Hypertension self-care practices and associated factors among people with hypertension on follow-up in selected public healthcare facilities in the Ashanti Region, Ghana. A multicentre cross-sectional survey

Abstract

Background

Hypertension self-care practices are essential for controlling blood pressure and preventing cardiovascular complications and mortality. However, research on adherence to self-care practices among people with hypertension in Ghana is limited. This study assessed hypertension self-care practices and associated factors among people with hypertension attending follow-up in selected public healthcare facilities in the Ashanti Region, Ghana.

Methods

This multicentre cross-sectional study was conducted in three randomly selected public healthcare facilities in the Ashanti Region from 1^st March to 30^th June 2025. A multistage sampling method was employed to recruit 545 people with hypertension on follow-up. Data on hypertension self-care practices, hypertension knowledge, socio-demographic and clinical characteristics, and psychosocial factors were collected using an interviewer-administered questionnaire and supplemented by a review of medical records. IBM-SPSS Statistics was used for data analysis. Descriptive statistics were used to summarize variables, while a binary logistic regression model was performed to identify the factors associated with hypertension self-care practices. Adjusted odds ratios (AORs) with corresponding 95% confidence intervals (CIs) were reported, and statistical significance was set at p<0.05.

Results

Of the 545 people with hypertension recruited, 510 participated in the study, yielding a response rate of 93.6%. Overall, 58.4% (95% CI: 54%-63%) of participants demonstrated good self-care practices. Among the individual practices, smoking cessation had the highest adherence (96.7%, n=493), whereas physical activity had the lowest adherence (22%, n=112). In multivariable analysis, comorbidities (AOR=0.56, 95% CI: 0.36-0.87) and depression (AOR=0.11, 95% CI: 0.05-0.23) were independently associated with lower odds of practising good self-care, whereas good self-efficacy (AOR=12.71, 95% CI: 6.64-24.30) was independently associated with higher odds.

Conclusion

Adherence to hypertension self-care practices was moderate; however, deficiencies were observed in salt reduction and physical activity. Comorbidity, depression and self-efficacy were associated factors of hypertension self-care practices. Interventions should prioritise mental health screening, strengthen self-efficacy through behavioural support, and provide tailored care for individuals with comorbidities to improve sustained self-management.

Introduction

Hypertension, defined as persistently elevated arterial blood pressure (>140/90 mmHg), remains one of the most prevalent non-communicable diseases worldwide and a major modifiable risk factor for cardiovascular morbidity and premature mortality.^1,2 The World Health Organization (WHO) estimates that approximately 1.5 billion people are living with hypertension, with nearly two-thirds residing in lower-and middle-income countries (LMICs). ³ In sub-Saharan Africa (SSA), the burden continues to rise, affecting approximately 125 million adults. ⁴ Ghana reflects this growing epidemic, with a pooled national prevalence of 27%, while the Ashanti Region has one of the highest prevalence rates in the country (29%), trailing only the Volta Region (39%) and the Greater Accra Region (32%). ⁵ This pattern reflects ongoing epidemiological transitions driven by urbanization, lifestyle changes and population ageing. ⁶

Beyond the increasing prevalence, hypertension is a major contributor to global morbidity and mortality. ⁷ It is a leading risk factor for cardiovascular diseases, including heart failure, myocardial infarction, stroke and renal failure. ⁸ Globally, elevated blood pressure is associated with an estimated 10.8 million deaths and 295 million disability-adjusted life years annually. ⁶ In addition, hypertension imposes a substantial socio-economic burden on individuals, households and the healthcare system, especially in resource-constrained settings.^9,10 The long-term costs of treatment and management of complications, increased healthcare utilization and reduced productivity, place considerable financial strain on affected populations.^11,12 These multifaceted consequences pose a challenge to achieving Sustainable Development Goal 3 (SDG-3), particularly Target 3.4, which aims to reduce premature mortality from non-communicable diseases by one-third by 2030. ¹³

Several strategies have been implemented globally and locally to improve hypertension management and treatment outcomes. These include advances in pharmacological therapies, the development of evidence-based clinical guidelines, and public health awareness campaigns, such as May Measurement Month.^14,15 In Ghana, hypertension care has been further strengthened through the integration of hypertension services into the National Health Insurance Scheme and the expansion of hypertension clinics across healthcare facilities. ¹⁶ Despite these interventions, optimal blood pressure control remains poor in many settings,^17,18 including Ghana, where approximately 50-80% of patients receiving antihypertensive treatment fail to achieve hypertension control.^19,20 Consequently, uncontrolled hypertension continues to contribute to stroke, renal failure, recurrent hospitalizations, and rising healthcare costs in the country. ²¹ Hypertension-related deaths also account for about 5.2% of total mortality in Ghana. ²² This disconnect between treatment availability and optimal blood pressure outcomes suggests that pharmacological treatment alone may be inadequate to achieve sustained blood pressure control and improve patient outcomes, reflecting the pivotal role of patient-related factors in hypertension management.

Hypertension self-care practices have therefore become central to contemporary hypertension management. These practices include dietary modifications, regular physical activity, weight management, moderation of alcohol intake, smoking cessation, and self-monitoring of blood pressure.^8,23 Hypertension self-care complements antihypertensive medications by enhancing treatment effectiveness, promoting long-term blood pressure control and improving cardiovascular outcomes. ²⁴ In spite of these benefits, studies have reported low adherence to recommended self-care practices, especially in Ghana (45.3%), ²⁵ Ethiopia (33.1%), ⁴ and Rwanda (34.2%), ²⁶ highlighting a persistent gap in hypertension self-management in SSA. Existing evidence further suggests that hypertension self-care practices are influenced by a complex interplay of socio-demographic variables, such as educational background, ²⁷ marital and occupational status,^27,28 age and gender,^27,29 and clinical factors such as comorbidities ³⁰ and hypertension duration.^8,29 Similarly, behavioural and psychosocial determinants such as hypertension knowledge,^29,31 self-efficacy,^4,32 depression, ⁴ and social support ²⁸ influence patients’ ability to initiate and sustain recommended hypertension self-care practices. Although these determinants have been reported across different settings, their magnitude and significance vary considerably. This variation may reflect differences in socio-cultural norms, socioeconomic conditions, healthcare systems, access to hypertension services, patient characteristics, and the measurement tools used to assess hypertension self-care practices and their associated factors,^4,33 thereby limiting the development of context-specific interventions.

