rural local governments using simple random sampling . Here Dunukofia local government area was selected.

In the second stage, 20 schools were selected using simple random sampling from an average of 46 schools per local government area.

In the third stage, 8 teachers were selected using stratified sampling with equal probability.

3.6 SAMPLING PROCEDURE

3.6.1 URBAN AREA:

25 primary school 11, Crowther primary school, Holy trinity primary school, Immaculata primary school

3.6.2 RURAL AREA:

The rural local government area selected after a simple random sampling is Dunukofia local government area. The schools arranged in alphabetical order includes: Aboh primary school

Umudioka, Aforigwe primary school Umudioka, Aguafor primary school Ukpo, Aguoji primary school Ifitedunu, Amagu mfs Ukwulu, Central school Ifitedunu, Central school Ukpo, Central school

Ukwulu, Central school Umudioka, Central school Umunnachi, Community primary school Ifitedunu,

Community primary school Nawgu, Community primary school Umunnachi, Eziagu primary school

Umunnachi, Igwebuike mfs Umunnachi, Iruka primary school Nawgu, Obiechi primary school

Central Ukpo, Community Nawgu, Obiechi Umunnachi, Unity Ukpo, Amagu Ukwulu, Central

Umunnachi, Igwebuike Umunnachi, Udodimma Ukwulu, and Aguafor Ukpo.

3.7 Inclusion criteria

The primary school teachers in the urban and rural local government areas of Anambra state.

3.8 Exclusion criteria

All the teachers in the unregistered primary schools were excluded from the study.

 The teachers in the semi urban local governments were also excluded from this study.

All the teachers that did not give consent to this study were also excluded.

 All pregnant women were excluded from the study, or women in the reproductive age

group whose last menstrual period could not be ascertained or have not seen it in the

last three months because pregnancy affects the weight, BMI, waist circumference

and blood pressure.

Teachers above 60 years were excluded

Hypertensives on drugs were excluded.

Known diabetics were excluded

Teachers with known heart diseases were excluded.

3.9 Data collection Instruments

3.9.1 Questionnaire

Data was collected using a semi-structured interviewer administered pretested questionnaire with the aid of a trained research assistant. Data from the questionnaire was in three sections; section A involving socio-demographic data, namely; age, sex, marital status, educational qualification, religion and anthropometric measurement. Section B contained questions assessing the awareness and practice of cardiovascular risk reduction measures. Section C contained anthropometric and laboratory measurements and helped to assess the cardiovascular risk of respondents.

3.9.2 Other data collection instruments

Instruments used for data collection were sphygmomanometer and stethoscope for blood pressure check, stadiometer for height measurement, beam balance for weight measurements, tape for waist circumference, calculator for BMI calculation, tape recorder and writing materials.

Table 3.1: Instruments and tools for data collection and their manufacturers.

Mercury sphygmomanometer (ALPK2) and Japan, USA stethoscope (3M™ Littmann™, Classic II SE) for measuring of blood pressure Beam balance for body weight measurement (SECA 770) Germany Calculator for calculating BMI (KADIO®--2420) China Stadiometer for height measurement (Invicta, IP1465, and UK) United Kingdom Different grade of automatic Eppendrof, England. Pipette. Water bath for specimen incubation kottermann- laboratechnic, Germany Centrifuge for sample spinning of specimen Runne-Heidelberg. Spectrophotometer for enzymatic Apple 303, Japan determination of total and HDL cholesterol Stop watch for accurate time keeping China 10ml disposable Syringes for collection of Medical jet ,Syria blood specimen Eppendrof tube 1ml for collection of whole China blood specimen before centrifugation. Centrifuge tube for centrifuging samples China Disposable test tube for collection of serum China sample

3.10 Validation of Questionnaire and Pretesting 3.10.1 Questionnaire:

Translation and back translation- The questionnaire was translated by a linguist from

English language to Igbo language and another linguist back translated the questionnaire from Igbo to English. The two English versions of the questionnaire was compared to ensure consistency in meaning and understanding. This was to prevent loss of information or misinterpretation that can result from translation. Both the English and the Igbo versions was used in the field but response was entered in English.

3.10.2 Pretesting- Pre-testing of questionnaire was carried out in a randomly selected primary school not among the schools to be sampled for the study (One school in the urban and one school in the rural area). The urban school was immaculate Primary School while the rural school was Obinagu primary school Nawgua. Aim of pretesting was to check for appropriateness, clarity; adequacy and to get an estimate of time needed to administer the

29 questionnaire on the teachers similar in characteristics to the population to be studied.

Familiarization visit to the field was made with the research team. At the end of each day, debriefing meeting was held on field experiences. Identified problems were solved. The questionnaire and other study instruments were reviewed and made more adequate for the study.

3.11 Validation of instruments of measurements

3.11.1 Mercury sphygmomanometer: It was ensured that the mercury meniscus returns to zero when the manometer is removed from the inflation system.

3.11.2 Stadiometer: A metal rod of known length was placed between the headboard and the floor so that it stands vertically. If the counter does not record the correct length of the rod, it is loosened by undoing the two metal retaining screws, and pulls the counter away from the main fiber cog of the carriage. In this position, the small metal cog of the counter is turned until the counter records the true length of the metal rod. The counter is pressed against the back-plate so that the teeth of the counter cog and the carriage cog engage, while tightening the retaining screws. The headboard is moved up and down a number of times to ensure that the counter continues to give accurate reading.

3.11.3 Beam balance: The beam balance is zeroed by sliding all of the weights to zero leaving the platform empty. If the pointer is not on zero, the zero adjustment knob is turned until the balance reads zero. A dumbbell with known non varying weight is placed on the platform. The weight is adjusted until the scale reads a balanced position. The dumbbells varying weight was compared to the weight indicated by the beam balance. If there is any alteration, the lever arm is adjusted according to the calibration to the change desired. The dumbbell was used every morning before conducting the study to ensure that the instrument is still valid and accurate in measurement.

3.11.4 Laboratory equipment:

Laboratory analysers and equipment used for the study underwent internal quality control by qualified laboratory scientist using appropriate calibration standards.

3.12 Focus group discussion

Two focus group discussions were carried out in the schools selected in the urban and rural areas respectively. With this we obtained qualitative data to augment the quantitative data.

Each focus group discussion involved 6 six participants and was held at Central school Ukpo for the rural area, and St. Mary’s primary school Onitsha for the urban area. The intended segregation by sex was not practicable as there was dearth of male teachers

3.13 Measurement procedure and standardization

3.13.1. Blood pressure measurement

All resting blood pressure measurements was manually recorded via auscultation using a mercury sphygmomanometer (ALPK2, Japan) and stethoscope (3M™ Littmann™, Classic II

SE, USA). The participant was instructed to sit on a chair with their spine resting against the back of the chair for at least four minutes. The cuff was placed around the left arm of the participant and inflated by the assistant researcher (trained registered nurse/midwife), while holding the participants arm at heart level. The bell of the stethoscope was placed over the artery in the ante-cubital fossa and participants was instructed to relax and stay as still as possible to ensure accuracy. A deflation rate of approximately 2-3 mmHg per second was used to increase the accuracy of the single measure. Systolic blood pressure was defined as the first Korotkoff sound (clear appearance of tapping sound) and diastolic blood pressure as the complete disappearance of Korotkoff sound. Blood pressure was measured and recorded.

The procedure was carried out by qualified nurse. 86

3.13.2 Waist circumference

The measurement of waist circumference was taken at the midline between the hip bone at superior iliac crest and the lowest rib while the participant is standing on a flat surface and the measuring tape parallel to the floor.87

3.13.3 Height measurement

Height was measured in metres using a stadiometer (Invicta, IP1465, and UK). Participants were asked to remove footwear before the measurement of height was obtained. The participants was instructed to stand with their feet together and against the arch of the - stadiometer, spine against the vertical pole of the stadiometer, while looking straight ahead and keeping the chin parallel with the floor. The headboard was then lowered down to rest against the vertex of the skull. The measurement was recorded to the nearest 0.1 cm and then the participant steps off. This process was completed twice and if consecutive values differ by more than 1 cm, a third measurement was taken and the average of the values obtained, to give the height for that participant.88

3.13.4 Weight measurement

Participants was asked to remove items from their pockets, remove their footwear and remove any heavy clothing (e.g jackets, coats) before measuring their body mass. Weight in kilograms was measured on calibrated beam balance (SECA 770, Germany).The same beam balance was used for the duration of the study. The beam balance was placed on a hard floor and participants were instructed to step on to the middle of the beam balance and look straight ahead. Weight was measured to the nearest 0.1 kg and then the participant steps off.

This process was completed twice and if consecutive values differ by more than 0.2 kg, a

32 third measurement was taken and the average of the values was obtained, to give the weight for that participant.88

3.13.5 Body mass index (BMI)

Body mass index (Quetelet index) which is used far more commonly to define obesity was calculated using a KADIO®--2420 made in China calculator using the formula below.

BMI (kg·m2) = weight / height2

Weight = kg

Height = m

A patient was considered obese if their BMI is more than 30 in males and females.

3.13.6 Blood cholesterol measurement

Total cholesterol assay was done by enzymatic spectrophotometric method44 using Randox reagents. The measurements were carried out by two laboratory scientist while the researcher bore the cost.

3.14 Training of the research assistant

Five research assistants who were professional staff nurse midwifes were trained on how to measure blood pressure, height and weight, waist circumference, and BMI calculation and used for data collection. Each question in the questionnaire was explained to the research assistants in the course of the training. The research assistants were also provided with a translated questionnaire to avoid loss of information in the course of translation. They were used for pretesting.

3.15 Data analysis

Data collected was analyzed using IBM-Statistical Packages for Social Sciences Version 22

(IBM-SPSS Version 22) and analyzed after data cleaning and editing. The categorical

33 variables (Fruit consumption, Cigarrette smoking etc) contained in section B of the questionnaire was summarized using proportions and percentages. The numerical variables

(Weight, Blood cholesterol etc) were summarized using proportions, percentages, means, standard deviation and range. The Test of significance for categorical variables were carried out using Chi-square and test for association done using logistic regression. Section C with numerical variables (Weight, Blood pressure, Blood cholesterol etc) was analyzed using t test. Data was presented using relevant tables and charts. Responses on awareness and practice were scored based on scoring tool developed for this study to enable comparison with scores for risk of cardiovascular diseases. See Appendix III for the scoring of responses.

Information from the focus group discussion was translated, transcribed and analyzed using thematic content with coding.

