Skip to main content
PMC home page
PLOS ONE logoLink to PLOS ONE
. 2020 Dec 31;15(12):e0244642. doi: 10.1371/journal.pone.0244642

Prevalence of hypertension and its determinants in Ethiopia: A systematic review and meta-analysis

Sofonyas Abebaw Tiruneh 1,*, Yeaynmarnesh Asmare Bukayaw 2, Seblewongel Tigabu Yigizaw 2, Dessie Abebaw Angaw 2
Editor: R Jay Widmer3
PMCID: PMC7774863  PMID: 33382819

Abstract

Introduction

Hypertension is a major public health problem globally and it is a leading cause of death and disability in developing countries. This review aims to estimate the pooled prevalence of hypertension and its determinants in Ethiopia.

Methods

A systematic literature search was conducted at the electronic databases (PubMed, Hinari, and Google Scholar) to locate potential studies. Heterogeneity between studies checked using Cochrane Q test statistics and I2 test statistics and small study effect were checked using Egger’s statistical test at 5% significance level. Sensitivity analysis was checked. A random-effects model was employed to estimate the pooled prevalence of hypertension and its determinants in Ethiopia.

Results

In this review, 38 studies that are conducted in Ethiopia and fulfilled the inclusion criteria with a total number of 51,427 study participants were reviewed. The overall pooled prevalence of hypertension in the country was 21.81% (95% CI: 19.20–24.42, I2 = 98.35%). The result of the review also showed that the point of prevalence was higher among males (23.21%) than females (19.62%). When we see the pervasiveness of hypertension from provincial perspective; the highest prevalence of hypertension was observed in Addis Ababa (25.35%) and the lowest was in Tigray region (15.36%). In meta-regression analysis as the mean age increases by one year, the likelihood of developing hypertension increases by a factor of 0.58 times (β = 0.58, 95% CI: 0.31–0.86, R2 = 36.67). Male sex (OR = 1.29, 95% CI: 1.03–1.61, I2 = 81.35%), age > 35 years (OR = 3.59, 95% CI: 2.57–5.02, I2 = 93.48%), overweight and/or obese (OR = 3.34, 95% CI: 2.12–5.26, I2 = 95.41%), khat chewing (OR = 1.42, 95% CI: I2 = 62%), alcohol consumption (OR = 1.50, 95% CI: 1.21–1.85, I2 = 64%), family history of hypertension (OR = 2.56, 95% CI: 1.64–3.99, I2 = 83.28%), and family history of diabetes mellitus (OR = 3.69, 95% CI: 1.85–7.59, I2 = 89.9%) are significantly associated with hypertension.

Conclusion

Hypertension is becoming a major public health problem in Ethiopia. Nearly two out of ten individuals who are older than 18 years living with hypertension. Sex, age, overweight and/or obese, khat chewing, alcohol consumption, and family history of hypertension and diabetes mellitus are statistically significant determinant factors for hypertension in Ethiopia. Primary attention should be given for behavioral risk factors to tackle the alarming increase of hypertension in Ethiopia.

Introduction

Globally, more than 1.13 billion people living with hypertension, of this two-thirds living in Low and Middle-Income Countries (LMICs) [1]. In the globe, by the end of 2025 1.56 billion people will live with hypertension [2]. In Africa, 46% of adults whose age is older than 25 years and above living with hypertension [3]. The prevalence of hypertension in Africa has raised from 19.7% in 1990 to 30.8% in 2010 [4]. One in every five people live with hypertension in LMICs and studies showed that 3 out of 4 people in these countries will live with hypertension by the end of 2025 [5]. Besides, 74.7 million people living with hypertension in Sub-Saharan Africa, and it will rise to 125.5 million by the end of 2025 [6]. These trends have been strongly linked with lifestyle changes such as an increase in smoking tobacco use, excessive alcohol consumption, and physical inactivity [7, 8]. To tackle the burden of hypertension, the Pan-African Society of Cardiology (PASCAR) identified 10 action points to be implemented by African ministers to achieve a 25% decline by the end of 2025 [7, 9].

In Ethiopia, non-communicable diseases account for 39% of all causes of mortality of which, cardiovascular disease accounts for 16% [10]. On the other hand, hypertension constitutes the majority (62.3%) of all the causes of cardiovascular-related morbidity and mortality [11]. This is because high blood pressure increases the risk of life-threatening complications on vital organs like heart, blood vessels, brain, and kidney which leads to premature mortality and disability [12].