Despite growing interest in hypertension self-care practices, evidence from Ghana remains limited and methodologically constrained. Some studies employed qualitative designs that did not quantify the prevalence of self-care practices or identify factors associated with adherence to recommended hypertension self-care practices.^34,35 Other studies were limited to a single facility ²⁵ or to specific subpopulations, such as pregnant women, ³⁶ whose clinical characteristics and management differ from those of general adult hypertensive patients, thereby limiting the generalizability and applicability of the findings. Additionally, other scholars have also relied on non-standardized or non-validated measurement guidelines, which may compromise the validity and reproducibility of findings. ³⁷ Key behavioural and psychosocial determinants, such as self-efficacy, depression, anxiety and social support, have not been adequately studied in Ghana.^25,37 This study therefore assessed hypertension self-care practices and associated factors among people with hypertension receiving treatment at selected public health facilities in the Ashanti Region. The findings are expected to generate context-specific evidence on hypertension self-care practices and their behavioural, clinical and psychosocial determinants, thereby informing the design of patient-centred interventions and strategies to improve control and overall patient outcomes.

Methods and materials

Study design, area and period

A multicentre, cross-sectional analytical study was conducted in the Ashanti Region of Ghana from 1^st March to 30^th June, 2025. The Ashanti Region is the second-most populous region and has an extensive public healthcare network serving rural, peri-urban, and urban communities, providing an appropriate setting to examine hypertension self-care practice across diverse health contexts. ³⁸

The study was conducted in three randomly selected public healthcare facilities representing different levels of healthcare delivery: Suntreso Government Hospital (secondary-level), Effiduase District Hospital (district-level) and Parkoso Health Centre (primary-level). These facilities were selected to capture variation in healthcare delivery and patient population across urban, rural and peri-urban settings. All selected healthcare facilities provide structured hypertension care, including blood pressure monitoring, medication refills, lifestyle counselling and follow-up care in accordance with the Healthy Heart Africa guideline, which emphasizes self-care practices as a key component of hypertension management. The inclusion of facilities at different levels of care enhanced the diversity of the study population and improved representativeness of findings within the public healthcare sector of the Ashanti Region.

Study population, inclusion and exclusion criteria

All people with hypertension attending follow-up clinics at the three selected healthcare facilities during the data collection period constituted the study population. Individuals aged ≥18 years, who had been diagnosed with essential hypertension and had been receiving antihypertensive treatment for ≥ 6 months prior to the study, were eligible for inclusion in the study. However, severely ill individuals were excluded to avoid delay in seeking immediate inpatient care. Individuals with documented cognitive impairments in their medical records or those who, during recruitment and the informed consent process, were assessed by trained professional nurse research assistants as unable to comprehend the study information, provide informed consent, or respond coherently during interview were also excluded to ensure accuracy and reliability of self-reported data.

Sample size determination

Five hundred and forty-five (545) people with hypertension on follow-up at the three selected healthcare facilities constituted the study sample. The sample size was determined using the single proportion formula, with the assumption of 95% confidence interval (CI), 5% significance level ( $\alpha )$ set at 5% for a two-sided test, a 5% margin of error (E) and a prevalence of good self-care practices of 33.1% in a multicenter study in Ethiopia. ⁴ The Ethiopian study was selected because, at the time of study design, no comparable Ghanaian multicentre study assessing overall hypertension self-care practices using similar self-care variables among people with hypertension was available to inform sample size estimation. To account for variability introduced by the multistage sampling strategy, a design effect (Deff) of 1.5 was applied to the initial sample size. An additional 10% of the initial sample size was also added to account for non-responsiveness. This resulted in a final sample size of 545. The sample size was calculated as follows;

$$\mathbf{n}\_\mathbf{intial}=\left[\frac{Z_{\left(1-\frac{\alpha }{2}\right)}^2\hspace{0.17em}p\hspace{0.17em}q}{E^2}\right]$$

$$\mathbf{n}\_\mathbf{initial}=\left[\frac{{1.96\hspace{0.17em}}^2\times 0.331\times 0.669}{{0.05}^2}\right]=340$$

$$\mathbf{n}\_\mathbf{final}=\left(\mathrm{n}\_\text{initial}*\hspace{0.17em}{\mathrm{D}}_{\text{eff}}\right)+\left(10\%*\hspace{0.17em}\mathrm{n}\_\text{initial}\right)$$

$$=\left(340\mathrm{x}1.5\right)+\left(0.10\mathrm{x}\hspace{0.17em}340\right)=545$$

where n_initial is the initial sample size, p is the prevalence of good self-care practices, Z (1- $\alpha /2)$ is the Z-statistic value at the 95% confidence level, and 5% significance level (α = 0.05) for two tails, which is 1.96, E is the margin of error 5% (0.05), $D_{eff}$ is the design effect of 1.5, and n_final is the final sample size.

Sampling procedure

A multistage sampling technique was used to select participants. First, health directorates in the region were stratified into three administrative levels: metropolitan, municipal, and district, to reflect urban, peri-urban, and rural healthcare contexts. One directorate was selected from each stratum, based on the availability of hypertension clinics and adequate patient volume. The selected directorates were the Kumasi Metropolitan Health Directorate, the Asokore Mampong Municipal Health Directorate, and the Sekyere East Health Directorate.

Next, healthcare facilities with hypertension clinics within these directorates were identified, and one facility per stratum was randomly selected using Excel’s RAND BETWEEN function. The selected facilities were Suntreso Government Hospital, Parkoso Health Centre, and Effiduase Government Hospital.

In the third stage, the total sample of 545 was proportionally allocated to the facilities based on average hypertension clinic attendance over the preceding three months using the formula, ni = (Ni/N) x n. This resulted in sample allocations of 260 for Suntreso Government Hospital, 200 for Effiduase District Hospital, and 85 for Parkoso Health Centre.

Finally, eligible participants at each facility were selected using simple random sampling. A sample frame of eligible patients was created, and identification numbers (IDs) were assigned in the order of arrival at the clinic (1, 2, 3, 4, 5...). Random numbers were generated for each eligible individual using Excel’s RAND () function. The list of participants was sorted in ascending order of the generated random numbers using Excel’s Sort function, and participants were selected sequentially from the pre-randomized list until the required sample size for each facility was achieved. The process ensured fair representation and access to a diverse patient population within the region.

A flowchart of the sampling process is shown in Figure 1.

Figure 1.

