Abstract
Background:
Hypertension is a premier risk factor for index and recurrent strokes globally. However, knowledge of hypertension as a risk factor for stroke occurrence and subsequent adverse vascular events among recent stroke survivors in the sub-Saharan Africa is limited.
Purpose:
To assess the level and determinants of knowledge on hypertension and risk of stroke among recent stroke survivors in Ghana.
Methods:
This is a cross-sectional survey conducted at enrollment of participants involved in the multi-center, phase III randomized trial titled Phone-based Intervention under Nurse Guidance after stroke II (PINGS-2) study. Recent stroke survivors within 1–2 months of stroke onset were recruited from 10 Ghanaian hospitals comprising of (five primary-level, two secondary-level, and three tertiary-level facilities) between 2020 and 2022. We assessed knowledge of hypertension and stroke using a validated 14-item questionnaire on hypertension and stroke. We analyzed data using univariate and multivariate analysis to determine the associations between sociodemographic variables and the knowledge on hypertension among recent stroke survivors.
Results:
We enrolled 500 participants, mean (SD) age of 58 (12) years, 56.2% being males and 73.3% had ischemic stroke. Out of 14 questions, the mean (SD) score was 8 (3) with a range of 0 to 13. Four factors significantly associated with knowledge of hypertension with adjusted β (95%CI) were Islam religion −1.40 (−2.40 - −0.49), NIHSS score −0.15 (− 0.22 - −0.07) for each unit increase and body mass index 0.08 (0.03 – 0.13) for each kg/m2 increase and educational attainment with primary level, secondary, and tertiary educational level 1.10 (0.02 – 2.10), 1.60 (0.52 – 2.70), 2.40 (1.20 – 3.60) compared with no education.
Conclusion:
We found substantial deficiencies in the knowledge on hypertension among recent hypertensive stroke survivors in the Ghanaian population in this multicenter study. Educational interventions are urgently needed to address these knowledge gaps to minimize risk of adverse outcomes among stroke survivors in resource-limited settings.
Keywords: Knowledge, Hypertension, Stroke survivors, Sub-Saharan Africa
1. Introduction
Stroke is a leading cause of morbidity and the second leading cause of mortality across the globe [1,2]. The burden of stroke is more pronounced in lower-middle-income-countries (LMIC) compared to high income countries with approximately 90% of stroke morbidity and mortality occurring in LMIC, particularly in Sub-Saharan Africa (SSA) and Asia [3]. Stroke in LMICs afflicts a younger and productive age demographic with social, family, community, and national repercussions and threatens to hamper economy of developing countries.
In SSA, there are 1.4 adults per 1000 population living with stroke [4] who are at risk of further adverse cardiovascular events without appropriate secondary prevention interventions. Low levels of awareness on the modifiable vascular risk factors would inexorably exacerbate the risk for stroke recurrence [5] Undoubtedly, systemic arterial hypertension is a veritable risk factor for stroke recurrence globally. Sadly, a constellation of factors notably adverse socioeconomic status, low health literacy rates, and uncoordinated health systems in SSA have inordinately led to abysmally high blood pressure rates among hypertensives. Knowledge of stroke among hypertensive and diabetic patients is well documented [6–8], however, the determinants of the knowledge of hypertension and stroke among stroke survivors is limited in literature in developing countries.
To develop effective secondary prevention interventions aimed at improving outcomes of stroke survivors in LMICs, the level of knowledge of its risk factors and determinants of this knowledge is required. We therefore aimed to explore the determinants of knowledge of hypertension and stroke among recent stroke survivors in the Ghanaian population. The information generated will assist in developing targeted interventions to address the deficits in knowledge of hypertension and stroke among high-risk populations in resource-limited settings.
2. Methods
2.1. Study design and participants
This is a cross-sectional analysis of baseline data collected in a phase III randomized clinical trial titled Phone-based Intervention under Nurse Guidance after Stroke II study (PINGS-2). Briefly, PINGS 2 seeks to assess the efficacy of a phone-based, nurse-led, mobile health assisted intervention for blood pressure control among 500 recent Ghanaian stroke survivors recruited from ten study sites [9]. Study participants were adults (18 years or more) who had survived stroke after 1 to 2 months and were known to be hypertensive on antihypertensive medications after stroke. Ethical approval for the study was provided by the Committee on Human Publications and Ethics and all participants or their legal representatives provided informed consent before taking part in the study.