3.16 Ethical consideration

Ethical clearance and approval for the study was obtained from Nnamdi Azikiwe University

Teaching Hospital Ethical Committee (NAUTHEC) see appendix IX. Approval was sought and obtained from the Anambra state universal basic education board see Appendix X and the various headmasters/mistresses of the individual schools used see Appendix XI

Participants were informed of the scope, demands and benefits of the study. They were also assured of confidentiality and that their names were not be included in the questionnaires but codes where necessary. Written informed consent was obtained from each participant.

Participants were informed of their right to withdraw from the study at any time in the course of the study see informed consent form in Appendix I.

3.17 Confounding variables.

Age: Age as a cofounder in this research was reduced at the level of analysis of the study where the ages of the respondents was stratified and analyzed separately. Also age as a

34 cofounding variable was reduced as very elderly people are excluded by the selection of teachers currently under the employment of the state government (this excludes people above

60years of age).

Sex: the different sexes were analyzed separately at point of analysis.

Place of residence: This was included in the questionnaire and the study objectives have also taken care of it as it specified that urban residents and rural resident were studied separately and so analyzed also.

Smoking: This was taken care of at analysis although the level of smoking found in this research was low.

Hypertension: The hypertensives on drugs were excluded.

Diabetes Mellitus: The known diabetic patients were excluded

Heart diseases: People with known heart diseases were excluded.

Oral hypoglycemics: Patients on these drugs were excluded as oral hypoglycemic drugs as this can affect their weights and blood pressure.

3.18 Limitations

The few male primary school teachers made comparability of risk factors by gender unreliable and difficult.

CHAPTER FOUR

4.0 RESULTS

This chapter presents the results of both the quantitative and the qualitative data. The quantitative data and its summarization with its analysis are presented in tables as proportions and percentages, and the tables are grouped under headings to reflect the different parts of the research study as the questionnaire under these sections.

 Socio demographic data

 Awareness of cardiovascular disease and risk factors

 Awareness of cardiovascular disease risk factor reduction measures

 Overall awareness of respondents based on scoring of responses

 Practice of cardiovascular disease risk factor reduction measures

 Overall practice of respondents based on scoring

 Anthropometric and laboratory measurements as raw numerical data or in there

categorized forms.

 Risk for cardiovascular diseases and its distribution based on residence

 Overall risk as urban or rural

 Relationship between awareness and practice of cardiovascular disease risk reduction

measures.

 Relationship between awareness and/or practice of cardiovascular disease risk factor

reduction measures with the risk of cardiovascular disease.

The qualitative data are presented in their thematic content format.

4.1 Quantitative findings

4.1.1 SECTION A: BIODATA (Socio demographic factors)

Table 1: Socio demographic characteristics of respondents (Categorical variables)

Variables Urban Rural (N=160) Total (N=320) Test statistics p-value (N=160) n(%) n(%) 2 n(%)

Sex Male 3(1.88) 4(2.5) 7(2.19) 0.146 0.276 Female 157 (98.13) 156(97.5) 313 (97.81) Missing Marital status Fishers exact Never married 8(5) 20(12.5) 28(8.75) 7.819 0.026** Married 152(95) 138(86.25) 290(90.63) Divorced 0 2(1.25) 2(0.63)

Educational Fishers exact FSLC 5(3.13) 4(2.5) 9(2.81) 22.767 0.02** TCII 0 4(2.5) 4(1.25) OND 0 2(1.25) 2(0.63) HND 1(0.625) 0 1(0.28) NCE 18(11) 4(2.5) 22(6.88) BED 22(13.75) 32(20) 54(16.88) Postgraduate 115(71.88) 114(71.5) 229(71.56) Age 85 (53.13) 75 (46.88) 160 (50) 7.882 0.002* Below 50 years 60 (37.50) 100 (62.50) 160 (50) Above 50 years Mean 50.78 + 5.13 Age Range 38-59 RELIGION Fishers Exact Roman catholic 98(61.25) 92(57.5) 190(59.38) 2.985

0.55 Anglican 45(28.13) 52(32.5) 97(30.31) Pentecostal 17(10.63) 14(8.75) 31(9.69) Traditional 0 1(1.25) 2(0.63) religion Islam

** = Fishers Exact statistically significant * = Chi-square statistically significant

Respondents are predominantly female (97.81%), while males are only 2.19% with variations in the male-female distribution of respondents in urban and rural areas. There was a significant variation in the marital status. (P=0.026). 1.25% of rural respondents are divorced.

Those with post graduate education were 71.56% and the educational level varied in rural and urban (P=0.02). The mean age for the respondents was 50.78 +5.13 years. Though half of the respondents were above 50 years, but 62.5% of these were in the rural areas. There was no statistically significant difference in the religion of the respondents who were majorly

Catholics 59.38%.

4.1.2 SECTION B

Awareness of cardiovascular disease risk and risk reduction measures

Table 2 Awareness of Cardiovascular disease risk factors

Variables Urban Rural (N=160) Total(N=320) Test p-value (N=160) statistics n(%) n (%) n(%) 2

Have you heard of CVD

Yes 141(88.13) 124(77.5) 265(82.81) 6.345 0.005*

No 19(11.88) 36(22.5) 55(17.19)

If yes what source

Radio/Tv 102 (72.34) 86(69.36) 188 (58.75) 29.392 0.008**

Friend 16(11.35) 16(12.90) 32(10)

Neighbor 10(7.09) 0 10(3.13)

Newspaper 8(3.55) 0 8(2.5)

Heath company 5(3.55) 20(16.13) 25(7.8)

School 0 2(1.61) 2(0.63)

141 124

Which of these is a risk of heart disease

Consumption of fatty foods

Yes 120(75) 108(67.5) 228(71.25) 2.197 0.033*

No 40(25) 52(325) 92(28.75)

Consumption of processed packaged foods

Yes 27(16.88) 28(17.5) 55(17.19) 0.022 0.116

No 133(83.13) 132 (82.5) 265(82.81)

Consumption of fruits fishers vegetables exact

Yes 2(1.25) 16(10) 18 (5.62) 11.538 0.000**

No 158 (98.75) 144(90) 302 (94.38)

Increased alcohol intake Fishers Exact

Yes 40(25) 70(43.75) 1101 (34.38) 12.468 0.000*

No 120 (75) 90.56.25 210(65.63)

Yes 158(98.75) 151(94.38) 309 (96.56) 9.889 0.126

No 2(1.25) 9 (5.63) 11.(3.44)

Risk of developing heart disease can be exercise Fishers Exact

Yes 4(2.5) 4(2.5) 4(1.25) 4.038 0.061*

No 156(97.5) 156(97.5) 31.6 (98.75)

Lack of exercise

Yes 69(43.13) 60(37.5) 129.(40.3) 1.052 0.054

No 91(56.88) 100 191 (59.69)

Physical inactivity

Yes 14(8.75) 22(13.75) 36 (11.25)

No 146(91.25) 138(8.25) 284 (88.75) 2.003 0.052

Overweight

Yes 101.(63.13) 106(66.25) 207 (64.69) 0.342 0.79

No 59(36.88) 54(33.75) 113 (35.31)

Stress

Yes 68(42.5) 48.(30) 116 (36.25) 5.409 0.006*

No 92(57.5) 112(70) 204 (63.75)

Where is weight deposition most dangerous

Arm 0 4(2.5) 4(1.25)

Head 7(4.38) 4(2.5) 11(3.44) 20.615 0.007**

Waist 16(10) 36(22.5) 52(16.25)

Chest 82(51.25) 84(52.5) 166(51.88)

Legs 22(51.25) 18(11.25) 40(12.5)

I don’t know 33 (20.63) 14 (18.75) 47(14.69)

** = Fishers Exact statistically significant * = Chi-square statistically significant

There was high level of awareness of cardiovascular disease (82.81%). This awareness was

higher in the urban respondents with a statistically significant difference (P=0.005). The

commonest source of information was from the media (TV/Radio) (58.75%) and this was

also higher in the urban respondents and a statistically significant difference existed between

urban and rural respondents and their source of information (P=0.008). Awareness on

consumption of fatty foods as a risk was higher in the urban than the rural and this was

statistically significant (P=0.033). Awareness of consumption of processed packaged foods

was low 17.19% were aware that it is a risk of heart disease. Over ninety percent correctly

identified that consumption of fruits and vegetables are not a risk for developing heart

disease. This awareness was higher in the urban respondents and it was statistically

significant (FI=11.538, P=0.000). Awareness of increased alcohol intake as a risk of heart

disease was low as only 34.38% and it was statistically significant as more rural respondents

identified alcohol as a risk of heart disease more than their urban counterparts. Ninety six

percent of respondents identified smoking as a risk for heart disease, and this high percentage

though slightly more in the urban respondents, but there was no statistically significant

41 difference. There was significant variation in the awareness of stress (P=0.006) as a contributor to cardiovascular diseases among urban and rural respondents, but no statistically significant difference in their awareness of overweight, physical inactivity, lack of exercise and exercise between the urban and the rural respondents.

TABLE 3: Awareness of cardiovascular disease risk reduction measures

Variables Urban Rural (N=160) Total (N=320) Test p-value (N=160) statistics n(%) n(%) n(%) 2

Which of these can reduce risk of heart disease

Exercise

Yes 51(31.88) 60(37.5) 111 (34.69) 1.117 0.054

No 109(68.13) 100 (62.5) 209(65.31)

Exercising at least 30 minutes a day

Yes 44(27.5) 62(47.7) 106(33.13) 12.610 0.000*

No 116(92.5) 68(52.37) 184 (57.5)

Smoking avoidance

Yes 62 (38.75) 58 (36.25) 120 (37.5) 0.213 0.083

No 98 (61.25) 102 (63.75) 200 (62.5)

Reduction of alcohol intake

Yes 76(47.5) 70(43.75) 146 (45.63) 0.453 0.71

No 84(52.5) 90(56.25) 174(54.38)

Consumption of fruits/vegetables

Yes 47(29.38) 38(23.75) 85(26.56) 1.298 0.53

No 113(10.63 122(26.25) 235(73.44)

Consumption of up to 5 servings of fruits a day

Yes 11(6.88) 42(76.25) 53(16.56) 21.731 0.000*

No 149(93.13) 118(73.75) 267(83.44)

Avoidance of fried foods

Yes 48(30) 62 (38.75) 110(34.38) 2.715 0.024*

No 112(70) 98 (61.25) 210(65.63)

Weight reduction

Yes 61(38.13) 58(36.25) 119(37.19) 0.123 0.087

No 99 (61.88) 102 (63.75) 201(62.81)

Regular blood pressure checks

Yes 62 (38.75) 62 124(38.75) 0.00 0.546

No 98 (61.25) 99(61.2) 196 (61.25)

Regular blood sugar test

Yes 38 23.75 42 26.25 80 (25) 0.267 0.90

No 122 (76.25) 118 (73.75) 240(75)

Regular blood cholesterol

Yes 79 (49.38) 68 (42.5) 147-(45.94) 1.523 0.042*

No 81(50.63) 92 (57.5) 173-(54.06)

Regular medical check up

Yes 77 (48.13) 80(50) 157(49.06) 0.113 0.084

No 83(51.88) 80 (50) 163(50.94)

* = Chi-square statistically significant

Awareness of exercise as a factor that can reduce the risk of heart disease was among 34.69%

with slightly higher proportion of rural respondents having this awareness. The awareness

that exercising at least 30 minutes a day was protective was among 33.13% of the

respondents. Smoking avoidance, reduction of alcohol intake was identified by 37.5% and

45.63% respectively and there was no difference between the urban and rural respondents.