A flowchart of the sampling technique used to select the study participants from the public healthcare facilities in Ashanti Region, Ghana. ni = sample size for each facility, Ni = average clinic attendance for each facility, N = total number across all facilities, and n = calculated sample size, i=1,2 and 3.

Data collection tools and procedures

We used a structured, pre-tested questionnaire to collect data from participants. The questionnaire was adapted from standardised, validated instruments and previous literature, and modified to suit the study’s context.^4,30,39–43 It also included items developed by the researcher on patients’ socio-demographic and clinical profiles. The questionnaire was prepared in English and organised into eight sections: Part I: Socio-demographic information; Part II: Clinical profile of patients; Part III: Hypertension self-care practices; Part IV: Hypertension knowledge; Part V: Self-efficacy measures; Part VI: Social support; Part VII: Depression; and Part VIII: Anxiety.

Data were collected from 1st March to 30th June 2025 at the hypertension clinics of the three selected healthcare facilities during routine hypertension clinic visits. Six professional nurses with Bachelor of Science in Nursing qualifications collected the data under the supervision of three persons: the principal investigator, a senior physician assistant (Head of the hypertension clinic at Parkoso Health Centre), and a Principal Nursing Officer (Head of the hypertension clinic at Suntreso Government Hospital). An interviewer-administered questionnaire, with items translated into the local language (Asante Twi) to ensure participants’ understanding, was used. Additionally, trained professional nurses reviewed patients’ medical records to extract clinical information, including hypertension duration and medically confirmed comorbidities.

Study variables

Outcome variable

Hypertension self-care practices.

Explanatory variables

The explanatory variables include socio-demographic characteristics (age, gender, marital status, educational status, residence, etc.), clinical profile (follow-up schedule, duration of hypertension, family history of hypertension, presence of comorbidities, etc.), hypertension knowledge, and psychosocial factors (self-efficacy, social support, depression and anxiety).

Variable measurement: Scale, scoring, categorization and definition

Hypertension self-care practice

Hypertension self-care practices were assessed using a composite measure derived from three sources: the Hypertension Self-Care Activity Level Effects (H-SCALE), ³⁹ Hill-Bone Compliance with High Blood Pressure Therapy Scale (HB-HBP) ⁴³ and one additional item adapted from the literature to assess self-monitoring of blood pressure (SMBP). ⁴⁰ Together, these instruments assessed seven recommended hypertension self-management behaviours: smoking cessation, alcohol abstinence, physical activity, weight management, salt reduction, follow-up attendance and self-monitoring of blood pressure.

Smoking status was assessed using one H-SCALE item. Participants who reported smoking or taking even a puff of a cigarette in the last 7 days prior to data collection were categorised as smokers. ³⁹ Alcohol consumption was assessed using one item on the H-SCALE. Male participants who reported consuming more than two units of alcohol per day and females who reported consuming more than 1 unit per day were classified as alcohol consumers.^44,45 Physical activity was assessed using two H-SCALE items, evaluating the “number of days participants engaged in at least 30 minutes of physical activity” and the “number of days participants participated in specific exercise activities outside of daily chores or work” over the last 7 days prior to the study. Total scores ranged from 0 to 14 days, with ≥ 8 days defining good physical activity.^39,46 Weight management was measured using the 10-item weight management subscale of the H-SCALE. Each item was rated on a five-point Likert scale ranging from strongly disagree ¹ to strongly agree.^5,39 The composite score ranged from 10 to 50, with scores ≥ 40 categorised as good weight management practices.^4,39

Salt consumption and follow-up attendance were assessed using the 3-item salt reduction subscale and the 2-item appointment-keeping subscale of the HB-HBP, respectively. ⁴³ Items were rated on a 4-point Likert-type scale (“all the time” = 4 to “none of the time” = 1), yielding composite scores ranging from 3 to 12 for salt reduction and 2 to 8 for follow-up attendance, respectively. ⁴³ Lower scores indicate better adherence. ⁴³ The distribution of composite scores was assessed and found to be non-normal (Kolmogorov-Smirnov test, p<0.05) for both variables; hence, the median split was used as the cut-off point for dichotomization. Participants with scores of ≤ 5(IQR=4-6) were categorized as adherent to salt reduction, while those with scores of ≤ 2 (IQR=2-3) were classified as adherent to follow-up attendance. ⁴⁷ SMBP was assessed using one item: whether patients “currently self-monitor their BP using a self-monitoring BP device at home or elsewhere”, rather than in the clinic during follow-up. The options were “yes” or “no.” Patients who responded “yes” were considered to have practised self-monitoring of blood pressure. ⁴⁰

For each participant, adherence across the seven self-care behaviours was summed to generate a composite score ranging from 0 to 7. Because the composite scores were not normally distributed (Kolmogorov-Smirnov test, p<0.05), the median score of 4 (IQR=3-7) was used as the cut-off point for categorization. Participants who adhered to at least four of the seven recommended self-care behaviours were classified as having good self-care practices.

Anxiety

The 7-item General Anxiety Disorder (GAD-7) scale was used to assess the presence of anxiety. Scores for each item were: “nearly every day”= 3, “more than half the days” = 2, “several days” = 1, and “not at all” = 0.^17,48 The total score ranged from 0 to 21, and a GAD-7 score ≥ 10 was defined as anxiety.^17,49

Depression

Depression was measured using the 9-item Patient Health Questionnaire (PHQ-9) scale. Each item was scored from 0 to 3 according to symptom frequency: “nearly every day”= 3, “more than half the days” = 2, “several days” = 1, and “not at all” = 0, ¹⁷ resulting in a total score of 0 to 27. A PHQ-9 score ≥10 was interpreted as indicative of depressive symptoms^17,49

Social support

The 3-item Oslo Social Support Scale (OSSS-3) was used to assess social support. Item 1 was rated on a 4-point Likert-type scale (1-4), while items 2 and 3 were scored on a 5-point Likert-type scale (1-5). ⁴⁹ The total scores ranged from 3 to 14 and were categorised as poor (3-8), moderate (9-11) or strong (12-14).^17,49

Self-efficacy

The variable was assessed using the 6-item self-efficacy scale for managing chronic disease (SEMCD-6). ⁵⁰ Items are rated on a 10-point scale (“not at all confident” = 1 to “totally confident” = 10), resulting in a composite score ranging from 6 to 60. ⁵¹ Scores above the overall mean [37.39 (SD=5.09)] on the SEMCD-6 items were classified as good self-efficacy. ⁵¹