2.2. Measurements of determinants of hypertension and stroke knowledge
Trained Research Assistants provided a structured questionnaire to all the participants. Socio-economic and demographic variables collected included age, biological sex, location of residence, educational status, marital status, religion, and household monthly income. Clinical information collected includes stroke type (ischemic or intracerebral hemorrhage determined using head Computerized tomography), stroke severity at time of enrollment into the study using the National Institute of Health Stroke Scale (NIHSS) [9,10], functional status assessed using the Modified Rankin Score, and performance status using the Barthels Index [11–14]. Blood pressure at enrollment was measured using an automated blood pressure monitor in accordance with standardized clinical guidelines. Body mass index calculated after measuring body weight (in kg) and height (in meters).
2.3. Hypertension / stroke knowledge questionnaire
This is a 14-item questionnaire with questions on the following:
cut-off values for defining hypertension (questions 1 and 2),
knowledge on treatment of hypertension and duration of hypertension treatment (questions 3 and 4),
lifestyle factors that may affect blood pressure control (questions 5 and 6),
deleterious effects of hypertension on health (question 7 to 10),
risk of stroke recurrence (questions 11 and 14) and adherence to antihypertensive medications (questions 12 and 13)
2.4. Statistical analysis
Baseline demographic, clinical characteristics, and responses to hypertension/stroke knowledge questionnaire of study participants were presented as frequencies and percentages. The median score on the HKSQ was used to dichotomize the study participants for comparison. Means and medians of continuous variables were compared using Students t-tests or the Wilcoxon rank sum test respectively. Proportions were compared using the Pearson’s Chi-square test or Fisher’s exact test. Next, a multivariate linear regression model was constructed to identify factors independently associated with scores obtained on the HSKQ. The independent variables included in the model were age, gender, marital status, educational status, living status, religion, domicile, monthly income, stroke type (ischemic, hemorrhagic, ischemic with hemorrhage), etiological subtypes of stroke, body mass index (BMI) and Barthels index. Throughout the analysis, p-value cut-off < 0.05 was deemed statistically significant.
3. Results
3.1. Demographic and clinical characteristics of participants
Of the 500 participants recruited, 470 (94%) of the study participants completed the HSKQ. The age range for the participants was from 24 to 88 years with a mean (±SD) age was 58 ± 12 years. There were 281 (56.2%) males. The proportion of participants with ischemic stroke was 306 (61.2%) while 109 (21.8%) had hemorrhagic stroke and 85 (17%) had missing information on stroke type. (Table 1)
Table 1.
Demographic and clinical characteristics of study participants.
| Characteristic | N = 5001 |
|---|---|
| Age in years | |
| Median (IQR) | 58 (51, 67) |
| Mean (SD) | 58 (12) |
| Range | 24, 88 |
| Gender | |
| Male | 281 (56.2) |
| Female | 219 (43.8) |
| Marital Status | |
| Currently Married | 333 (66.6) |
| Previously Married | 144 (28.8) |
| Never Married | 23 (4.6) |
| Educational Status | |
| None | 49 (9.8) |
| Primary | 205 (41.0) |
| Secondary | 164 (32.8) |
| Tertiary | 82 (16.4) |
| Living Status | |
| Lives Alone | 29 (5.8) |
| Lives With Spouse and Children | 272 (54.4) |
| Lives in a Nursing Home | 1 (0.2) |
| Lives With Spouse | 30 (6.0) |
| Lives With Extended Family | 72 (14.4) |
| Lives With Children | 96 (19.2) |
| Religion | |
| Christianity | 448 (89.6) |
| Islam | 49 (9.8) |
| Other | 3 (0.6) |
| Domicile | |
| Rural | 35 (7.0) |
| Semi-Urban | 165 (33.0) |
| Urban | 300 (60.0) |
| Income in GHC | |
| 0–100 | 102 (20.6) |
| 101–250 | 160 (32.4) |
| 251–500 | 145 (29.4) |
| >500 | 87 (17.6) |
| Missing | 6 |
| Stroke Type (Choose One) | |
| Ischemic Stroke | 306 (61.2) |
| Intracerebral Hemorrhagic Stroke | 109 (21.8) |
| Untyped Stroke (no CT scan available) | 85 (17) |
| Body Mass Index | |
| Median (IQR) | 26.2 (22.7, 30.0) |
| Mean (SD) | 26.6 (5.5) |
| Range | 11.4, 47.9 |
| Missing | 24 |
| Barthels Index | |
| Median (IQR) | 80 (40, 90) |
| Mean (SD) | 66 (27) |
| Range | 0, 90 |
| Missing | 19 |
| Health institution category | |
| Primary | 148 (29.6) |
| Secondary | 119 (23.8) |
| Tertiary | 233 (46.6) |
Of the participants, 142 (30.2%) received their health care from a primary facility while 111 (23.6%) and 217 (46.2%) received care from secondary and tertiary care levels respectively. The place of domicile for a greater proportion of the participants was in the urban area followed by semi-urban and rural in the proportions of 279 (59.4%), 157 (33.4%) and 35 (7.2%) respectively. Regarding educational level, 44 (9.4%) had no formal education while 193 (41.1%), 156 (33.2%) and 77 (16.4%) had primary, secondary and tertiary levels of education respectively. Table one describes the sociodemographic and clinical characteristics of the recent stroke survivors.