In 2015, a systematic review and meta-analysis was conducted in Ethiopia [13]; but this study did not identify the pooled effects of factors affecting the prevalence of hypertension. Besides, there are several studies published after the previous review. Therefore, this systematic review and meta-analysis gives updated pooled prevalence and factors affecting the prevalence of hypertension in Ethiopia.

Moreover, documenting the updated pooled prevalence and its determinants of hypertension will help to achieve the action plan of the Pan-African Society of Cardiology and global targets regarding hypertension. Therefore, the objective of this systematic review and meta-analysis is to synthesize updated pooled prevalence and its determinants of hypertension in Ethiopia. The finding of this review will show the trends of hypertension in Ethiopia and that can be used for health planners, policymakers, and for the community itself to curve the alarming rise of hypertension in Ethiopia.

Methods

Study setting and search strategies

Ethiopia is found in the horn of Africa and has nine administrative regional states and two city administrations. Potential studies were identified using electronic databases (PubMed/MEDLINE, Hinari, Google scholar) and google search. Besides, unpublished theses were also reviewed out from some research centers and library sources. The sources are reviewed limited to English language and studies published after 01/01/2000. The task of searching sources was carried out from all stated electronic databases performed on October/24/2019. All included studies defined hypertension as Systolic Blood Pressure (SBP) ≥ 140 mmHg and/or a Diastolic Blood Pressure (DBP) ≥ 90 mmHg or known hypertensive patients on treatment. The search MeSH headings were hypertension and synonyms for hypertension were used. The synonyms of hypertension are “blood pressure, high”, “and blood pressures, high”, “high blood pressure”, and “high blood pressures”. Finally, the search combination used as; “Hypertension” OR "Blood Pressure, High” OR "High Blood Pressure" OR "High Blood Pressures" OR "Blood Pressure, High" OR "Blood Pressures, High" AND Ethiopia (S1 Table).

Eligibility criteria

We used CoCoPop (Condition, Context, and Population) approach for prevalence studies to declare inclusion and exclusion criteria.

Inclusion criteria and exclusion criteria

Studies conducted on the prevalence and/or associated factors of hypertension in Ethiopia were included. Besides, all full-text articles written in English language (with response rate > 85%), with participants older than 18 years and published after January 01/2000 are included for this review. Studies conducted on pregnancy-induced hypertension, for the reason that has no prevalence report on hypertension, and hypertension prevalence reports on other comorbidities excluded for this review.

Measurement of the outcome variable

The primary outcome of interest for this review was to estimate the pooled prevalence of hypertension and its determinants. Potentials of extracted factors from each study considered as an independent factor for hypertension.

Study selection and data collection

All the studies reviewed through different electronic databases were combined, exported, and managed using Endnote version X9.2 (Thomson Reuters, Philadelphia, PA, USA) software. All duplicate studies were removed and full-text studies downloaded using Endnote software and manually. The eligibility of each study was completely assessed independently by two reviewers (SA. &YA.). Exaggerated differences in the results of the two reviewers narrowed through discussion and other reviewer members (ST. & DA.).

Assessment of the quality of the individual studies

The quality of the studies assessed using the validated modified version of a quality assessment tool for prevalence studies [14]. Two reviewers (SA. & YA.) were independently assessed to check the quality of the included studies. The problem of subjectivities between the two reviewers was solved through discussion and other review teams (ST. & DA.). The quality assessment tool has nine-questions. Based on the score of the quality assessment tool the highest score had the minimum risk of bias. Overall scores range from (0–3), (4–6), and (7–9), which are declared low, moderate, and high risk of bias respectively [14].

Data extraction and management

All-important parameters extracted from each study were reviewed by two authors (SA. &YA.) independently using Microsoft Excel. The discrepancies between the two authors managed through discussion and/or the other authors (ST. & DA.). The data extraction format was prepared using the assistance of the Joanna Briggs Institute (JBI) data extraction tool for prevalence studies. For each study, authors, years of publication, study design, sample size, the prevalence of hypertension with their standard error, and determinant factors effect size with their standard error were extracted.

Statistical analysis

The extracted data were exported to STATA/MP version 16.0 software for analysis. The pooled prevalence of hypertension and its determinants analyzed by the random effects model using DerSimonian-Laird model weight [15]. Heterogeneity in meta-analysis is mostly inevitable due to differences in study quality, its sample size, method, and different outcome measurements across studies [16, 17]. Statistically, significant heterogeneity was checked by Cochrane Q-test and I2 statistics [18]. To minimize the variance of estimated points between primary studies, a subgroup analysis was carried out in reference to the regions, age categories, and residence. Besides, a sensitivity analysis was also conducted to determine the influence of single studies on the pooled estimates. Univariate meta-regression conducted using year of publication, the mean age of the respondent from primary studies, sample size, and region using random effects model. Publication bias (small study effect) checked using graphically and Egger’s statistical test [19]. Statistically significant Egger’s test (P-value < 0.05) indicates that the presence of a small study effect and handled by non-parametric trim and fill analysis using the random effects model [20].