Hypertension knowledge

This variable was assessed using the HK-LS, which comprised 22 items across six domains: definition (2 items), medical treatment (4 items), drug compliance (4 items), lifestyle modification (4 items), diet (2 items), and complications (5 items). ⁴² Each item had three options (“yes”, “no” and “unknown”), with correct responses scored as 1 and incorrect or “unknown” responses as 0, yielding a total score of 0-22. The total scores were computed and assessed for normality using the KS test. Data were normally distributed, and the mean was used as the cut-off point for categorizing the HK-LS scores. Adequate hypertension knowledge was defined as HK-LS scores ≥ the mean of 16.67 (SD=3.35). ⁴⁹

Quality control measures

To ensure construct validity, the study employed standardized and previously validated instruments including the HK-LS,^42,52 HB-HBP,^43,53 H-SCALE,,^39,54 GAD-7, OSSLO-3, and PHQ-9.^17,41,55 Face validity was established through expert review by a Senior Lecturer and a Cardiovascular Consultant at a Ghanaian Teaching Hospital, who evaluated the clarity, relevance, comprehensiveness, and suitability of the instruments for the study context.

To ensure linguistic equivalence, the interviewer-administered questionnaire, originally developed in English, was translated verbally into Asante Twi (the local language) during the interviews by professional nurses and field supervisors, who were fluent in both English and Asante Twi. Participants’ responses, provided in Asante Twi, were recorded in English on the questionnaire. The professional nurses and field supervisors also underwent three days of training on the study protocol, ethical principles underpinning the study and procedures for administering the questionnaire to ensure consistency throughout the data collection process.

Prior to the main data collection, the questionnaire was pilot-tested among 30 people with hypertension (5.5% of the estimated study sample) attending the Ejisu Municipal Hospital. The pilot study assessed the clarity, comprehensibility, consistency and feasibility of the questionnaire. Minor grammatical corrections and wording revisions were made before the commencement of the main study. The internal consistency of the study instruments was subsequently assessed using Cronbach’s alpha, and all scales demonstrated acceptable reliability. The Cronbach’s alpha coefficients are presented in Table 1.

Table 1.

Internal consistency (Cronbach’s alpha coefficient) of instruments in the study context.

Scale	Number of items	Cronbach’s alpha (α)
Follow-up attendance (Hill-Bone Appointment keeping subscale)	2	0.70
Salt reduction (Hill-Bone Salt reduction subscale)	3	0.71
H-SCALE	14 (Weight management=10, physical activity=2, alcohol consumption=1, smoking=1)	0.74
HK-LS	22	0.76
OSSLO-3	3	0.82
GAD-7	7	0.78.
PHQ-9	9	0.73
SEMCD	6	0.76

Data processing and analysis

Data were entered and cleaned using Microsoft Excel 2020 before being exported to IBM SPSS Statistics 31 for analysis. Categorical variables were summarized using frequencies and percentages. Continuous variables were presented as mean with standard deviation (SD) for normally distributed data and as median with interquartile range (IQR) for skewed data. For continuous variables without established criteria for categorization, either the median (for skewed data) or the mean split (for normally distributed data) was used as the threshold for dichotomization. Normality was assessed using the Kolmogorov-Smirnov test, with p > 0.05 indicating normal distribution.

A binary logistic regression model was fitted to identify factors associated with self-care practice. Bivariate logistic regression was initially performed, and independent variables that demonstrated statistical significance at a 95% confidence interval (CI) and p < 0.25 were included in the multivariable model to control for potential confounding variables. Assumptions for logistic regression analysis, including multicollinearity [Variance Inflation Factor (VIF) < 5], influential outliers (studentized residuals > ±3 or Cook’s distance, D>1), and independence of observations, were assessed, and no violations were identified. Model fitness was confirmed by a significant Omnibus Test (p< 0.05) and a non-significant Hosmer-Lemeshow test (p >0.05).

We performed a multivariable logistic regression analysis to model the association between independent variables and self-care practices, and the variables that remained significant were considered independent associated factors. The significance level for association was set at p < 0.05, and the strength of association was estimated using AORs with corresponding 95% CIs.

Results

Socio-demographic characteristics of participants

Of the 545 people with hypertension recruited, 510 participated in the study, resulting in a response rate of 93.6%. Participants had a mean age of 61.73 years (SD = 11.46). Most participants were females (n=422, 82.7%), had formal education (n=396, 77%) and were self-employed (n=274, 53.7%). Detailed sociodemographic characteristics are presented in Table 2.

Table 2.

Socio-demographic characteristics of participants on follow-up at public healthcare facilities in Ashanti Region, Ghana (n=510).

Variable	Category	Frequency (n)	Percentages (%)
Age range (years)
Mean = 61.73 (SD=11.46)	29-49	69	13.5
	50-59	147	28.8
	60-74	223	43.7
	≥75	71	13.9
Gender
​	Male	88	17.3
	Female	422	82.7
Marital Status
​	Single	32	6.3
	Married	230	45.1
	Divorced/separated	106	20.8
	Widowed	142	27.8
Educational status
​	No formal education	114	22.4
	Formal education	396	77.6
Employment status
​	Unemployed	189	37.0
	Self-employed	274	53.7
	Formally employed	32	6.3
	Retired	15	3.0
Monthly income (GHS)
Median =900 (IQR=100-1700)	Less than 1000	254	50.0
	1000-1999	145	28.0
	2000-2999	61	12.0
	3000 and above	50	10.0
Residence
​	Rural	147	28.8
	Peri-urban	251	49.2
	Urban	112	22.0

Clinical characteristics of the participants

The mean systolic and diastolic blood pressure were 138.10 mmHg (SD = 17.74) and 82.84 mmHg (SD = 10.78), respectively. Approximately one-third of the participants (n = 178, 34.9%) had controlled hypertension. Over one-third (n = 181, 35.5%) had medically confirmed comorbidities, of whom diabetes mellitus (n = 145, 80.1%) was the most common comorbid condition. Most participants were overweight (n = 202, 39.6%), nearly two-thirds (n = 332, 65.1%) reported a family history of hypertension, and the largest proportion had a two-monthly follow-up schedule (n = 180, 35.0%). (Table 3).

Table 3.

Clinical characteristics of the participants on follow-up at public healthcare facilities in Ashanti Region, Ghana (n=510).