3.2. Knowledge on hypertension and stroke among participants
Only 24% of respondents knew that a blood pressure of 115 / 75 mmHg was normal while up to 67% correctly identified a BP of 160 / 100 mmHg as elevated and 36% knew hypertension was a chronic medical condition. (Table 2). Regarding the control of hypertension, 95% knew that antihypertensive medications were to be taken every day, 66% and 75% respectively responded that weight loss and eating less salt would lead to lower BP. On the deleterious effects of hypertension, 70%, 48%, and 79% correctly associated hypertension with heart attacks, kidney problems, and stroke respectively.
Table 2.
Item by item response on the hypertension / stroke knowledge questionnaire by participants.
| QUESTION AND ANSWER OPTIONS | RESPONSE RATE N = 5001 |
|---|---|
| (1) If someone’s blood pressure is 115/75. it is …… | |
| High | 51 (10.3) |
| Low | 158 (31.8) |
| Normal | 119 (23.9) |
| Don’t Know | 169 (34.0) |
| Missing | 3 |
| (2) If someone’s blood pressure is 160/100. It is.… | |
| High | 330 (66.7) |
| Low | 10 (2.0) |
| Normal | 9 (1.8) |
| Don’t Know | 146 (29.5) |
| Missing | 5 |
| (3) Once someone has high blood pressure, it usually lasts for | |
| A few years | 76 (15.4) |
| 5–10 Years | 25 (5.1) |
| The Rest of their Life | 178 (36.0) |
| Don’t Know | 216 (43.6) |
| Missing | 5 |
| (4) People with high blood pressure should take their medicine | |
| Everyday | 465 (95.3) |
| At Least a few Times a week | 11 (2.3) |
| Only When They feel sick | 12 (2.5) |
| Missing | 12 |
| (5) Losing weight usually makes blood pressure | |
| Go up | 40 (8.2) |
| Go Down | 322 (66.4) |
| Stay the same | 123 (25.4) |
| Missing | 15 |
| (6) Eating less salt usually makes blood pressure | |
| Go Up | 50 (10.2) |
| Go Down | 370 (75.2) |
| Stay the Same | 72 (14.6) |
| Missing | 8 |
| (7) High blood pressure can cause heart attacks | |
| Yes | 345 (69.7) |
| No | 11 (2.2) |
| Don’t Know | 139 (28.1) |
| Missing | 5 |
| (8) High blood pressure can cause cancer | |
| Yes | 147 (29.6) |
| No | 59 (11.9) |
| Don’t Know | 290 (58.5) |
| Missing | 4 |
| (9) High blood pressure can cause can kidney problems | |
| Yes | 238 (48.0) |
| No | 23 (4.6) |
| Don’t Know | 235 (47.4) |
| Missing | 4 |
| (10) High blood pressure can cause strokes | |
| Yes | 392 (79.2) |
| No | 8 (1.6) |
| Don’t Know | 95 (19.2) |
| Missing | 5 |
| (11) Someone who has had a stroke is at higher risk of having another | |
| Yes | 258 (52.1) |
| No | 29 (5.9) |
| Don’t Know | 208 (42.0) |
| Missing | 5 |
| (12) If someone is not having headaches they can stop taking medications | |
| Yes | 94 (19.0) |
| No | 274 (55.4) |
| Don’t Know | 127 (25.7) |
| Missing | 5 |
| (13) If someone is feeling good it is ok to miss doses of medication | |
| Never | 354 (71.5) |
| Once a Month | 11 (2.2) |
| Once a week | 7 (1.4) |
| Don’t know | 123 (24.8) |
| Missing | 5 |
| (14) Once someone has had a stroke, they will be at risk for stroke for …. | |
| A Few Years | 139 (28.2) |
| 5–10 Years | 21 (4.3) |
| The Rest of Their Life | 62 (12.6) |
| Don’t Know | 271 (55.0) |
| Missing | 7 |
| Total HKQ Score | |
| Median (IQR) | 8 (6, 10) |
| Mean (SD) | 8 (3) |
| Range | 0, 13 |
| Missing | 30 |
| Categorised Total HKQ Score | |
| Median & below | 240 (51.1) |
| Above Median | 230 (48.9) |
| Missing | 30 |
3.3. Demographic and clinical characteristics of participants by questionnaire scores
Out of 14 questions, the mean (SD) score was 8 (3) with a range of 0 to 13. Participants whose scores were above the median were more likely to be male, had higher educational status with higher monthly income (Table 3). Clinically, those whose scores were above the median had a significantly lower stroke severity on the NIHSS but no differences in stroke type and blood pressures were observed.