Although 26.56% of respondents are aware that consumption of fruits and vegetables were protective and this did not vary from urban and rural respondents, but only 16.56% of respondents were aware that consumption of fruits of up to 5 servings a day. Also the urban respondents knew the protective effects of regular blood cholesterol check than their rural counterparts p<0.05.

Table 4: Overall awareness of cardiovascular diseases risk/reduction measures in urban and rural primary school teachers in Anambra State

Variables Urban Rural (N160) Total(N=320) Test p-value (N=160) statistics n(%) (%) n(%) 2

Overall Awareness High 99 (61.88) 104 (65) 203 (63.44) 0.643 0.321

Low 61 (38.13) 56 (35) 117 (36.56)

Sixty-three percent of respondents had high awareness and of this, 65% were rural

respondents but this did not show any statistically significant difference between the urban

and rural respondents.

4.1.3 SECTION C: Practice of cardiovascular disease risk reduction measure

Table 5 Practice of cardiovascular disease risk reduction measure

Variables Urban Rural (N-160) Total (N=320) Test statistics p-value (N=160) n(%) n(%) 2 n(%)

Do you smoke

Yes 5(3.13) 8(5) 13(4.06) 0722 0.158

No 155 (96.88) 152(95) 307(95.94)

Do you exercise

Yes 124(77.5) 148(93.67) 272(85) 16.801 0.000*

No 36(22.5) 10(6.33) 46(14.38)

If yes how long 20-17.54 26(17.81) 46- (17.69) I don’t know 22(19.3) 36(24.66) 58-(22.31) 3.28 0.020* up to 10 minutes 50(43.86) 58(39.73) 108(41.54)

20minutes 22(19.3) 26(17.81) 48 (18.46)

30 minutes

If yes how often 15 (16.61) 40(26.67) 55 (21.64) daily 49 (41.53) 66(44) 115 (18.07) up to 3 times weekly 26(22.03) 22(14.67) 48 (42.91) weekly 25(21.19) 22.(4.67) 47(18.08) 9.952 0.19 sparingly - - -

never

Do you eat Fishers Exact fruits and vegetables

Hardly 7(4.38) 12(7.9) 19(5.94) 9.799 0.044**

Daily 119(74.38) 98(64.47) 217(67.8)

Weekly 24(15) 20(13.18) 44(13.75)

More than 10 18(11) 248(8.75) once daily up to 5 times 0 4(2.63) 4(1.25) daily

Do you drink alcohol

Yes 34(21.25) 22(13.92) 56.(17.5) 2.941 0.058

No 126(47.91) 136(51.91) 262(82.39)

Avoidance of fried foods

Yes 76 (47.5) 88 (55.7) 164 (51.25) 2.138 0.088

No 84 (52.5) 70(44.3) 154 (48.75)

Weight reduction

Yes 65(40.63) 46 (29.11) 111(34.69) 4.636 0.021*

No 95 (59.38) 112 (70.89) 207(64.69)

Regular blood pressure check

Yes 67(41.88) 66(41.77) 133(41.22) 0.001 0.538

No 93(58.13) 92(58.23) 185(57.81)

Regular blood sugar check

Yes 51(31.88) 26(16.46) 77(24.06) 10.300 0.001*

No 109(68.22) 132(83.54) 241(75.31)

Regular blood cholesterol check

Yes 37(23.13) 46(30) 83(25.94) 1.478 0.138

No 123(76.88) 112(70) 235(73.44)

Regular medical check up Yes 36(22.5) 32(21.25) 68(21.25) 0.239 0.363

No 124(77.5) 126(78.75) 250(78.13)

** = Fishers Exact statistically significant * = Chi-square statistically significant

Smokers were only 4.06% and there was no statistically significant distribution of smokers into urban or rural respondents. Rural respondents exercised more than the urban respondents

(P=0.00) both in duration (P=0.021) but not frequency (P=0.19). Consumption of fruits and vegetables was significantly more in the rural respondents (P=0.044). Alcohol consumption, avoidance of fried foods, regular blood pressure check, regular blood cholesterol check and regular medical checkup did not vary among rural and urban respondents, but effort at weight reduction was more among the urban respondents and this varied significantly (P=0.021).

Table 6: Overall practice of cardiovascular diseases risk/reduction measures in urban and rural primary school teachers in Anambra State

Variables Urban Rural (N160) Total(N=320) Test p-value (N=160) statistics n(%) (%) n(%) 2

Overall Practice High 140 (87.5) 152 (95) 292 (91.25) 5.636 0.014*

Low 20 (12.5) 8 (5) 28 (8.75)

* = Chi-square statistically significant

Overall practice of cardiovascular risk reduction was high in this study as 91.25% of

respondents recorded above average score and this was higher in the rural respondents as

95% of those with high awareness are from the rural area, and this is statistically significant

(P=0.014)

4.1.4 Section D: Anthropometric/laboratory measurements for urban and rural primary school teachers in Anambra State.

TABLE 7 Numerical measurements for anthropometric and laboratory data

Variables Range Mean Standard Deviation Cholesterol 124-230 177.79 20.24 BMI 16.80- 30.30 5.72 45.00 Weight 45-125 81.18 16.09

Height 151-175 162.98 5.15

The mean cholesterol is 177.79+20.24mg/dl, mean BMI 30.30+5.72kg/m2, mean weight

81.18+16.09kg and mean and standard deviation of height with their various ranges.

TABLE 8: Categorized Body Mass Index for urban and rural primary school teacher in teachers in Anambra State

Variables Urban Rural (N160) Total(N=3 Test p-value (N=160) 20) statistics n(%) n(%) (%) 2

BMI Fishers exact

Less than 18.50 __ 4 (2.5) 4 (1.25) 12.238 0.032**

18.50 – 24.99 19 (11.88) 18 (11.25) 37 (11.56)

25.00 – 29.99 58 (36.25) 52 (32.5) 110 (34.42)

30.00 – 34.99 40 (25) 58 (36.25) 98 (30.63)

35.00 – 39.99 28 (17.50) 22 (13.75) 50 (15.63)

Above 40.00 15 (9.38) 6 (3.75) 21 (6.56)

* = Chi-square statistically significant

BMI varied significantly (P=0.032) with more obesity in the urban respondents.

Table 9: Categorized Waist circumference of urban and rural primary school teachers in Anambra state

Variables Urban Rural (N160) Total(N=3 Test p-value (N=160) 20) statistics n(%) n(%) (%) 2

Below 102cm 61 (38.13) 99 (61.88) 160 (50) 19.013 0.000*

Above 102cm 100 (62.50) 60 (37.50) 160 (50)

* = chi-square test statistically significant

Central obesity was more amongst urban respondents than the rural respondents but the

variation is not statistically significant.

Table 10 Categorized Systolic blood pressure for urban and rural primary school teachers in Anambra State

Variables Urban Rural (N160) Total(N=3 Test p-value (N=160) 20) statistics n(%) n(%) (%) 2

Systolic Fishers Exact blood Pressure (mmgh)

Less than 130 109(68.13) 84(52.5) 193 15.622 0.004** (60.31)

130-139 __ 6(3.75) 6 (1.88)

140-159 28(17.5) 44(27.5) 72 (22.5)

160179 19(11.88) 16(10) 35 (10.94)

Above 180 4(2.5) 10(6.25) 14 (4.38)

** = Fishers exact statistically significant

Systolic blood pressure level was more among the rural than the urban respondents and the

variation was statistically significant at (P=0.004).

Table 11 – Categorized Diastolic Blood Pressure for primary school teachers in urban

and rural areas in Anambra state.

Variables Urban Rural (N160) Total(N=3 Test p-value (N=160) 20) statistics N (%) N (%) (%) 2

Diastolic

Blood Pressure Fishers Exact

Less than 85 123 (76.88) 70 (43.750 193 39.080 0.000** (60.31)

85-89 __ 2 (1.25) 2 (0.63)

90-99 30 (18.75) 64 (40) 94 (29.38)

100-109 3 (1.86) 16 (10) 19 (5.94)

≥110 4 (2.5) 8 (5) 12 (3.75)

** = Fishers exact statistically significant

Diastolic blood pressure was higher in rural respondents than urban respondents and this was

statistically significant (P=0.000).

Table 12 – Categorized cholesterol level for urban and rural primary school teachers in Anambra State

Variables Urban Rural (N160) Total(N=3 Test p-value

(N=160) n(%) 20) statistics

n(%) (%) 2

Cholesterol level

Below 200mg/dl 133 (83.13) 135 (84.38) 268 0.92 0.115

(83.75)

Above 200mg/dl 27 (16.88) 25 (15.63) 52 (16.25)

No significant variation existed in their cholesterol levels of urban and rural respondents and

those with above normal cholesterol level to be 16.25%.

TABLE 13: Risk Factor of Cardiovascular Disease For Urban and Rural primary school teachers in Anambra state.

Variables Urban Rural (N160) Total(N=320) Test p-value (N=160) statistics n(%) (%) n(%) 2

Age of respondents

Below 50 years 85 (53.13) 60 (37.50) 145 (45.31) 7.882 0.02*

Above 50 years 75 (46.88) 100 (62.5) 175 (54.69)

BMI

Normal 5 (3.13) 11 (6.88) 16 (5) 3.047 0.020

Overweight 17 (10.63) 21 (13.13) 38 (11.88)

Obese 138 (86.25) 128 (80) 266 (83.13)

Systolic Blood Pressure

Normal 109 (68.1) 90 (56.3) 199 (62.19) 4.798 0.029*

Hypertensive 51 (31.9) 70 (43.8) 121 (37.81)

Diastolic Blood Pressure

Normal 123 (76.9) 72 (45) 195 (60.94) 34.146 0.000*

Hypertensive 37 (23.1) 88 (55) 125 (39.06)

Blood Cholesterol

Normal 133 (83.1) 135 (84.4) 268 (83.75) 0.092 0.762

Raised cholesterol 27 (16.9) 25 (15.6) 52 (16.25)

* = Chi-square statistically significant

Significant risk factors for cardiovascular diseases were age, BMI, systolic blood pressure

and diastolic blood pressure and all these risk factors were not evenly distributed among the

57 rural and urban respondents. There were older age groups in the rural area (X2=0.882, p=0.02), more obese persons in the urban areas (X2=3.047, P=0.02) more persons with rise in systolic blood pressure in the rural areas (X2=4.798, P=0.029) and also more persons with rise in diastolic blood pressure in the rural areas. There was no statistically significant difference recorded in the cholesterol measurement of rural and urban respondents as shown in the table above.