Results

Study selection and identification

Of the 784 studies reviewed, 336 were excluded, because they were duplications. By reading their titles and abstracts, 406 studies excluded as they were irrelevant for this review. Again, five studies excluded, because of the outcome not reported, inadequate sample size, and lack of full text. Finally, 38 potential studies have been included for qualitative and quantitative synthesis influences as summarized in the PRISMA flow diagram [21] (Fig 1).

Fig 1. PRISMA flow diagram of article selection for systematic review and meta-analysis of the prevalence of hypertension and its determinants in Ethiopia.

Fig 1

Open in a new tab

Characteristics of included studies

Among the included studies, 20 (52.60%) studies published after 2016. All the included studies were cross-sectional surveys, of which 27 community based, six health facility-based, and five studies were institutional-based (Schools, College, Bank…). Overall, a total number of 51,427 study participants who are older than 18 years included for this review. The minimum and maximum sample sizes were 306 and 9788 respectively [22, 23]. A minimum of (7.47%) and maximum of (41.90%) prevalence of hypertension were reported from the studies conducted in the Oromia region [24, 25]. Five regions and two city administrations (Addis Ababa and Dire Dawa) were represented for this review. Seven from Amhara Region [26–32], eight from Oromia Region [24, 25, 33–38], six from South National and Nationalities of People’s Region (SNNPR) [22, 39–43], four from Tigray Region [44–47], three from Somali Region [48–50], eight from Addis Ababa [51–58], two from Dire Dawa [37] and one national study in Ethiopia [23] were included. No studies reviewed from Gambela, Afar, Benishangul Gumez, and Harari Regional states of Ethiopia (Table 1).

Table 1. Characteristics of the included studies and their prevalence of hypertension in Ethiopia, 2019.

S. No Author Publication year Region Sample size Response rate (%) Prevalence of hypertension Quality score
1 Zekewos et al. [42] 2019 SNNPR 425 - 21.80 1
2 Kiber et al. [30] 2019 Amhara 456 95.6 12.50 2
3 Shukuri et al. [25] 2019 Oromia 401 96 41.90 1
4 Abebe et al. [56] 2019 Addis Ababa 487 100 34.70 0
5 Roba et al. [59] 2019 Dire Dawa 872 96.5 24.40 3
6 Belachew et al. [27] 2018 Amhara 308 100 27.30 0
7 Gebreyes et al. [23] 2018 National 9788 95.4 18.05 0
8 Bayray et al. [46] 2018 Tigray 1523 99.7 15.90 0
9 Tesfaye et al. [38] 2018 Oromia 648 97 14.2 0
10 Esaiyas et al. [40] 2018 SNNPR 620 99.6 19.70 0
11 Bekele et al. [51] 2018 Addis Ababa 758 100 15.90 0
12 Asfaw et al. [41] 2018 SNNPR 524 99.8 30.00 0
13 Mara et al. [39] 2018 SNNPR 346 97.4 23.00 0
14 Neba et al. [50] 2017 Somali 548 100 21.90 0
15 Demisse et al. [28] 2017 Amhara 3057 94.8 27.40 0
16 Asresahegn et al. [48] 2017 Somali 487 98.9 28.30 0
17 Birhanu Tolera [57] 2017 Addis Ababa 401 98.5 14.00 1
18 Seifu et al. [49] 2017 Somali 330 100 13.30 1
19 Gebrihet et al. [45] 2017 Tigray 521 96 16.50 0
20 Fikadu et al. [52] 2016 Addis Ababa 1866 100 21.00 0
21 Tadele et al. [22] 2016 SNNPR 306 95.9 27.80 3
22 Abdissa et al. [54] 2015 Addis Ababa 2716 100 24.90 1
23 Anteneh et al. [32] 2015 Amhara 678 99.6 25.10 1
24 Asresahegn et al. [34] 2015 Oromia 830 100 36.40 3
25 Angaw et al. [55] 2015 Addis Ababa 629 96 27.30 0
26 Birlew et al. [24] 2015 Oromia 4055 90.7 7.47 2
27 Abebe et al. [26] 2015 Amhara 2141 97.3 27.90 1
28 Bissa et al. [35] 2014 Oromia 701 96.02 21.30 1
29 Zikru et al. [47] 2014 Tigray 709 99.7 11.00 3
30 Mengistu et al. [44] 2014 Tigray 1183 100 18.10 1
31 Tadesse et al. [31] 2014 Amhara 610 100 7.70 2
32 Helelo et al. [43] 2014 SNNPR 518 96.6 22.40 2
33 Gudina et al.[36] 2014 Oromia 396 93.8 16.92 2
34 Gudina et al. [33] 2013 Oromia 734 100 13.20 0
35 Nshisso et al. [53] 2012 Addis Ababa 2153 100 19.10 1
36 Awoke et al. [29] 2012 Amhara 679 97.6 28.30 0
37 Muluneh et al. [37] 2012 Oromia 3223 - 9.30 2
38 Tesfaye et al. [58] 2009 Addis Ababa 648 93.2 14.20 1
Open in a new tab