Table 3.
Comparison of demographic and clinical characteristics of study participants by their median score on HKQ.
| Characteristic | Categorised Total HKQ Score |
Overall, N = 4701 | p-value2 | |
|---|---|---|---|---|
| Median & below, N = 2401 | Above Median, N = 2301 | |||
| Age in years | 58 (50, 68) | 58 (52, 65) | 58 (51, 67) | 0.717 |
| Male sex | 115 (47.9) | 144 (62.6) | 259 (55.1) | 0.001 |
| Educational Status | <0.001 | |||
| None | 32 (13.3) | 12 (5.2) | 44 (9.4) | |
| Primary | 117 (48.8) | 76 (33.0) | 193 (41.1) | |
| Secondary | 71 (29.6) | 85 (37.0) | 156 (33.2) | |
| Tertiary | 20 (8.3) | 57 (24.8) | 77 (16.4) | |
| Religion | 0.060 | |||
| Christianity | 208 (86.7) | 212 (92.2) | 420 (89.4) | |
| Islam | 29 (12.1) | 18 (7.8) | 47 (10.0) | |
| Other | 3 (1.3) | 0 (0.0) | 3 (0.6) | |
| Domicile | 0.376 | |||
| Rural | 14 (5.8) | 20 (8.7) | 34 (7.2) | |
| Semi-Urban | 85 (35.4) | 72 (31.3) | 157 (33.4) | |
| Urban | 141 (58.8) | 138 (60.0) | 279 (59.4) | |
| Income in GHC | 0.001 | |||
| 0–100 | 109 (45.6) | 58 (25.2) | 167 (35.5) | |
| 101–250 | 64 (26.6) | 79 (34.3) | 143 (30.4) | |
| 251–500 | 43 (17.7) | 61 (26.5) | 104 (22.1) | |
| >500 | 24 (10.1) | 32 (13.9) | 56 (12.0) | |
| Stroke Type (Choose One) | 0.055 | |||
| Ischemic Stroke | 154 (64.7) | 169 (72.8) | 323 (68.7) | |
| Intracerebral | 50 (21.0) | 45 (19.4) | 95 (20.2) | |
| Hemorrhagic Stroke | ||||
| Untyped Stroke (no CT scan available) | 34 (14.3) | 18 (7.8) | 52 (11.1) | |
| Modified Rankin Score | 0.023 | |||
| Median (IQR) | 2.00 (1.00, 3.00) | 2.00 (1.00, 3.00) | 2.00 (1.00, 3.00) | |
| NIH Stroke Scale | 4.0 (0.0, 9.0) | 2.0 (0.0, 6.0) | 3.0 (0.0, 8.0) | <0.001 |
| Systolic blood pressure (mm Hg)-Baseline | 155 (146, 172) | 154 (146, 168) | 155 (146, 170) | 0.265 |
| Diastolic Blood Pressure | 96 (89, 106) | 94 (87, 103) | 95 (88, 105) | 0.070 |
| Body Mass Index | 25.9 (22.4, 28.7) | 26.4 (23.0, 30.9) | 26.2 (22.7, 30.1) | 0.059 |
| Health institution category | 0.672 | |||
| Primary | 75 (31.3) | 67 (29.1) | 142 (30.2) | |
| Secondary | 59 (24.6) | 52 (22.6) | 111 (23.6) | |
| Tertiary | 106 (44.2) | 111 (48.3) | 6.2) | |
Median (IQR); n (%).