Table 14: Cross tabulation of Body mass index (BMI) with systolic blood pressure, cholesterol, Diastolic blood pressure.

BMI

Variables Normal Raised (N=279) Total(N=320) Test p-value (N=44) statistics n(%) (%) n(%) 2

Systolic Blood pressure

Normal 34 (10.6) 165 (51.6) 199 (62.19) 8.602 0.003*

Raised 7 (2.2) 114 (35.6) 121 (37.81)

Cholesterol

Normal 35 (10.9) 233 (72.8) 268 (83.75) 0.090 0.764

Raised 6 (1.8) 46 (14.4) 52 (16.25)

Diastolic B.P Fishers Exact

Normal 36 (11.3) 159 (49.7) 195 (60.94) 14.261 0.000*

Raised 5(1.6) 120 7.5) 125 (9.06)

* = Chi-square statistically significant

Systolic blood pressure rise is more among obese persons than non-obese person (X2=8.602,

P=0.003) Those with raised BMI also had higher risk of having raised diastolic blood

pressure (X2=14.261, P=0.000). There was no association between the BMI and the

cholesterol level of the respondents in this study as shown above.

Table 15: Cross tabulation of waist circumference with Systolic blood pressure, Diastolic blood pressure and cholesterol

WAIST CIRCUMFERENCE

Variables Normal Raised (N=159) Total(N=320) Test p-value (N=161) statistics n(%) (%) n(%) 2

Systolic Blood Pressure

Normal 94 (29.4) 105 (32.5) 199 (62.19) 1.992 0.158

Hypertensive 67 (20.9) 54 (16.9) 121 (37.81)

Diastolic Blood Pressure

Normal 94 (29.4) 101 (31.6) 195 (60.94) 0.887 0.346

Raised cholesterol 67 (20.9) 58 (18.1) 125 (39.06)

Cholesterol

Normal 136 (42.5) 132 (41.3) 268 (83.75) 7.7250 0.124

Raised 25 (7.8) 27 (8.4) 52 (16.25)

Waist circumference was not associated significantly with systolic blood pressure, diastolic

blood pressure or cholesterol level as can be seen from the table above.

Table 16: Cross tabulation of Systolic blood pressure with BMI, Cholesterol, Diastolic Blood pressure and Waist circumference

SYSTOLIC BLOOD PRESSURE

Variables Normal (N=199) Raised (N=121) Total(N=320) Test p-value statistics n(%) n(%) (%) 2

BMI

Normal 34 (10.6) 7 (2.2) 41 (12.8) 0.003 8.602 *

Obese 165 (51.6) 114 (35.6) 279 (87.2)

Cholesterol 199 (62.2) 121 (37.8)

Normal 167 (52.2) 101 (31.6) 268 (83.75) 0.916 0.011

Raised 32 (10) 20 (6.3) 52 (16.25)

Diatolic B.P

Normal 175 (54.7) 20 (6.3) 195 (60.94) 0.000 161.202 *

Raised 24 (7.5) 101 (31.6) 125 (39.06)

Central Obesity

Normal 94 (29.4) 67 (21) 161 (50.31) 0.158 1.992

Obese 105 (32.8) 54 (16.9) 1599.69)

* = Chi-square statistically significant

Respondents with raised systolic blood pressure were among the obese group and that raised systolic blood pressure is associated with a raise in diastolic blood pressure (X2=161.202,

P=0.000)

Table 17: Cross tabulation of Diastolic blood pressure with Body mass index, Cholesterol, waist circumference and systolic blood pressure

DIASTOLIC BLOOD PRESSURE

Variables Normal (N=195) Raised (N=125) Total(N=320) Test p-value statistics n(%) n(%) (%) 2

BMI

Normal 36 (11.3) 5 (1.6) 41 (12.81) 0.000* 14.261

Obese 159 (49.7) 120 (37.5) 279 (87.19)

Cholesterol

Normal 158 (49.4) 110 (34.4) 268 (83.75) 0.099 2.722

Raised 37 (11.6) 15 (4.7) 52 (16.25)

Waist circumference

Normal 94 (29.4) 67 (20.9) 161 (50.31) 0.346 0.887

Obese 101 (31.6) 58 (18.1) 159 (49.69)

Systolic

Normal 175 (54.7) 24 (7.5) 199 (62.19) 0.000* 161.202

Raised 20 (6.3) 101 (31.6) 1217.81)

* = Chi-square statistically significant

Diastolic blood pressure is associated with BMI but not with cholesterol and waist

circumference.

Table 18: Cross tabulation of Cholesterol with Body mass index, diastolic blood pressure, waist circumference and systolic blood pressure

CHOLESTEROL

Variables Normal Raised (N=52) Total(N=320) Test p-value (N=268) statistics n(%) (%) n(%) 2

BMI

Normal 35 (10.9) 6 (1.9) 41 (12.81) 0.090 0.764

Obese 233 (72.8) 46 (14.4) 279 (87.19)

Diastolic blood pressure

Normal 158 (49.4) 37 (11.6) 195 (60.94) 2.722 0.099

Raised 110 (34.4) 15 (4.7) 125 (39.06)

Waist circumference

Normal 136 (42.5) 25 (7.8) 161 (50.31) 0.124 0.725

Obese 132 (41.3) 27 (8.4) 159 (49.69)

Systolic

Normal 167 (52.2) 32 (10) 199 (62.19) 0.011 0.916

Raised 101 (31.6) 20 (6.3) 121 (37.81)

Cholesterol level rise is not associated with any of the other parameters of BMI, Diastolic

blood pressure, waist circumference and systolic blood pressure.

Table 19: Cross tabulation of categorized age of respondents with cholesterol, body mass index, diastolic blood pressure, systolic blood pressure and waist circumference and risk for Cardiovascular disease.

AGE (years)

Variables Below 50 Above 50 Total(N=320) Test p-value (N=145) (N=175) (%) statistics n(%) n(%) 2 Cholesterol Normal 129 (88.97) 139 (79.43) 268(83.75) 0.0015* 5.300 Raised 16 (11.03) 36 (20.57) 52 (16.25) BMI Normal 21 (14.48) 20 (11.43) 41 (12.81) 0.259 0.662 Obese 124 (85.52) 155 (88.57) 179 (87.19) Diastolic BP Normal 87 (60) 108 (61.71) 195 (60.94) 0.421 0.098 Raised 58 (40) 67 (38.29) 125 (39.06) Systolic BP Normal 95 (65.52) 104 (59.33) 199 (62.19) 0.150 1.250 Raised 50 (34.48) 71 (40.57) 121 (37.81) Waist circumference Normal 82 (56.55) 63 (36) 145 (45.31) 4.129 0.027*

Central obesity 79 (43.35) 96 (64) 175 (54.69) Risk for CVD Low risk 143 (98.62) 127 (72.57) 270 (84.38) 0.000* 40.814 High risk 2 (1.38) 48 (27.43) 50 (15.63) * = Chi-square statistically significant

Increasing age leads to increased level of cholesterol (X2=5.300, P=0.0015). Of the 16.25% of respondents with raised cholesterol level, 20.57% were above 50 as against 11.03% that were below 50. Increasing age above 50 was not associated with increased BMI, diastolic blood pressure and systolic blood pressure but significantly associated with increased waist circumference (X24.129, P=0.027) and risk for cardiovascular disease (X2=40.814, P=0.000) as shown above.

TABLE 20: Cross tabulation of gender with body mass index, waist circumference, systolic blood pressure, diastolic blood pressure and cholesterol

GENDER

Variables Male (N=7) Female Total(N=320) Test p-value (N=313) statistics n(%) (%) n(%) 2

Male Female Total Test P- Statistics Values

BMI

Normal 0 41 (13.10) 41 (12.81) 1.052 0.379

Raised 7 (100) 272 (86.90) 279 (87.18)

Waist Circumference

Normal 3 (42.85) 158 (50.48) 161 (50.31) 0.159 0.722

Raised 4 (57.15) 155 (49.52) 159 (49.69)

Systolic BP

Normal 4 (57.15) 195 (62.30) 199 (62.19) 0.77 0.533

Raised 3 (42.85) 118 (37.70) 121 (37.81)

Diastolic BP

Normal 3 (42.85) 192 (61.34) 195 (60.94) 0.983 0.438

Raised 4 (57.15) 121 (38.66) 125 (39.06)

Cholesterol Normal 7 (100) 261 (83.39) 268 (83.75) 1.389 0.285

Raised 0 52 (16.61) 52 (16.25)

Table 16 From the above table, we can see that there is no association of gender with raised

BMI, waist circumference, systolic blood pressure, diastolic blood pressure and cholesterol.

TABLE 21: Logistic regression showing adjusted odds ratio for predictors of risk for cardiovascular diseases

Risk for cardiovascular disease

VARIABLES ODDS RATIO 95%Confidence P-VALUE

interval

Systolic BP 0.273 0.122-0.613 0.002**

Cholesterol 0.269 0.101-0.714 0.008**

Diastolic BP 1.309 0.599-2.862 0.499

Central Obesity 0.795 0.433-1.427 0.442

Generalized Obesity 0.775 0.344-1.747 0.539

Age 11.448 6.033-21.723 0.000**

Sex 4.000 0.876-18.271 0.074

** = Fishers Exact statistically significant

Adjusted odds ratio of systolic blood pressure (OR=0.273, P=0.002), age above 50 carried an

11 times risk of developing cardiovascular disease than age below 50 (P=0.000). Cholesterol was also a significant predictor for risk of cardiovascular disease (OR=0.269, P=0.008) other parameters assessed above were not significant predictors for risk of cardiovascular disease

TABLE 22: Distribution of overall risk for cardiovascular disease in urban and rural primary school teachers in Anambra state

Variables Urban Rural (N=160) Total(N=320) Test p-value (N=160) statistics n(%) (%) n(%) 2

Overall Risk for cardiovascular disease Low 125 (78.13) 98 (61.25) 223 (69.69) 10.785 0.001

High 35 (21.88) 62 (38.75) 97 (30.31)

High overall risk of developing cardiovascular disease was among 30.31% of the respondents

and high risk was found more among the rural respondents than the urban respondents

(X2=10.785, P=0.001)

4.1.5: SECTION E: Relationship between awareness and practice of cardiovascular disease risk/reduction measures and the risk for cardiovascular diseases

Table 23: Relationship of awareness of cardiovascular disease risk/reduction measures and practice of cardiovascular disease risk reduction measures Practice of cardiovascular risk reduction

Awareness Low (N=28) High Total(320) Test Stat 2 P-Value (N=292) Low 19 (67.86) 98 (33.16) 117 (36.56) 12.956 0.000**

High 9 (32.14) 194(66.84) 203 (63.44)

** = Fishers Exact statistically significant

With increasing awareness of cardiovascular risk, there is a corresponding increase in the practice of cardiovascular disease risk reduction measures (X2= 12.956, P=0.000).