The pooled prevalence of hypertension in Ethiopia

In random effects model, the pooled prevalence of hypertension in Ethiopia was 21.81 (95% CI = 19.20–24.42); significant heterogeneity observed among studies (I2 = 98.4, P-value < 0.001). The highest weight among studies observed from the studies conducted by Muluneh et al. [37], Gebreyes et al. [23], and Birlew et al. [24] (Fig 2). Among 23 studies in the random effects model, the pooled prevalence of hypertension among males were 23.21 (95% CI:18.86–27.57) (Fig 3) with statistically significant heterogeneity (I2 = 97.5%, P-value < 0.001). Besides, the overall pooled prevalence of hypertension among females were 19.62 (95% CI: 16.26–22.97) (Fig 4); heterogeneity (I2 = 96.08%, P-value <0.001). Egger’s statistical test evidenced that has no publication bias among the included studies (β = -0.615, P-value = 0.91).

Fig 2. Pooled prevalence of hypertension age greater than 18 years in Ethiopia.

Fig 2

Open in a new tab

Fig 3. Pooled prevalence of hypertension among males in Ethiopia, 2019.

Fig 3

Open in a new tab

Fig 4. Pooled prevalence of hypertension among females in Ethiopia, 2019.

Fig 4

Open in a new tab

Handling heterogeneity

Significant heterogeneity observed from random effects model pooled estimate. To handle this heterogeneity sensitivity analysis, subgroup analysis, and meta-regression analysis were performed.

Sensitivity analysis

From the random effects model, there are no studies that excessively influence the overall pooled estimate of hypertension (S1 Fig).

Subgroup analysis

Even though subgroup analysis was carried out across the administrative regions of the country, age category, and residence as the source of heterogeneity was not handled. In the subgroup analysis, the highest prevalence of hypertension observed in Addis Ababa (25.35%) followed by Southern Nations Nationalities and People’s Region (23.83%); whereas the lowest prevalence was in Tigray regional state of Ethiopia (15.36%). The pooled prevalence of hypertension (27%) was higher in the age category which is older than 35 years. Also, the highest prevalence of hypertension was observed in urban inhabitants (22.85%) (Table 2).

Table 2. Sub-group pooled prevalence of hypertension in Ethiopia, 2019 (n = 38).

Variables Included studies Sample size Prevalence (95%CI) Heterogeneity (I2, p-value)
By region Tigray 4 3936 15.36 (12.33–18.39) 85.4%, < 0.001
Amhara 7 7929 22.27 (15.44–29.11) 98.1%, < 0.001
Oromia 8 10988 19.83 (14.09–25.28) 98.7%, < 0.001
SNNPR 6 2739 23.83 (20.93–26.72) 77.0%, < 0.001
Addis Ababa 8 9658 25.35 (21.25–29.45) 96.3%, < 0.001
Somali 3 1365 21.14 (12.86–29.42) 93.3%, < 0.001
By age category > 18 years 25 38360 19.92 (24.28–29.56) 98.4%, < 0.001
> 25 years 7 8304 24.37 (19.84–28.89) 95.4%, < 0.001
> 30 years 2 1196 23.86 (21.22–26.49) 15.9%, 0.275
> 35years 3 2888 26.92 (24.28–29.56) 53.7%, 0.115
By residence Rural 5 10814 18.45 (12.41–24.48) 99.03, < 0.001
Urban 28 26554 22.85 (20.34–25.36) 95.91, < 0.001
Both urban and rural 5 14059 18.45 (12.41–24.48) 98.19, < 0.001
Open in a new tab

Meta-regression

Univariate meta-regression analysis revealed that the mean age and region were statistically significant with hypertension. As the mean age increased by one year, the likelihood of developing hypertension increases by a factor of 0.58 times (β = 0.58, 95% CI: 0.31–0.86); with a total proportion of hypertension explained by the covariate mean age by 36.67% (adjusted R2 = 36.67). The linear relationship between mean age and hypertension was presented as shown in Fig 5 below. Besides, the pooled prevalence of hypertension was higher in the capital city of Addis Ababa, Ethiopia as compared to Tigray regional state of Ethiopia (β = 10.01, 95% CI: 1.22–18.80) (Table 3).