Wilcoxon rank sum test; Pearson’s Chi-squared test; Fisher’s exact test.
3.4. Factors associated with hypertension and stroke knowledge
On bivariate linear regression, we identified that male sex, educational status, religion, modified Rankin score, NIH stroke scale score, body mass index and level of health institution were associated with scores obtained on the knowledge questionnaire (Table 4). Four factors significantly associated with knowledge of hypertension with adjusted (95%CI) were islam religion −1.40 (−2.40 - −0.49), NIHSS score −0.15 (− 0.22 - −0.07) for each unit increase and body mass index 0.08 (0.03 – 0.13) for each kg/m2 increase and educational attainment with primary level, secondary, and tertiary educational level 1.10 (0.02 – 2.10), 1.60 (0.52 – 2.70), 2.40 (1.20 – 3.60) compared with no education.
Table 4.
Factors associated with hypertension knowledge among recent Ghanaian stroke survivors.
| VARIABLE | BIVARIATE |
MULTIVARIATE |
|||
|---|---|---|---|---|---|
| Unadjusted β (95% CI) | P-value | Adjusted β (95% CI) | P-value | ||
| Age in years | 470 | −0.02 (−0.05, 0.00) | 0.092 | ||
| Male sex | 470 | ||||
| No | Ref | — | |||
| Yes | 0.67 (0.10, 1.20) | 0.022 | 0.41 (−0.21, 1.00) | 0.196 | |
| Educational Status | 470 | ||||
| None | Ref | Ref | |||
| Primary | 1.50 (0.51, 2.50) | 0.003 | 1.10 (0.02, 2.10) | 0.046 | |
| Secondary | 2.20 (1.20, 3.20) | <0.001 | 1.60 (0.52, 2.70) | 0.004 | |
| Tertiary | 3.10 (2.00, 4.30) | <0.001 | 2.40 (1.20, 3.60) | <0.001 | |
| Religion | 470 | ||||
| Christianity | Ref | Ref | |||
| Islam | −1.6 (−2.6, −0.69) | <0.001 | −1.4 (−2.4, −0.49) | 0.003 | |
| Other | −3.6 (−7.1, −0.04) | 0.048 | −3.4 (−7.5, 0.68) | 0.102 | |
| Domicile | 470 | ||||
| Rural | Ref | ||||
| Semi-Urban | −0.87 (−2.0, 0.30) | 0.143 | |||
| Urban | −0.94(−2.1,0.18) | 0.101 | |||
| Monthly | 470 | ||||
| 0–100 | 0.04(−0.77,−0.84) | 0.930 | |||
| 101–250 | 0.32(−0.51,−1.1) | 0.451 | |||
| 251–500 | 0.32 (−0.51, 1.1) | 0.451 | |||
| >500 | 0.31 (−0.63, 1.3) | 0.512 | |||
| Stroke Type (Choose One) | 405 | ||||
| Ischemic Stroke | Ref | ||||
| Intracerebral Hemorrhagic Stroke | −0.48 (−1.2, 0.21) | 0.170 | |||
| Ischemic With Hemorrhagic Transformation | −0.40 (−2.4, 1.6) | 0.692 | |||
| Untyped Stroke | −1.9 (−4.5, 0.76) | 0.163 | |||
| Modified Rankin Score | 469 | −0.39 (−0.61, −0.16) | <0.001 | 0.05 (−0.25, 0.35) | 0.726 |
| NIH Stroke Scale | 461 | −0.13 (−0.18, −0.08) | <0.001 | −0.15 (−0.22, −0.07) | <0.001 |
| Systolic blood pressure (mm Hg)-Baseline | 467 | −0.01 (−0.03, 0.00) | 0.113 | ||
| Diastolic Blood Pressure | 467 | −0.01 (−0.03, 0.01) | 0.216 | ||
| Body Mass Index | 451 | 0.10 (0.05, 0.15) | <0.001 | 0.08 (0.03, 0.13) | 0.002 |
| Health institution category | 470 | ||||
| Primary | Ref | Ref | |||
| Secondary | 0.81 (0.03, 1.60) | 0.042 | 0.48 (−0.30, 1.30) | 0.228 | |
| Tertiary | 0.50 (−0.16, 1.2) | 0.137 | −0.39 (−1.1, 0.34) | 0.297 | |
C.I Confidence Interval.