Table 24: Relationship of awareness of cardiovascular disease risk reduction measures and risk for cardiovascular diseases

Risk for cardiovascular disease

Awareness of Low High (N=50) Total (320) Test Stat P-Value

Cardiovascular (N=270) disease

Low Awareness 102 (37.78) 15 (30) 117 (36.56) 1.100 0.188

High 168 (62.22 35 (70) 203 (63.64)

Awareness

There was no relationship between the awareness of cardiovascular disease risk and its reduction measures and the risk for cardiovascular disease.

TABLE 25 Relationship of overall practice of cardiovascular disease risk reduction measures and risk for cardiovascular diseases

Risk for cardiovascular disease

Practice of Low (N=270) High (N=50) Total(N=320) Test Stat P-Value

CVD Risk reduction

Low Practice 26 (9.63) 2 (4) 28 (8.75) 1.675 0.152

High Practice 244 (90.37) 48 (96) 292(91.25)

There is no relationship between the overall practice of cardiovascular disease risk reduction measure and the risk f cardiovascular disease (X2=1.675, P=0.152) as shown above.

4.2 Qualitative findings

Focus group discussion

The results of the focus group discussions that were held in an urban school and a rural school are presented below. The themes generated from this qualitative focus group discussion did overlap between that of the rural and that of the urban and is presented in a thematic content analysis involving open coding of participants words and generation on analytic schema. The theme generated was presented under these headings as subsections:

 Cardiovascular disease and risk factors

 Cardiovascular disease risk factor reduction

 Practice of Cardiovascular disease risk reduction measures

 Relationship with weight and Cardiovascular disease

 Impact of Cardiovascular disease risk reduction effort

4.2.1 Cardiovascular disease and risk factors

Most respondents in both rural and urban locations had an idea of the meaning of cardiovascular disease and this they explained in lay terms. One of the respondents said “It is when the heart fails to perform its normal function” (Response from a rural participant). In another words a respondent explained that cardiovascular disease involves frequent tiredness.

In her words “it is when the heart does not pump blood well”

On risk factors for cardiovascular disease, most respondents were able to identify the following risk factors salt intake, high cholesterol, stress and smoking and alcoholism. A female teacher in an urban area said “Another thing that causes cardiovascular disease is being under the sun for too long” Other responses on this were as follows

“for me, it is when one eats a lot of salt”,

“the risk factor is too much sleeping”,

“those that drink too much alcohol suffer it”,

“I think it is because of cholesterol”

From the above, it is evident that some of the respondents have good knowledge on cardiovascular disease and cardiovascular disease risk factors.

4.2.2 Cardiovascular disease risk factor reduction

On Cardiovascular disease risk factor reduction, responses shows that the awareness of cardiovascular disease risk factor reduction was there. Respondents highlighted a number of measures that can reduce cardiovascular disease risk. Some of the responses showed that the measures were exercise, avoidance of fatty foods, avoidance of salt and were expressed in their words as follows:

“me I believe its by doing exercise that one can be healthier”

“some people eat a lot of fried foods that has fat, they should avoid it”

“abstaining from salt intake”

“If people will reduce the way they drink alcohol, the risk will reduce”

“for me, its by not staying near people that smoke”

4.2.3 Practice of Cardiovascular disease risk reduction

It was surprising to discover from this focus group discussion that exercise was taken very seriously by respondents in this research. This showed clearly in their responses

“since I heard about the death of that fat Mr Okafor, I now trek to morning mass”

“me I walk to school and walk back, that way I am even safe from okada accident and I know

I helps me to be healthier”

“I try to move around and do things because I noticed that anyday I stay at home all day, I fall sick”.

“for me, I avoid eating fried foods”

“What I do to prevent heart disease is that I go to hospital and check my BP and my cholesterol”

4.2.4 Relationship with weight and Cardiovascular disease

Responses gotten showed that few people are aware of the relationship between weight and cardiovascular disease as most respondents were more interested in other risk factors like smoking. However, some respondents had this to say

“people that are fat are always sick”

“overweight is not good”

Some of the respondents expressed views that showed they did not believe that something can be done about weight. One of the respondents had this to say “I believe that weight comes naturally, and when it comes you don’t have to kill yourself, I was very slim before I got married, now inspite of all the housework I do, I am still fat”.

4.2.5 Impact of Cardiovascular disease risk reduction effort

In the words of the respondents, it was clear that some believed that cardiovascular risk reduction was an odd practice that everyone should do. Many of them had this to say

“I believe if you help your heart, it will help you”

“all this things that we do like avoiding fried foods, they help very well”

“I used to have ulcer and since I was asked to stop eating fried foods the pain doesn’t come again, and from the way I feel in my body, I know that it is not only ulcer that it stopped”

“one day I went to lab and I was told I had high cholesterol, since then I stopped eating fatty foods and I check my cholesterol every year and it doesn’t go up”

At the end of the focus group discussion, respondents suggested that since health workers were always busy in the hospital that this kind of interview and teaching should be brought to their schools in the future.

CHAPTER FIVE

DISCUSSION

General awareness of cardiovascular disease, the awareness of risk factors for developing cardiovascular diseases, and the awareness of cardiovascular disease risk reduction measures was assessed. The general awareness of CVD, was significantly higher in the urban teachers than the rural teachers (P<0.01) one can infer that urban teachers have heard about

Cardiovascular disease more than the rural respondents in this study. In a similar study in

Kano,53 only 75.6% of respondents were aware of CVD.81 This is not surprising as one will expect a higher awareness among teachers than the general population. The Kano53 study was carried out in the general population.

The common source of information on CVD was from the media (radio and Tv) (58.75%) and more urban respondents got their information through the media. The other sources of information especially from health institutions/workers were more among rural respondents.

One can infer from here that the respondents from the rural area, got information from the health institutions more than their urban counterparts. This variations in the sources of information in the rural and urban respondents was significant (P<0.01). In the study, information was gotten from media in 58.75% while in a similar study in Kano53 information from media (radio/tv) was 34.2%. On the contrary 22.9% of respondents in the Kano53 study got information from health workers/institutions, while only 7.8% got information from health workers/institution in this research. 81 Anambra State has more urban and semi-urban areas and inhabitants are of higher socioeconomic level that can afford electronic gadgets.

This can explain the higher dissemination of information through the media than the experience in Kano study. Whereas there is a higher awareness of CVD in this study (see table 2) with the common source of information being the media, there was more information dissemination from health workers in the Kano study than in this study.53 Information from

76 health workers was also more for the rural respondents. The implication of the source of information especially if gotten from health worker is that the individual will have the opportunity to evaluate the information, ask questions and personalize the information obtained. This may therefore encourage better practice than when non-personalized information is received from the media. On awareness of risk for developing CVD, the awareness of the following risk factors were explored (Nutritional risk factors, lifestyle risk factors/alcohol and smoking, overweight and stress). Little above 70% of the respondents identified consumption of fatty foods as a risk factor for CVD. More urban respondents

(75%) as against rural respondents (67.5%) identified this risk factor. There was a statistically significant difference in the awareness of consumption of fatty foods as a risk of CVD among urban and rural respondents (P<0.05) when compared to the Kano study53, only 6.4% identified consumption of fatty foods as a risk factor for developing CVD while 31.3% identified this risk factor in a study in Belgium19. The awareness of consumption of fatty foods as a risk factor for CVD was higher in this study than other studies both studies were carried out among military men, while our study was among teachers. The higher awareness might be as a result of high educational qualification, teaching occupation and overall increased awareness in South East Nigeria especially among teachers. Rural respondents agreed more than the urban respondents that processed packaged foods is a risk of developing

CVD to 10% of rural respondents identified wrongly consumption of fruits and vegetables as a risk of CVD, while only 1.25% of urban respondents identified it as not a risk factor.

Increased alcohol intake was identified as a risk factor by 34.38% of the respondents. This awareness was more among rural respondents (43.75%) than urban respondents (25%) and this variation is statically significant (P<0.01). On the contrary, more urban respondents

(98.75%) identified smoking as a risk factor for CVD than rural respondents (94.38%), but this was not statistically significant (P>0.05). Not surprisingly, smoking was the most

77 identified risk factor for CVD overall in this research. Lack of exercise as a risk factor for

CVD was identified by 40.37% of the respondents and the awareness of this risk factor was more among urban respondents (43.13%). This variation awareness is not statistically significant and could be due to chance. High percentage of respondents (88.75%) could not identify physical inactivity as a risk factor for CVD.

In a study in Kano,53 70.6% of respondents were aware of smoking as a risk factor for developing CVD, while 60.1% of respondents in a Belgium study19 identified smoking as a risk factor for CVD 40.3% of respondents also in the Belgian study identified lack of exercise as a risk factor as against 88.9% in this study.19 The instance that there is higher risk factor awareness particularly on lifestyle factors (alcohol, smoking and lack of exercise) can be made from the above figures. One can also say since the two comparing studies were carried out among army personnel that there may be a higher awareness of CVD risk factors among teachers than army personnel. Overweight as a risk factor for CVD was identified by 64.69% of respondents in this research in contrast with the army personnel in Belgium19 14.3% identified it and army personnel in Kano 41.6%.53 Surprisingly stress as a risk factor was identified by 36.2% while in the Kano study 87% identified stress and the Belgian study

(34.9%). Up to 16.82% of respondents are aware that weight deposition at the waist carried significant risk for developing heart disease while in a comparison study in Ibadan, only 1% had this awareness.51 This awareness that fat deposition at the waist was a risk for CVD was more among rural respondent (22.5%) than urban respondents (10%) and this was statistically significant (P <0.05). One can still infer that the awareness of overweight as a risk factor for

CVD is higher in this study (see table 2) than other comparison studies, while 1% of respondent identified stress as a risk factor for CVD in northern Nigeria which is lower than the findings in this study.