Variable	Category	Frequency (n)	Percentages (%)
Follow-up schedules
​	Every week	76	15.0
	Every two weeks	49	10.0
	Every three-weeks	40	8.0
	Monthly	180	35.0
	Two-monthly	165	32.0
Blood pressure control status
mSBP=138.10mmHg (SD=17.74)	Controlled	178	34.9
mDBP =82.84mmHg (SD=10.78)	Uncontrolled	332	65.1
Presence of comorbidity
​	Yes	181	35.5
	No	329	64.5
Type of comorbidity (n=181)
​	Diabetes mellitus	145	80.1
	Heart failure	6	3.3
	Chronic kidney disease	9	5.0
	Stroke	12	6.6
	Others*	9	5.0
Body mass index (kgm -2 )
​	Normal weight	161	31.6
	Underweight	9	1.8
	Overweight	202	39.6
	Obese	138	27.1
Family history of hypertension
​	Yes	332	65.1
	No	178	34.9
Duration of hypertension
​	> 5 years	161	31.6
	≥ 5 years	349	68.4

*Others: ulcer, myocardial infarction, ischemic heart disease, mSBP=means systolic blood pressure, mDBP=mean diastolic blood pressure.

Psychosocial-related characteristics of participants

Based on respective standardized scales and recommended cut-off points, 34.1% (n=174) had good self-efficacy, and 18.6% (n=95) had strong social support. Regarding psychological conditions, 16.1% (n=82) of the participants had depression, while 8.2% (n= 42) had anxiety (Table 4).

Table 4.

Psychosocial-related characteristics of people with hypertension on follow-up at public healthcare facilities in Ashanti Region, Ghana (n=510).

Variable	Category	Frequency (n)	Percentages (%)
Depression
​	Yes	82	16.1
	No	428	83.9
Anxiety
​	Yes	42	8.2
	No	468	91.8
Level of social support
​	Low	209	41.0
	Moderate	206	40.4
	Strong	95	18.6
Level of self-efficacy
​	Good	174	34.1
	Poor	336	65.9

Knowledge about hypertension and its management

Nearly two-thirds of the participants (n=332, 65%) scored at least the overall mean HK-LS of 16.67 (SD=3.35), indicating adequate overall knowledge (Figure 2). However, HK-LS scores varied across various domains. The domain with the highest mean HK-LS score was complications of hypertension at 92.8%, whilst dietary requirements for hypertension had the lowest HK-LS score at 50.5% (Table 5).

$$\text{Means}\hspace{0.17em}\text{score}\hspace{0.17em}\%=\left(\frac{mean\hspace{0.17em}score}{number\hspace{0.17em}of\hspace{0.17em}items}\times 100\%\right)$$

Figure 2.

Overall knowledge about hypertension and its management among people with hypertension on follow-up at selected public healthcare facilities in Ashanti Region, Ghana (n=510).

Table 5.

Overall HK-LS score.

Domain	Number of items	Mean score	Mean score (%)	Rank
Diet	2	1.01 (0.49)	50.5%	6th
Definition	2	1.19 (0.66)	59.5%	5th
Drug compliance	4	2.82 (0.55)	70.5%	4th
Lifestyle	5	3.88 (1.15)	77.6%	3rd
Medical treatment	4	3.13 (0.72)	78.3%	2nd
Complication	5	4.64 (1.56)	92.8%	1st
Overall HK-LS	22	16.67 (3.45)	75.77%	​

Hypertension self-care practices among the participants

Overall, 58.4% (95% CI: 54%-63%) of the participants had good hypertension self-care practices. Self-care practices varied considerably across the individual domains. The vast majority of participants were non-smokers (n=493, 96.7%) and abstained from alcohol (n=451, 90%), while approximately two-thirds (n=330, 64.7%) complied with recommended follow-up schedules. However, 43.3% (n=222) of participants engaged in regular self-monitoring of blood pressure. Good weight management was reported by one-third of participants (n=170, 33.3%), while 26.3% (n=134) adhered to recommended salt-reduction practices. Physical activity was the least frequently practised domain, with only 22.0% (n=112). (Figure 3).

Figure 3.

Hypertension self-care practices among people with hypertension on follow-up at selected public healthcare facilities in Ashanti Region, Ghana.

Bivariate and multivariable analysis of the factors associated with hypertension self-care practices

Table 6 represents the factors associated with adherence to hypertension self-care practices. In the bivariate (unadjusted) analysis, marital status, residence, employment status, BMI, comorbidity, depression, social support, hypertension knowledge, and self-efficacy were associated with self-care practices at p<0.25 and were included in the multivariable model.

Table 6.

Factors associated with self-care practices among people with hypertension on follow-up at selected public healthcare facilities in Ashanti Region, Ghana (n=510).