4. Discussion
In this multicenter study in Ghana, we have identified deficiencies in the knowledge on hypertension, the premier risk factor for stroke occurrence and recurrence worldwide. The four factors significantly associated with knowledge of hypertension were educational status, islam religion, body mass index and stroke severity.
In unadjusted analyses, we found that male sex is a strong determinant of the knowledge of hypertension and stroke after stroke occurrence. This finding was comparable to two previous studies in Asia (Malaysia and China) which investigated gender differences and the associations between hypertension and stroke knowledge [15, 16]. Whiles the Malaysian study found male sex to be associated with higher knowledge of hypertension and stroke and that the males knew what to do during stroke [15], the Chinese study found that although male patients had greater stroke knowledge, they exhibited worse pre-stroke health behaviors [16]. These findings were also corroborated by findings from the Stroke Investigative Research and Educational Network (SIREN) study which found that males usually present with less severe forms of stroke than females in Africa [17] which could be attributable to the higher level of knowledge of hypertension and stroke among males. The poor knowledge of stroke among females may always explain the higher incidence of strokes among female [18–21]. This is a clarion call for intensification of stroke education with great emphasis on its risk factors and warning signs through public or social media and health education targeting the adult populations with a special focus on the females because approximately 80% of new stroke incidence could be avoided by improving knowledge related to the risk factors of stroke [22].
We found graded association between the level of education and the knowledge of hypertension. The higher the level of education, the higher the knowledge of hypertension and stroke. Tertiary level education was the strongest determinant of one’s level of knowledge of hypertension and stroke followed by secondary and primary levels. This finding was comparable with several published data in both the developing and the developed countries. In Nepal, South Asia, Ghimire et al. found that higher level of education was significantly associated with good level of knowledge of hypertension and stroke [23]. Similarly, a longitudinal data comparing 10 European populations demonstrated that stroke mortality is negatively affected by lower levels of education, with similar effects on both males and females with relative risk of 1.27 (95% CI, 1.24 to 1.30) in men and relative risk of 1.29 (95% CI, 1.27–1.32) in women [24], thus, higher education empowers the individual to master the vascular risk factors of stroke as well as the signs and symptoms of stroke so as to put in the necessary interventions to prevent the occurrence of an index stroke or to adhere strictly to secondary preventive measures after stroke. Also, poor level of education has a greater influence on the individual’s health seeking behavior. Studies from Ghana and Nigeria have shown that lower educational level and lower socioeconomic status, are paramount among the reasons why sick persons in some rural communities in Africa will not seek orthodox medical care as the first option [25,26].
Our study found a very significant association between the National Institute of Health Stroke Scale (NIHSS) score and the knowledge of hypertension and stroke with a P-value of (<0.001). There was paucity of data on this subject, thereby making it difficult to directly compare our findings to previously published data, however, significant inferences could be made. Kabanda et al. found that, in Kinshasa, Democratic Republic of Congo, patients with lower NIHSS were less likely to report early to the hospital [27]. A similar report was found in India where Ashraf et al., reported that patients with higher NIHSS score report early to the hospital after stroke occurence [28]. Since patients with severe forms of stroke present with higher NIHSS score [29], the patients or their caregivers can recognize that stroke might have occurred and report early for interventions. Another plausible explanation to this phenomenon is the fact that the poor knowledge of hypertension and stroke as alluded to by our study and has been confirmed by other studies [15–17] could be the reason why women usually present with severe forms of stroke [29–31].
We observed in this current study that, among recent stroke survivors, one’s religious affiliation is associated with the level of knowledge of hypertension and stroke. Being Islam was significantly associated with lower level of knowledge of hypertension and stroke with a beta estimation value of (−1.4) 95% C.I (−2.4–0.49) and a P-value of (0.003). There is a dearth of evidence regarding this matter in literature, however, a study from rural Tanzania has shown a gross misconception among religious leaders regarding the knowledge of hypertension [32]. The perception about hypertension by some of the Islamic religious leaders in rural Tanzania is akin to the findings in this current study and points us in the right direction as where to focus our energies in our bid to control the stroke epidemic in Africa. Religious misconceptions about the knowledge of hypertension, the most robust modifiable risk factor for stroke is widespread in Africa with evidence from Ghana, Nigeria, Democratic Republic of Congo, and Uganda [33–36]. Since religious leaders have great influence on their followers, it will be quite appropriate to empower them with the right information about hypertension and stroke and leverage on their influence to reduce the burden of hypertension and stroke in a continent where greater proportion of the people reports highest confidence in religious institutions (76%) as against 51% in health institutions and 44% in government [37].