This study showed that only 4.06% of respondents smoked cigarettes (5% rural, 3.13 urban).

Though this difference in the prevalence of smoking amongst urban and rural teachers was not statistically significant and as such could be due to chance, but one can also notice that urban respondents had higher awareness of smoking as a risk factor and smoking avoidance as a risk reduction measure. One can deduce from the results that the higher prevalence of smoking amongst the rural teachers could be as a direct result of their lower awareness of smoking as a risk of CVD, and its avoidance as a risk reduction measure. One can also attribute this higher prevalence to the sex difference since there were more male teachers in the rural than in the urban and smoking in our environment is usually more among male than females. When compared with findings of other researchers, the smoking prevalence was higher in the studies carried out in secondary school teachers in Oyo (12.3%),51 and among police officers in India (50%),65,66,67 but the prevalence of smoking in the study was much higher than the prevalence of smoking amongst female teachers in Iraq (0.5%)72. The higher smoking prevalence in the study in Oyo among secondary school teachers51 could be from the more male participants in the study when compared to this study where 97.8% are females.

The Indian study may have recorded a higher prevalence than this study because it was among police officers who are mainly male and are also exposed to more occupational stress than teachers. One can infer that this study recorded a high prevalence of smoking, considering 0.5% prevalence among female teachers in Iraq72 could be due to high percentage of Muslims and less permissiveness of Islamic religion which is predominantly practiced in that region. Stratifying prevalence of smoking by sex, 57.14% of males smoked, while only

2.88% of females smoke. This is still higher than 0.5% of female teachers in Iraq who smoke72.

A significantly higher proportion of rural respondents in this study engaged in exercise than their urban counter parts (P<0.01) most of the respondents engaged in exercise of up to 30

79 minutes (41.54%) per session, and exercised up to three time weekly (42.91%). Those who exercise up to 3 times weekly or daily were more amongst the rural respondents than the urban respondents, while those carrying out exercise weekly or sparingly were more among the urban respondents than the rural respondents and this variation was statistically significant (P<0.01). One can attribute the low frequency of exercise among the urban respondents to lack of space for recreational activities. This is even more pronounced as the urban respondents are from Onitsha characterized with built up areas, high rise buildings and little or no space for recreation. The transport system in the urban area is also more advanced than that in the rural area. So while rural respondents have more space, less traffic and are generally more likely to engage in physical activity (exercise), they can also be involved in forced exercise due to poor transportation means in the rural area. Comparing this study with other similar studies while 85% of the total respondents engaged in exercise, 80% of secondary school teachers in Oyo51 engaged in exercise, while 93.1% of army personnel in

Kano engage in exercise.53 The study using army officers in Kano may have recorded higher exercise, because army personnel as part of their work/training engage in exercise. Though there was higher practice of exercise in the Kano study53 than this study, but when stratified according to location, the rural respondents in this study have similar high levels of exercise.

Whereas this study recorded a higher proportion of people practicing exercise than the level of exercise of the secondary school teachers in Oyo51 was higher than the level among the urban respondents in this study, this can still be attributed to the built up areas in Onitsha metropolis. The comparison was made as the Oyo study was in Ibadan which is also an urban area.

Surprisingly, consumption of fruits and vegetables daily was higher in the urban respondents

(74.38) of this study than the rural (64.47%) respondents, but rural respondents were more likely to consume fruits regularly as upto 2.63% of rural respondents ate fruits and vegetables

80 up to 5 times daily. In a similar study 52.4% consume fruits and vegetables regularly which was lower than 67.8% consuming fruits and vegetables daily in this study. High consumption of fruits and vegetables in this study could be as a direct result of the high awareness of risk factors for CVD and its reduction measures. Also a healthier lifestyle should be expected from teachers than army personnel since they teach children and have health education in their curriculum.

Prevalence of alcohol consumption was 17.5% and was significantly higher with the urban teachers than the rural.

The variation in alcohol consumption noticed may be due to higher availability of bars, hotels and alcohol outlets in the urban areas than in the rural areas, the general alcohol consumption is expected to be more in urban than in rural area. However, alcohol consumption in this study is lower than other comparison studies as the prevalence among secondary school teachers in Oyo51 was 32.1% with army personnel in Kano53 was 51.2% and police officers in

India65,66,67 was 48%. One can deduce that the overall level of alcohol consumption among primary school teachers is low when compared to secondary school teachers, army personnel and police officers. When stratified according to sex, 57.14% of the male and 16.7% of female primary school teachers in this study drink alcohol. The low level of alcohol intake among primary school teachers in this study could have been only as a result of few male primary school teachers involved in the study.

Other studies may have recorded higher prevalence of alcohol consumption not only as a result of professions, but also as a result of the male preponderance in those studies than in our study. Teachers who avoid fried food as a CVD risk reduction measure were 51.25%.

However teachers involved in weight reduction measures were more in the urban area

(40.63%) than in the rural area (29.11%). Regular blood pressure check was practiced by

41.82% of respondents while regular blood pressure check was practiced by 21.06%. Regular blood cholesterol check was higher among the urban respondents (31.88%) than the rural respondents (16.46%) and was statistically significant (P<0.01).

There were more blood cholesterol check in the rural respondent than the urban respondent.

Regular medical checkup was practiced by 21.25% of the respondents. This is significantly higher than 5% of army personnel in Kano53 who practice regular medical checkup, whereas

24.5% of respondents undergo regular blood pressure check. Our study revealed that 41.82% of respondents are involved in regular blood pressure check. In the overall assessment of practise of cardiovascular disease risk reduction, there was a statistically significant relationship between residence of the teachers and their practice of cardiovascular risk reduction(P- 0.013). This difference in the practice of cardiovascular risk reduction could be because there are more space for recreation in the rural areas, some teachers in the rural areas walk to school and a few even engage in faming activities.

There was a statistically significant difference in the body mass index of urban and rural respondents (P<0.05) in this study.

The waist circumference of urban and rural respondents varied in distribution with more central obesity in the urban respondents than the rural respondents (P<0.01)

A research study70 found out that 13% of respondents had raised blood cholesterol while this study recorded raise cholesterol in 16.25%. The comparism study was among general population. One may agree with the study in Sofia71 that recorded a higher prevalence of risk factors for Cardiovascular disease among teachers than the general population since this study also reported higher prevalence of risk factors than its comparison studies in the general population.

The body mass index expressed in three categories as normal, overweight and obese showed a statistically significant difference in its distribution by urban and rural primary school

82 teachers (P<0.05). A total of 266(83.13%) of the respondents were obese BMI> 30. Among those in this category, more of the urban respondents (86.25%) fell into this category as against 80% of the rural respondents, while the respondents who had normal body mass index

(18.5-24.9) were just 5% of the respondents (3.13% urban, 6.88% rural). One can infer that there were more obese primary school teachers in the urban primary schools in Anambra state than in the rural primary schools. Comparing this result with a similar study carried out in

South Africa70 in 2006, where 66% of the study population had high body mass index and

40% were obese, one can say that the prevalence of obesity in this study is higher than the comparism study in South Africa70. The difference in the prevalence of obesity in these two studies could be because our study is restricted among teachers while the comparism study was carried out among the general black population in South Africa70 which will include sports people and those in varied occupation. There may also be a higher awareness translating to higher practice of cardiovascular risk reduction in South African population than in Anambra, Nigeria. The difference might also be as a result of differences in males in the South African population and the Anambra-Nigerian population although none of this research looked into the male pattern of the population investigated. In Bashra city-Iraq72,

40.9% of the population was overweight while 37.7% were obese. Comparing this with the

11.88% overweight and 83.13% obese in this study, one can also conclude that there is higher prevalence of obesity in the Anambra-Nigeria than in the Bashra city study72. Considering that the study in Bashra city was among secondary school teachers, one can now appreciate the high prevalence of obesity discovered in this study. This is because this study though intended to be carried out among primary school teachers, but only about 2% of the primary school teachers were males. With the same occupation and almost the same sex in this study and the comparism study in Bashra city-Iraq72, one can almost conclusively say that there is higher prevalence of obesity in Anambra-Nigeria than Bashra city-Iraq72. The reason for this

83 high prevalence could be said to be either cultural (meals, lifestyle) or environmental. There may also be differences in the awareness level in this study and that of Bashra city-Iraq72, but because the Iraq study did not assess the awareness of the secondary school teachers, one cannot make any comparism based on this. We can therefore attribute some of the difference in the obesity level to differences that maybe from awareness.

Systolic blood pressure varies significantly in the urban or rural respondents in this research

(P<0.05). More hypertensives were found in the rural population than the urban population

43.8% and 31.9% respectively. Overall, the prevalence of hypertension was 37.81%. In

Enugu-Nigeria,40,41,42 68.8% female respondents were hypertensive but only 31.2% of male respondents were hypertensive, and the population were people aged between 40-70 years.

The age range of this study group is between 38-59 years with a mean of 50.78+5. This two studies are both conducted in South East Nigeria, but the prevalence of hypertension in the

Enugu study was almost double the findings in this study. This could be due to the differences in the ages of the respondents in the two studies or because the Enugu study was among general population who may have higher risk of hypertension than teachers. One makes this comparism using rate of hypertension among females bearing in mind that this study was carried in a predominantly female population. Although the prevalence in the general population in the Enugu40,41,42 study was 46%, this is still higher than the prevalence of hypertension in this study. Another study carried out among teachers within the ages of 25-

55 years in Sofia71 recorded the prevalence of hypertension to be 31%. This is lower than the findings in this study. This difference can be as a result of the differences in ages of the two populations. The age range in this study is higher than the age range in the Sofia71 study one can attribute the higher prevalence of hypertension in this study to the difference in ages.71

Diastolic blood pressure also varies significantly between the rural and the urban population

(P<0.01) 39.06% of respondents had diastolic hypertension, among this 55% of then in the rural and 23.1% of them in the urban.

Blood cholesterol did not record any statistically significant variation in the rural or the urban population. Respondents with central obesity were 49.69% with more respondents in the urban areas 61.88% having central obesity than from the rural areas 37.5%. This difference is a statistically significant (P<0.01). Central obesity in Enugu is 35.4%.40,41,42 The high prevalence of central obesity in this study could be from the influence of the urban respondents. When stratified by urban and rural, the prevalence of central obesity in the rural the prevalence of central obesity in the rural was 37.5% which though higher than the prevalence of central obesity in the comparism study (35.4%), but its now closer to the findings in the Enugu study. One can say that this study recorded a higher incidence of central obesity than the comparism study that was among the general population. From the findings so far, obesity either generalized or central is higher in this study than other studies.