Variable	Hypertension self-care practices		COR (95% CI)	p value	AOR (95% CI)	p value
	Good N (%)	Poor N (%)
Marital status				0.178	​
Single	16 (50.0%)	16 (50.0%)	0.89 (0.42-1.92)	0.767	1.52 (0.63-3.66)	0.352
Married	145 (63.0%)	85 (37.0%)	1.52 (0.99-2.33)	0.051	1.51(0.59-3.90)	0.398
Divorced/separated	62 (58.5%	44 (41.5%)	1.26 (0.76-2.10)	0.370	1.38 (0.55-3.47)	0.501
Widowed	75 (52.8%)	67 (47.2)	Reference (1)	​	Reference (1)	​
Residence				0.126	​
Rural	96 (65.3%)	51(34.7%)	1.41 (0.85-2.34)	0.178	1.56 (0.86-2.83)	0.144
Peri-urban	138 (55.0)	113 (45.0)	0.92 (0.58-1.44)	0.690	0.89 (0.51-1.58)	0.694
Urban	94 (66.2%)	48 (33.8%)	Reference (1)	​	Reference (1)	​
Employment status				0.055	​
Unemployed	102 (54.0%)	87 (46.0%)	Reference (1)	0.345	Reference (1)	0.984
Self-employed	160 (58.4%)	114 (41.6%)	1.20 (0.82-1.74)	0.014	1.01(0.64-1.58)	0.134
Formally employed	25 (78.0%)	7 (22.0%)	3.05 (1.26-7.39)	0.157	2.22 (0.78-6.29)	0.327
Retired	11 (73.3%)	4 (26.7%)	2.35 (0.72-7.63)	​	1.90 (0.53-6.83)	​
Comorbidity				0.006	​
Yes	91(50.3%)	90 (49.7%)	0.60 (0.41-0.86)	​	0.56 (0.36-0.87)	0.009*
No	202(62.3%)	122 (37.7%)	Reference (1)		Reference (1)	​
Body mass index				0.170	​
Underweight	4 (44.4%)	5 (55.6%)	Reference (1)	​	​	​
Normal weight	104 (64.6%)	57 (35.4%)	2.28 (0.59-8.83)	0.233	2.56 (0.54-12.22)	0.984
Overweight	124 (61.4%)	78 (38.6%)	1.99 (0.52-7.63)	0.317	2.03 (0.43-9.56)	0.134
Obese	66 (47.8%)	72 (52.2%)	1.15 (0.30-4.45)	0.844	1.10 (0.23-5.26)	0.327
Social support				0.012	​
Low	108 (51.7%)	101 (38.3%)	Reference (1)	​	Reference (1)	​
Moderate	124 (60.2%)	82 (39.8%)	1.414(0.96-2.09)	0.081	1.58 (0.98-2.53)	0.060
Strong	66 (69.5%)	29 (30.5%)	2.13 (1.27-3.56)	0.004	1.67 (0.87-3.19)	0.122
Hypertension knowledge				0.010	​
Adequate	212 (64.0%)	119 (36.0%)	1.93 (1.17-3.20)	​	1.19 (0.66-2.14)	0.570
Inadequate	86 (47.5%)	93 (52.5%)	Reference (1)		Reference (1)	​
Self-efficacy				<0.001	​
Good	142 (81.6%)	32 (18.4%)	5.12 (3.3-7.95)	​	12.71 (6.64-24.30)	<0.001**
Poor	156 (46.4%)	180 (53.6%)	Reference (1)		Reference (1)	​
Depression				0.001	​
Yes	34 (41.5%)	48 (58.5%)	0.44 (0.27-0.71)	​	0.11 (0.05-0.23)	<0.001**
No	264 (61.7%)	164 (38.3%)	Reference (1)		Reference (1)	​
Model performance Indicators
Hosmer and Lemeshow	p=0.730	​	​	​	​	​
Omnibus test of model coefficient	p=0.020

Hosmer and Lemeshow Goodness of fit, p=0.730: Reference category= poor self-care practice: AOR= odds for good self-care practice, ** significant at p<0.001, *significant at p<0.05, Omnibus Test of Coefficient, P=0.020.

In the multivariable analysis, comorbidity, depression, and self-efficacy remained independently associated with self-care practices at p<0.05 after adjusting for confounding variables. Accordingly, participants with medically confirmed comorbidities (AOR=0.56, 95% CI: 0.36-0.87) and those with depression (AOR=0.11, 95% CI: 0.05-0.23) were less likely to practice good self-care. However, the likelihood of good self-care was 12 times higher among participants with good self-efficacy (AOR=12.71, 95% CI: 6.64-24.30) than among those with poor self-efficacy.

Adequate hypertension knowledge (COR=1.93, 95% CI: 1.17-3.20), strong social support (COR=2.13, 95% CI: 1.27-3.56), and formal employment (COR=3.05, 95% CI: 1.26-7.39) were significantly associated with increased odds of good self-care practices in the bivariate (unadjusted) analysis; however, these associations lost significance after accounting for potential confounders in the multivariable model.

Discussion

Hypertension self-care practices remain fundamental to effective hypertension management and are widely recommended as the first-line approach before initiating medication. ¹⁵ Consequently, adherence to recommended lifestyle and behavioural modifications is essential for achieving optimal blood pressure control and reducing the risk of hypertension-related complications. This study assessed adherence to hypertension self-care practices among people with hypertension receiving treatment in the Ashanti region, Ghana.

The findings of the present study revealed that 58.4% (95% CI: 54%-63%) of participants demonstrated good hypertension self-care practices, indicating a moderate level of adherence to recommended self-care behaviours. While this level is encouraging, it suggests that a substantial proportion of people with hypertension may not consistently practise behaviours essential for effective blood pressure control and long-term cardiovascular risk reduction. Similar levels of hypertension self-care adherence have been reported in Gondar (59.4%), ⁵⁶ whereas higher estimates have been observed in Ghana (72%), ³⁷ Puducherry, India (70.6%), ³³ and Chennai, India (80.5%). ²³ Conversely, lower adherence has been documented in Harar, Ethiopia (29.9%), ³¹ Bale Zone, Ethiopia (33.1%), ⁴ and Rwanda (34.2%). ²⁶ Methodological variations, particularly in measurement tools, the components of self-care, and operational definitions, plausibly explain the differences in reported adherence rates across studies. For instance, our study assessed self-care practices using standardized instruments, with a stringent classification threshold (≥4 out of 7 behaviours). Contrastingly, the Ghanaian study by Obirikorang et al. ³⁷ employed non-standardized measures, and the study in Chennai, India, by Sivakumar et al. ²³ applied a less stringent cut-off point (≥3 out of 6 behaviours), potentially overestimating adherence rates. Furthermore, the current study specifically focused on non-pharmacological self-care behaviours, whereas other studies by Tebelu et al. ⁴ and Hussen et al. ³¹ incorporated pharmacological components, such as medication adherence. The inclusion of medication adherence, often reported at lower levels due to fear of side effects and cost implications, may have contributed to lower overall adherence rates in those studies. ²²

Methodological differences alone may not fully explain the observed variation in adherence across studies. Contextual factors including differences in healthcare systems, access to chronic disease services, sociodemographic characteristics, availability of patient education programmes, affordability of healthy foods and home blood pressure monitoring devices and organization of follow-up care may also influence the ability of people with hypertension to adopt and sustain recommended self-care behaviours.^4,57

Beyond the overall adherence rate, the findings revealed considerable variation across individual self-care behaviours, suggesting that some lifestyle modifications are more readily adopted than others. Specifically, adherence to smoking cessation (96.7%) and alcohol abstinence (90%) was exceptionally high, consistent with studies conducted in Ethiopia,^29,30 Morocco, ⁵⁸ Nepal ⁵⁹ and Indonesia. ⁶⁰ This high adherence in smoking cessation and alcohol abstinence may be justified by sociocultural and religious norms, especially in Christian and Islamic-dominated settings, whose doctrines frown upon such practices.^30,59 Furthermore, alcoholism and smoking are associated with grave health outcomes, such as carcinomas. ⁶¹ Fear of and increased awareness of these health consequences may further discourage engagement in these behaviours. Routine counselling during follow-up visits may reinforce sustained abstinence by increasing awareness of the health risks associated with tobacco use and harmful alcohol consumption. Nevertheless, the possibility of social desirability bias and underreporting cannot be overlooked, as stigma surrounding these behaviours may lead to overestimation of adherence, since individuals may be less inclined to admit to smoking and alcoholism. ⁵⁸