The current study found a significant relationship between Body Mass Index (BMI) and the knowledge of hypertension and stroke among recent stroke survivors with a beta estimate of (0.08), 95% CI of (0.03–0.13) and a P-value of (0.002). The higher one’s BMI, the higher their level of knowledge of hypertension and stroke. Comparable data assessing the relationship between BMI and the knowledge of hypertension and stroke among stroke survivors was rare in literature. However, data from Ghana and Venezuela assessing same among healthy individuals without stroke found no significant association between BMI and the knowledge of hypertension and stroke [38,39]. The differences could be attributable to the patient category in the different studies. The strong association between high BMI and the incidence of stroke should be a motivating factor for clinicians to spend additional time educating obese patients on the cardiovascular complications of obesity. Public health agencies must also be interested in intensifying the education of obesity and its complications.
5. Conclusions
As observed in this present study, there are significant gaps in the knowledge on hypertension and stroke among recent stroke survivors in the Ghanaian population. Overall, factors that determined the knowledge on hypertension and risk of stroke recurrence among recent stroke survivors in Ghana includes male sex, higher level of education and high BMI. These findings support the need to intensify the education on hypertension and stroke to beat the stroke epidemics in Ghana.
Acknowledgement
We want to acknowledge the National Heart, Lung, and Blood Institute (R01HL152188), for the support provided in funding the study. Nonetheless, the funders will not be involved in the study design, data collection and management, analysis and interpretation, report writing, or publication decisions and will have no authority over these activities.
Footnotes
CRediT authorship contribution statement
Rexford Adu Gyamfi: Writing – review & editing, Writing – original draft, Methodology. Albert Akpalu Professor: Writing – review & editing, Methodology, Investigation. Ansumana Bockarie: Writing – review & editing, Investigation. Priscilla Abrafi Opare-Addo: Writing – review & editing, Methodology, Investigation. Nana Kwame Ayisi-Boateng: Writing – review & editing, Investigation. Douglas Anning Opoku: Writing – review & editing, Investigation. Jude Domfeh Darkwah: Writing – review & editing, Investigation. Emmanuel Konadu: Writing – review & editing, Investigation. Agnes Arthur: Writing – review & editing, Investigation. Kwadwo Agyenim-Boateng: Writing – review & editing, Investigation. Christiana Neizer: Writing – review & editing, Investigation. Timothy Fiattor: Writing – review & editing, Investigation. Nyantakyi Adu-Darko: Writing – review & editing, Investigation. Nathaniel Adusei Mensah: Writing – review & editing, Investigation. Raelle Tagge: Writing – review & editing, Investigation. Michael Ampofo: Writing – review & editing, Investigation. Hilda Kwapong: Writing – review & editing, Investigation. John Akassi: Writing – review & editing, Investigation. John Humphrey Amuasi: Writing – review & editing, Investigation. Samuel Blay Nguah: Writing – review & editing, Investigation, Data curation. Bruce Ovbiagele: Writing – review & editing, Methodology, Investigation, Conceptualization. Fred Stephen Sarfo: Writing – review & editing, Methodology, Investigation, Conceptualization.
IRB statement and IRB number
Institutional approval for the study was obtained from the Committee of Human Research Publication and Ethics (CHRPE/AP/016/20) in Kumasi, Ghana.
Consent statement
Institutional approval for the study was obtained from the Committee of Human Research Publication and Ethics (CHRPE/AP/016/20) in Kumasi, Ghana. All participants were provided with a written informed consent before screening for eligibility into the trial.
Ethical statement
1) This material is the authors’ own original work, which has not been previously published elsewhere.
2) The paper is not currently being considered for publication elsewhere.
3) The paper reflects the authors’ own research and analysis in a truthful and complete manner.
4) The paper properly credits the meaningful contributions of co-authors and co-researchers.
5) The results are appropriately placed in the context of prior and existing research.
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I agree with the above statements and declare that this submission follows the policies of Solid State Ionics as outlined in the Guide for Authors and in the Ethical Statement.
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Declaration of competing interest
Although Bruce Ovbiagele, is an Editorial Board Member, he will not be involved in the Review and Editorial decisions concerning this manuscript and therefore, he has no conflict to declare.
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