One can begin to conclude that there is higher incidence of obesity among primary school teachers in Anambra state, than the general population based on findings of other research journals.

Cross tabulating for the risk factors for overweight and systolic blood pressure, is there a statistically significant association (P<0.01). Of the 121 (37.81%) respondents with systolic hypertension, 114 (35.6%) were people with abnormal BMI. Therefore 94.2% of those with systolic hypertension were found amongst the overweight group. Weight is therefore a significant risk factor for developing systolic hypertension as seen in this study. A similar study in Isfahann- Iran74 showed that there was high systolic blood pressure among students with BMI greater than 25kg/m2 (P<0.01) Similar findings was recorded in Ethiopia75 where systolic blood pressure and diastolic blood pressure increased with BMI quintiles. At Lady

Reading hospital Peshawar-Pakistan76, systolic and diastolic blood pressure was higher in

85 both overweight and obese individuals than in the normal weight subjects (P<0.01). This findings was also repeated in a study in Switzerland where diastolic blood pressure was found to be highest among those with BMI > 40. The association between BMI and blood pressure as seen in this research is not an isolated finding, however search to find a study that did not elicit association between this two yielded no result. One can infer with greater certainty that the higher the BMI of an individual, the higher the blood pressure. This association is not only for systolic blood pressure, but also for diastolic blood pressure. This is evidently shown since of 125 (39.06%) of respondents that had raised diastolic blood pressure, 120 (37.5%) are those with high BMI. Ninety six percent of respondents with raised diastolic blood pressure were also overweight. No statistically significant association existed between being overweight and cholesterol level. (P<0.05), however a statistically significant association existed between overweight and diastolic blood pressure.

The association that existed between generalized obesity and other risk factors for cardiovascular disease was dissimilar with the associations found with central obesity. There was no statistically significant association with central obesity and systolic blood pressure, diastolic blood pressure and blood cholesterol level. Systolic hypertension was significantly associated with BMI as seen earlier and also with diastolic blood pressure (P<0.01). Diastolic blood pressure is also significantly associated with BMI (P<0.01) and systolic blood pressure as seen earlier but not central obesity (P>0.05) and cholesterol level (P>0.05). Cholesterol level had no association with other risk factors for cardiovascular disease (systolic BP, diastolic BP, BMI and central obesity). Cholesterol levels in other studies were found to be associated with BMI in studies in Pakistan76 and Switzerland.74

After stratifying age into those above 50 and below 50 and comparing it with other risk factors for cardiovascular disease, the age was significantly associated with cholesterol

(P<0.05) but not significantly associated with BMI (P>0.05), Diastolic blood pressure

(P>0.05) and systolic blood pressure (P>0.05). whereas the waist circumference was significantly higher amongst higher age group (P<0.05). There was also statistically higher significant risk for developing cardiovascular disease in those above 50 and those below 50

(P<0.01). Gender did not increase the risk for cardiovascular disease in all the parameters checked. This is in contrast with findings in a Pakistan76 study where cholesterol levels were significantly different among male and female subjects. Although this comparism cannot be made objectively considering the preponderance of females in this study but one cannot say the picture is the same here.

When adjusted odd ratio was done to determine the predictors for cardiovascular diseases, the following were significant predictors for this research; systolic blood pressure (OR=0.273,

CI=0.122-0.613, P=0.002), cholesterol level (OR=.269, CI= 0.101-0.714, P=0.008) and age

(OR=1.448, CI=6.033-21.723, P=0.000). One can conclusively say that the highest contributors to the risk of developing cardiovascular diseases are age, systolic blood pressure and cholesterol respectively in order of importance.

The risk for cardiovascular disease in this study was significantly higher in the rural teachers than the urban teachers (P<0.01). Of the 97 (30.31%) of respondents with high risk for cardiovascular diseases, 62(38.75%) were rural respondents. This represented 63.92% of the total respondents at risk for developing heart disease. Therefore we can conclude that risk of developing cardiovascular disease is higher in the rural primary school teachers than the urban primary school teachers in Anambra state. This finding is similar with a research study in Australia59 that found higher mortalities in coronary heart disease in the rural than the urban cities. This study also associated the higher mortalities to be disproportionate distribution of elderly persons in the rural and urban. This agrees confidently with our findings of higher risk of cardiovascular disease in the rural than the urban teachers in

Anambra state.

Findings of this research shows a statistically significant association between the awareness of cardiovascular disease and its risk reduction measures and the practice of cardiovascular risk reduction measures (P<0.01). With higher awareness of cardiovascular disease risk and its reduction measures, there is high practice of cardiovascular risk reduction. This is not an isolated finding as a interventional study in united states found an association between the increased awareness of cardiovascular disease risk reduction measures and the practice of cardiovascular risk reduction measures.78

There is no statistically significant association between the awareness of cardiovascular disease risk and its reduction measures and the actual risk for developing cardiovascular disease (P>0.05). So we will accept the null hypothesis of no relationship and fail to accept the alternate hypothesis of relationship. There is also no statistically significant association between the practice of cardiovascular disease risk reduction and the risk of cardiovascular diseases (P>0.05). We will also accept the null hypothesis of no relationship and fail to accept the alternate hypothesis of relationship. However other research studies like the study in United states, recorded an association between the awareness and cardiovascular disease risk reduction practices with clinical outcomes.78 This is in contrast with a comparism study in our literature review that was conducted among 900 police officers where poor practice of

Cardiovascular disease risk reduction measures lead to increased risk of Cardiovascular disease61,65,67,80.

CHAPTER SIX

CONCLUSION AND RECOMMENDATIONS

6.1 CONCLUSION

This study has shown that the risk for cardiovascular disease is high among primary school teachers in Anambra state especially the rural teachers despite the high awareness and practice. Rural respondents had higher practice of cardiovascular risk reduction measures whereas there was no difference in the overall awareness of the rural and the urban teachers.

Age was the most implicated factor found to increase the risk for cardiovascular disease whereas the most implicated important modifiable risk factor increasing risk for cardiovascular disease was systolic blood pressure and then serum blood cholesterol level.

6.2 RECOMMENDATIONS

The crucial goal of any civilized society should be the prevention of departures from health, promotion of healthy living and protection of its citizens from ill health. In view of the findings in this study, these recommendations are made to the following bodies:

To government and health institutions

1. Efforts should be made to increase the level of awareness of cardiovascular disease

risk factor and risk reduction practices through the use of other channels of

information dissemination on health.

2. Dissemination of health messages in the mass media should be improved particularly

those serving the rural populace.

3. Information on cardiovascular disease risk reduction measures should be improved

especially in the urban areas as they heard less awareness in this area and better

awareness of the risk factors.

4. Town planners should provide more space for recreational activities in the urban cities

to increase physical activity and exercise among its inhabitants.

5. Recreational facilities should be provided by the governments as the ones provided by

private agencies are often expensive and out of reach of primary school teachers.

6. Schools should have gardens and beautified with fruits in order to enhance fruit and

vegetable consumption.

To communities and schools

Communities should liaise with the relevant health agencies like ministry of health to

bring to them health awareness messages on cardiovascular diseases.

Schools should organize exercise for their pupils.

To families

1. Families should increase their consumption of organic foods and avoid highly

processed packaged foods.

2. As families practice group prayers for their spiritual growth so also should group

exercises be practiced for their health and longevity.

To individuals

Since this study has shown that age is the most significant contributor to risk of heart

diseases so ageing individuals should practice cardiovascular risk reduction measures

of increased exercise, consumption of fruits and smoking avoidance to help modify

and reduce their risk.

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APPENDIX 1

INFORMED CONSENT:

Sir/Madam,

My name is Dr Ofoegbu Cosmas Chiedozie. I am a resident doctor in public health department of Nnamdi Azikiwe University Teaching Hospital, Nnewi doing the part two exam of National Postgraduate Medical College of Nigeria. The purpose of this consent form is to provide you with the information you need to know in deciding whether to participate in the research study titled: RURAL-URBAN COMPARISON OF CARDIOVASCULAR RISK

REDUCTION MEASURES AND RISK OF CARDIOVASCULAR DISEASE AMONGST

PRIMARY SCHOOL TEACHERS IN ANAMBRA STATE.

Purpose of the study:

The purpose of this study is to assess the level of awareness and practice of cardiovascular risk reduction amongst teachers in Anambra state. It will also compare the awareness and practices among teachers in rural and urban areas and their risk for cardiovascular disease.

Study procedure:

Participants in this study will be required to give a written consent before included in the study. They will complete a questionnaire and anthropometric measurements to be taken (this will require physical contact with the research assistants i.e. measurement of waist circumference as well as laboratory investigation as blood cholesterol level will be checked).

The information you give will be used solely for the study and confidential.

Participation:

Your participation in this study will be completely voluntary. You have the right to withdraw from the study at any time and such decision will not in any way affect you.

Confidentiality:

All information that will be obtained from you in the course of this study will remain confidential.

Study risk:

Participants will not be exposed to any harm but slight pain from needle prick in the course of this study.

Potential benefits:

For participants; they will be better informed about cardiovascular risk reduction methods.

This will serve as a motivation for its practice and translate to improved health. The risk assessment involves a medical checkup which will identify teachers with high risk for cardiovascular disease and subsequent management through referral to skilled professionals for management.

For their families; participants’ families will also benefit indirectly from the improved knowledge gotten by the participants as well as improved health.

For the health sector; the overwhelming cases of cardiovascular accidents will reduce in the long run.

For the society; we will have a healthier society, reduction in the disability adjusted life years, morbidity and mortality indices.

100

Payment of participants:

There is no financial reward for participating in this study.

Consent form

Now that you fully understand the purpose and procedure of participating in this study, are you willing to take part in this study? (a) Yes [ ] (b) No [ ]

I(Researcher) have fully explained the purpose and benefit of this study to

……………………………………. in English, Pidgin and Igbo language. She/he have been given sufficient information including risk and benefit to make an informed decision.

Signature:……………………………………………… Date:………………………………

Name: Dr Cosmas Chiedozie Ofoegbu. Phone: 08037417782

I(Participant) has read the description of the research and I understand that my participation is voluntary. I know enough about the purpose of the research study to judge that I want to take part in it. I understand that I may freely stop being part of the study at any time. I have received a copy of this consent from the additional sheet to keep for myself.

Signature:……………………………………………… Date:………………………………

Name:…………………………………………………. Phone:……………………………...