Conversely, adherence to weight management, reduced salt consumption and physical activity was low. These findings are consistent with previous studies in Ethiopia and India, which similarly reported poor adherence to dietary salt reduction and physical activity.^33,62 The consistently low adherence observed across diverse settings suggests that these behaviours remain among the most challenging components of hypertension self-care, particularly in SSA. Several factors may account for these findings. In the present study, most participants were older adults (>60 years), and a substantial proportion had comorbidities such as stroke and heart failure. These demographic and clinical profiles reflect functional limitations and reduced physical capacity, which can hinder engagement in regular physical activities and weight management practices. ⁵⁷ In addition, the poor adherence to dietary salt reduction observed in the present study may be influenced by entrenched traditional cooking practices, the continued use of salt-based food preservation practices such as curing (salting), and the increasing consumption of processed foods in many parts of sub-Saharan Africa. ⁶³ The findings may also be partly explained by inadequate knowledge of recommended dietary practices as reflected in some participants’ belief that antihypertension medication alone is sufficient to control hypertension and that dietary salt intake can remain unrestricted while taking antihypertensive medication.

Overall, the findings suggest that although participants were generally successful in avoiding harmful behaviours such as smoking and alcohol consumption, substantial challenges remain in adopting lifestyle modifications that require sustained daily commitment and continuous motivation. These findings underscore the need for hypertension programmes to prioritize behavioural interventions that promote physical activity, healthy weight management, and salt reduction, while reinforcing existing successes in smoking cessation and alcohol abstinence.

The study further examined factors associated with hypertension self-care practices. Self-efficacy emerged as an independent predictor of self-care practices, with participants exhibiting higher efficacy demonstrating significantly greater odds of adhering to recommended self-care practices. This finding is consistent with studies in Ethiopia, ⁴ North Carolina, ³² Saudi Arabia ⁶⁴ and China, ⁵⁰ which similarly reported a positive association between self-efficacy and good self-care practices, supporting the central role of self-efficacy in facilitating behavioural change and sustained adherence to recommended self-care practices.

Self-efficacy strengthens individuals’ confidence in their ability to manage hypertension and execute required behaviours. ³² People with hypertension who have higher efficacy are better positioned to initiate behavioural change, persist in the face of challenges, and effectively overcome barriers to adherence. They also tend to engage proactively with healthcare providers, utilize available support systems and maintain consistent self-care routines. ⁴ Consequently, people with hypertension who perceive their condition as manageable, understand their role in its management and are confident in their ability to manage the condition are more likely to engage in optimal self-care behaviours.

Despite this invaluable finding, the cross-sectional design of the present study precludes establishing the temporal relationships between self-efficacy and hypertension self-care practices. While higher self-efficacy may facilitate the adoption and maintenance of recommended self-care behaviours, it is also plausible that sustained engagement in self-care reinforces individuals’ confidence in managing their hypertension over time. ³² Furthermore, although the analyses adjusted for several covariates, residual confounding from unmeasured behavioural or psychosocial factors cannot be entirely ruled out. Nevertheless, the observed association is consistent with social cognitive theory, reinforcing the role of self-efficacy in promoting effective hypertension self-management. ⁶⁵

Taken together, these findings suggest that interventions designed to improve self-efficacy may enhance individuals’ capacity to adopt and sustain recommended self-care behaviours. Strategies such as skill-based training, goal setting, action planning and motivational interviewing may empower people with hypertension to actively manage their condition and achieve sustained improvements in self-care practices.

Comorbidity was independently associated with lower odds of good self-care practices. This finding aligns with evidence from Ethiopia and Tunisia, which suggests that additional chronic conditions undermine patients’ ability to engage in recommended self-care behaviours.^30,31,66 Several mechanisms may explain this relationship. Patients with comorbidities such as stroke, diabetes, and heart failure often experience functional limitations, fatigue and reduced physical activity, which may hinder engagement in physically demanding activities, including exercise and weight management. ⁶⁷ Another explanation relates to the complexities of managing multiple chronic conditions. Patients are often required to follow multiple treatment regimens simultaneously, leading to polypharmacy, complex dosing schedules, and competing lifestyle recommendations.^68,69 These overlapping demands may overwhelm patients and divert attention from hypertension management, particularly because hypertension is often asymptomatic. These challenges may be further compounded by frequent healthcare visits and fragmented care, where patients attend separate clinics for different conditions, often scheduled on different days. ⁷⁰ Such challenges increase time, financial, and physical burdens and may further reduce patients’ capacity to consistently adhere to recommended hypertension self-care practices. ⁶⁹ The findings highlight the importance of adopting integrated, person-centred models of chronic disease management that address multiple long-term conditions concurrently rather than through fragmented care pathways. Coordinating care, simplifying treatment regimens and aligning self-care recommendations across chronic conditions may improve adherence to hypertension self-care practices and enhance overall health outcomes.

The study revealed the impact of depression on self-care practices. Depression was independently associated with self-care practices, with participants experiencing depressive symptoms demonstrating lower odds of practising good self-care. This finding is consistent with similar studies in Ethiopia, which similarly reported depression as an independent predictor of poor hypertension self-care practices.^4,55 The consistency of these findings across different settings suggests that depression remains an important psychosocial barrier to effective hypertension self-management.

Depression is often characterized by low motivation, reduced energy levels, loss of appetite, impaired concentration and cognitive functioning, suicidal ideation, and a feeling of hopelessness, making it difficult for individual to maintain healthy dietary practices, engage in regular physical activity, attend follow-up appointments and consistently monitor their blood pressure.^71,72 In addition, depression may reduce patients’ perceived value of engaging in self-care behaviours, further undermining adherence.^72,73 These behavioural and psychosocial challenges may collectively contribute to poorer self-management and suboptimal blood pressure control among people with hypertension. The findings highlight the importance of integrating routine mental health screening, counselling services and appropriate referral pathways into hypertension care to facilitate early identification and management of depressive symptoms and improve engagement in recommended hypertension self-care practices.

Hypertension knowledge and social support were associated with hypertension self-care practices in the unadjusted analysis but lost significance in the multivariable model, suggesting they were not independent predictors of good self-care practices. This finding appears inconsistent with the Chronic Care Model (CCM), which conceptualizes patient knowledge (decision support) and social support (community and family resources) as important enablers of effective self-management. ⁷⁴ Contrastingly, other studies have identified adequate knowledge and social support as independent determinants of good self-care practices, suggesting that their influence may be context-dependent^28,29,31

One plausible explanation is that the influence of hypertension knowledge and social support on self-care practices may be indirect, mediated by more proximal determinants such as self-efficacy and comorbidities. These factors may exert a stronger and more immediate influence on individuals’ ability to adopt and sustain recommended self-care behaviours in the population. Consequently, knowledge alone may not necessarily translate into sustained behavioural change unless individuals possess the confidence, motivation and practical skills required to implement recommended self-care behaviours. Likewise, social support may be most effective when it actively facilitates self-management rather than merely providing emotional or informational support. This may explain why both factors lost statistical significance after adjustment for self-efficacy, depression and comorbidities.

Collectively, these findings suggest that improving hypertension self-care requires more than patient education alone. Effective interventions should combine patient education with strategies that strengthen self-efficacy, identify and manage depression, and support people with hypertension who have multiple chronic conditions. Such multidimensional interventions are more consistent with the principles of the Chronic Care Model, which emphasizes coordinated, patient-centred care to improve long-term self-management and health outcomes.

Limitations and strengths

The study had some limitations. A cross-sectional design was employed, limiting the ability to establish causal inferences between identified associated factors and self-care practices. Consequently, the temporal sequence between associated factors and self-care practices could not be established, and reverse causality cannot be ruled out.

Reliance on self-reported data may introduce social desirability and recall biases, particularly for behaviours such as alcohol consumption and smoking, potentially leading to overestimation of adherence. Furthermore, the exclusion of people with severe illness and those with cognitive impairment may have introduced selection bias, as these individuals may have different self-care practices and clinical and behavioural characteristics from those included in the study, thereby limiting generalizability of findings to all people with hypertension.

Additionally, because the study was conducted exclusively in public healthcare facilities, the findings may not be generalizable to people with hypertension receiving care in private healthcare facilities, where patient characteristics, access to care and service delivery may differ.

Despite these limitations, notable strengths should be acknowledged. The study used standardized, validated measures, including the H-SCALE, HB-HBP, GAD-7, and PHQ-9, thereby enhancing the reliability and comparability of the findings. The multicentre design, which incorporated facilities across different administrative levels and diverse geographic settings (rural, peri-urban, and urban), improved the representativeness of the study population and the generalizability of the findings within the public healthcare sector of the Ashanti Region. Overall, the findings provide contextually relevant insights into hypertension self-care practices and their predictors among people receiving care in public healthcare facilities.

Future research direction

Future research should employ longitudinal and interventional study designs to better understand changes in hypertension self-care practices over time and to establish the temporal relationships and causal pathways between identified associated factors and hypertension self-care practices.

Further intervention studies are also required to evaluate the effectiveness of programmes and interventions aimed at strengthening self-efficacy and addressing depression, such as integrating mental health screening and skill-based training into hypertension management. Future studies should also explore implementation strategies for integrating these interventions into primary healthcare settings and evaluate their cost-effectiveness to inform policy and scale-up decisions.

Additionally, a future qualitative design is warranted to complement the quantitative findings by providing richer insights into patients’ lived experiences, beliefs and the contextual barriers that influence adherence to self-care. This is particularly important for understanding complex psychosocial factors such as self-efficacy, depression and social support, which may not be fully captured by a structured questionnaire.

Conclusion and recommendations

In conclusion, overall adherence to recommended hypertension self-care practices was moderate; however, there were notable deficiencies in key lifestyle behaviours, particularly in physical activity and dietary salt reduction. Comorbidity, depression and self-efficacy were independently associated factors of hypertension self-care practices. Hypertension knowledge and social support were initially associated with self-care practices; their lack of significance in the adjusted model suggests that hypertension self-care practices are more strongly driven by psychological readiness and disease burden than health information or external support alone.

The findings highlight important implications for clinical practice. Hospital managers and healthcare providers should routinely assess psychosocial and behavioural factors, including depression, self-efficacy, and comorbid conditions, during follow-up visits and incorporate these assessments into individualized care plans. Patient-centred behavioural interventions including skill-based training and motivational interviewing, together with coordinated management of comorbidities through multidisciplinary team-based approaches should be integrated into routine hypertension care to strengthen patients’ self-management capacity.

From a public health and policy perspective, the Ghana Health Service (GHS) and the Ministry of Health (MoH), Ghana should strengthen the national hypertension programmes by integrating behavioural and mental health components in hypertension management guidelines. Capacity building for healthcare providers on chronic care models, behavioural counselling and multidisciplinary team-based care should be prioritized. In addition, improving access to essential self-management resources, including validated home blood pressure monitors and community-based lifestyle support programmes, may facilitate sustained engagement in recommended self-care practices.

ORCID iD

Bernard Gyamfi Anane https://orcid.org/0009-0005-0699-1428

Ethical considerations

The study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval for the study (Ref No: CHRPE/AP/178/25) was granted by the Committee on Human Research, Publication, and Ethics (CHRPE) at KNUST. Administrative permission was obtained from the management of the three selected hospitals (Suntreso Government Hospital, Effiduase District Hospital, and Parkoso Health Centre). Written informed consent was obtained from all participants after the purpose, procedures, potential risks, and benefits of participation were explained. For participants with no formal education, the information contained in the consent form was read aloud and explained to them in a language they understood. They were given the opportunity to ask questions and seek clarification before deciding whether to participate. Participants who could not sign their names provided a thumbprint on the consent form to indicate their agreement to participate, while those who could sign provided their signature. Participation was voluntary, and participants were assured of their right to decline or withdraw from the study without repercussions. Anonymity was strictly maintained, as no personal identifiers were used, and all responses were used solely for academic purposes. Permission to use validated instruments was also obtained as necessary. Survey data were securely stored on encrypted, password-protected servers accessible only to the researcher, with potential access available upon request.

Consent to participate

All participants provided written informed consent before commencing the survey.

Data Availability Statement

The datasets used and analyzed during the study are available from the corresponding author upon request.*