WITNESS

Signature------Date------

Name------Phone number------

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APPENDIX 11

Questionnaire

The purpose of this study is to access your awareness and practice of cardiovascular risk reduction measures. All information obtained shall be treated with confidentiality.

SECTION A: BIODATA.

1) Age at last birthday……………………

2) Address: urban [ ] rural [ ]

3) Sex: male [ ] female [ ]

4) Marital status: Never married [ ] Married [ ] Divorced [ ] Separated [ ]

5) Educational qualification:

FSLC [ ] TC11 [ ] OND [ ] HND [ ] NCE [ ] BSC [ ] POSTGRADUATE [ ]

6) Religion:

Roman Catholic [ ] Anglican [ ] Pentecostal [ ] Traditional religion [ ] Islam [ ]

SECTION B

MEDICAL HISTORY.

1) Do you have any chronic medical condition?

A) Hypertension

B) Diabetes

C) Heart disease

D) Others specify……………………………………….

2) Are you on any medications

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A) Antihypertensive

B) Antidiabetes

C) Contraceptive drugs

E) Others specify

3) When last did you measure your blood pressure

A) Within the last 3months

B) Within one year ago

C) More than one year

D) More than three years ago

E) I cant remember ever measuring it

4) What was your last blood pressure reading…………………………………..

5) Have you ever measured your weight

Yes [ ] No [ ]

6) What was your last weight…………………………….

7) Have you ever measured your blood cholesterol

Yes [ ] No [ ] Not Aware [ ]

8) Last menstrual period (for females).

A) This month

B) Last month

C) Two months ago

D) Up to three months

E) More than three months

AWARENESS

7) Have you heard of cardiovascular risk reduction? Yes [ ] No [ ]

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8) If yes, where?

Radio/TV [ ] friend [ ] neighbor [ ] newspaper [ ] health campaign [ ] school [ ]

9) What are the cardiovascular risk reduction methods?

Exercise [ ] Exercising at least thirty (30) minutes every day [ ] Smoking avoidance [ ]

Reduction of alcohol intake [ ] Consumption of fruits and vegetable [ ] Consumption of up to five (5) servings of fruits a day[ ] Avoidance of fried food [ ] Weight reduction [ ]

Regular blood pressure check [ ] Blood sugar check [ ] Regular blood cholesterol check [ ]

Regular medical checkup[ ]

10) Where is weight/fat deposition most dangerous

A) Arm

B) Head

C) Waist

D) Chest

E) Legs

F) I don’t know

11) What is the cut off point for blood pressure reading for hypertensive?......

PRACTICE

12) Do you smoke? Yes [ ] No [ ]

If yes how many sticks per day......

13) Do you exercise? Yes [ ] No [ ]

If yes how often?

A) Daily

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B) 3 times weekly

C) Weekly

D) Sparingly

E) Never.

14) What cardiovascular risk reduction method do you practice?

Exercise [ ] Exercising at least thirty (30) minutes every day [ ] Smoking avoidance [ ]

Reduction of alcohol intake [ ] Consumption of fruits and vegetable [ ] Consumption of up to five (5) servings of fruits a day[ ] Avoidance of fried food [ ] Weight reduction [ ]

Regular blood pressure check [ ] Blood sugar check [ ] Regular blood cholesterol check [ ]

Regular medical checkup[ ]

15) Do you eat fruits/vegetables

A) Hardly

B) Daily

C) Weekly

D) More than once daily

E) Up to five times a day

16) Do you drink alcohol? Yes [ ] No [ ]

If yes what quantity per day…………….

SECTION C

Anthropometric/ laboratory measurements

BMI:

< 18.50 [ ] 18.50-24.99 [ ] 25.00-29.99 [ ] 30.00-34.99 [ ] 35.00-39-99 [ ] ≥40.00 [ ]

105

Waist Circumference

Men…………………………………below 102cm [ ] above 102cm [ ]

Women………………………………below 88cm [ ] above 88cm[ ]

Blood Pressure/mmHg

< 130/85 [ ] 130/85-139/90 [ ] 140/90-159/99 [ ] 160/100-179/109 [ ] >180/110 [ ]

Blood sugar reading……………………….

Blood cholesterol reading………………………

SECTION D

Global Risk Assessment Scoring using multiple risk factors.

Risk Points Risk Factor Men Women Age, y <34 −1 −9 35–39 0 −4 40–44 1 0 45–49 2 3 50–54 3 6 55–59 4 7 60–64 5 8 65–69 6 8 70–74 7 8 Total cholesterol, mg/dL <160 −3 −2 169–199 0 0 200–239 1 1 240–279 2 2 ≥280 3 3 HDL cholesterol, mg/dL <35 2 5 35–44 1 2 45–49 0 1 50–59 0 0

106

Risk Points Risk Factor Men Women ≥60 −2 −3 Systolic blood pressure, mm Hg <120 0 −3 120–129 0 0 130–139 1 1 140–159 2 2 >160 3 3 Diabetes No 0 0 Yes 2 4 Smoker No 0 0 Yes 2 2 Adding up the points Age……………………………. Cholesterol……………………. HDL-C……………………….. Blood pressure………………… Diabetes……………………….. Smoker………………………… Total points……………………. Percentage risk…………………

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Appendix III

Scoring for responses in awareness and practice section of the questionnaire

Overall awareness scoring -1 0 1 2 Have you heard about cardiovascular heart disease Yes X No X If yes, what is your source of information Radio/Tv X Friend X Neighbor X Newspaper X Health company/Health worker X School X Which of these is a risk for developing heart disease Consumption of fatty food Yes X No X Consumption of highly processed fatty foods Yes X No X Consumption of fruits and vegetables Yes X No X Increased alcohol intake Yes X No X Is smoking a risk for developing heart disease Yes X No X Risk of developing heart disease can be I don’t know X Exercise Yes X No X Lack of exercise Yes X No X Physical inactivity Yes X No X Overweight Yes X No X Stress Yes X No X Where is weight/fat deposition most dangerous

108

I don’t know X Arm X Head X Yes No Waist X Yes No Chest X Yes No Legs X Yes No Which of these can reduce the risk of heart disease I don’t know Yes No Exercise Yes X No X Exercising at least thirty minutes a day Yes X No X Smoking avoidance Yes X No X Reduction of alcohol intake Yes X No X Consumption of fruits and vegetables Yes X No X Consumption of up to five servings of fruits a day Yes X No X Avoidance of fried foods Yes X No X Weight reduction Yes X No X Regular blood pressure check Yes X No X Regular blood sugar check Yes X No X

109

Regular blood cholesterol check Yes X No X Regular medical check-up Yes X No X

Practice of cardiovascular risk reduction measures -1 1 2 3 4 5 Do you smoke Yes X No X Do you exercise Yes X No X If yes, how long per session of exercise No Up to 10 minutes X Up to 20 minutes X Up to 30 minutes X More than 30 minutes X If yes, how often Daily X Up to 3 times weekly X Weekly X Sparingly X Never X Do you eat fruits/vegetables Hardly X Daily X Weekly X More than once daily X Up to 5 times a day X Do you drink alcohol Yes X No X What other cardiovascular disease risk reduction measures do you practice Avoidance of fried food Yes X No X Weight reduction Yes X No X Regular blood pressure check Yes X

110

No X Regular sugar check Yes X No X Regular blood cholesterol check Yes X No X Regular medical check-up Yes X No X

111

APPENDIX IV

FOCUS GROUP DISCUSSION GUIDE:

Brief introduction and general comments.

Questions:

1) What do you know about cardiovascular risk reduction?

2) What are the possible ways you can learn about cardiovascular risk reduction?

3) What are the different ways of cardiovascular risk reduction?

4) Which of the methods of cardiovascular risk reduction do you practice?

5) Do you think that weight has any relationship with your cardiovascular health?

6) Is the practice of cardiovascular risk reduction likely to lead to a better health outcome?

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APPENDIX V: Work plan/Gantt chart

Week: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Training of research assistants R

Community entry R, A

Data collection R, A

Data analysis, Writing up report R

Revision and draft dissertation R, S

Final submission R

Key: R = principal researcher; A = research assistants; S = Supervisors .

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APPENDIX VI:

‘Definitions of body mass index (BMI) categories’

Category BMI (kg/m2)

Underweight <18.5

Normal weight 18.5-24.9

Overweight ≥25.0

Moderate overweight/Pre-obese 25.0-29.9

Obesity ≥30.0

- Obesity class I 30.0-34.9

- Obesity class II 35.0-39.9

- Obesity class III ≥40.0

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APPENDIX VII

‘WHO/ISH Definitions and Classification of Blood Pressure Levels’.

CATEGORY SYSTOLIC DIASTOLIC

(mmHg) (mmHG)

Optimal <120 <80

Normal <130 <85

High – Normal 130-139 85-89

Grade 1 Hypertension ("mild") 140-159 90-99

Subgroup: Borderline 140-149 90-94

Grade 2 Hypertension ("moderate") 160-179 100-109

Grade 3 Hypertension ("severe") 180 110

Isolated Systolic Hypertension 140 <90

Subgroup: Borderline 140-149 <90

When a patient's systolic and diastolic blood pressures fall into different categories, the

higher category should apply.

‘Stratification of Risk to Quantify Prognosis’91

115

BLOOD PRESSURE (mmHg)

Other Risk Factors & Grade 1 Grade 2 Grade 3

Disease History (mild hypertension ) (moderate hypertension ) (severe hypertension )

SBP 140-159 or SBP 160-179 or SBP 180 or

DBP 90-99 DBP 100-109 DBP 110

I.. no other risk factors LOW RISK MED RISK HIGH RISK

II. 1-2 risk factors MED RISK MED RISK V HIGH RISK

III. 3 or more risk factors or HIGH RISK HIGH RISK V HIGH RISK

TOD or diabetes

IV. ACC V HIGH RISK V HIGH RISK V HIGH RISK

TOD - Target Organ Damage

ACC - Associated Clinical Conditions, including clinical cardiovascular disease or renal

disease

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APPENDIX VIII

1: The prevalence of risk factors for cardiovascular disease in Nigeria as compared to Japan.

COUNTRIES NIGERIA JAPAN NIGERIA JAPAN

MALE MALE FEMALE FEMALE

CARDIOVASCULAR RISK FACTORS

Raised fasting blood sugar 7.9% 7.2% 12.0% 4.7%

Raised blood pressure

38.6% 26.4% 41.2% 16.7%

Prevalence of Obesity

5.1% 5.5% 9.0% 3.5%

Smoking

10.7% 42% 3% 12%

Alcohol consumption/litre/person/year 7.8%

12.7%

117