Fig 5. The relationship between mean age and hypertension in the Ethiopian population, 2019.

Fig 5

Open in a new tab

Table 3. Univariate meta-regression analysis results for the prevalence of hypertension in Ethiopia, 2019.

Study level variables Adjusted R2 Standard error Coefficients (95% CI)
Mean age 36.67 0.14 0.58 (0.31–0.86) *
Publication year 00 0.57 0.58(-0.54–1.69)
Sample size 00 0.0008 0.00072 (-0.0023–0.0009)
Regions Tigray 1 1 1
Amhara 4.59 6.88 (-2.13–15.89)
Addis Ababa 20 4.48 10.01(1.22–18.80) *
Oromia 4.49 4.39 (-4.40–13.19)
SNNPR 4.76 8.67 (-0.65–18.00)
Somali 5.64 5.77 (-5.30–16.54)
Dire Dawa 8.21 9.03 (-7.07–25.12)
Open in a new tab

NB:

* = Statistically significant at 5% level, CI = Confidence Interval.

Factors associated with hypertension

As summarized in Table 4, sex, age, Body Mass Index (BMI), chat chewing, alcohol consumption, and family history of hypertension and diabetes mellitus were statistically significant factors for hypertension.

Table 4. Summary of the pooled effects of factors associated with hypertension in Ethiopia, 2019.

Variables OR (95% CI) Heterogeneity (I2, P-value) Egger’s P-value Total studies Sample size
Sex Female 1
Male 1.29 (1.03–1.61) * 81.35%, < 0.001 0.544 15 19957
Age < 35 years 1 1
> 35 years 3.59 (2.57–5.02) * 93.48%, < 0.001 0.487 15 27365
BMI Normal 1
Underweight 0.68 (0.30–1.56) 94.00%, < 0.001 0.229 16
Overweight and /or obese 3.34 (2.12–5.26) * 95.41%, < 0.001 0.176 18 13383
Khat chewing No 1 1
Yes 1.42 (1.10–1.85) * 62.2%, 0.005 0.267 10 8687
Smoking No 1 1
Yes 1.55 (1.00–2.38) 67.56%, 0.002 0.873 10 9556
Alcohol drinking No 1 1
Yes 1.50 (1.21–1.85) * 64.0%, 0.001 0.005 14 12988
Physical activity Active 1 1
Inactive 1.24 (0.83–1.85) 91.28%, < 0.001 0.0002 15
Family history of HTN No 1 1
Yes 2.56 (1.64–3.99) * 83.28%, < 0.001 0.016 11 5918
Family history of DM No 1 1
Yes 3.69 (1.85–7.59) * 89.93%, < 0.001 0.4707 9 14660
Open in a new tab

NB:

* = Statistically significant at 5% level, OR = Odds Ratio, CI = Confidence Interval.

Fifteen [22, 24, 26, 28, 30, 31, 33, 41, 43, 46, 48, 51, 52, 54, 59] studies were included to identify the association between sex and hypertension. Five of these studies [22, 26, 28, 33, 59] had no statistically significant association between sex and hypertension. From random effects model estimate, the pooled odds of developing hypertension among males were 29% more likely to develop hypertension than females (OR = 1.29, 95% CI: 1.03–1.61); with statistically significant heterogeneity between studies (I2 = 81.3%, P-value < 0.001) (Fig 6). Egger’s test indicates that no small study effect (P-value = 0.544) and in random effects model there was no single study that excessively influences the pooled estimate of hypertension (S2 Fig).

Fig 6. The association between males and hypertension.

Fig 6

Open in a new tab

The pooled effect of age has a significant association with hypertension. From fifteen [23, 24, 28, 30, 35, 40, 41, 46, 48, 50, 51, 52, 54–56] studies only one [24] study had no significant association between age and hypertension. The pooled odds of developing hypertension among individuals older than 35 years was 3.59 times higher than age younger than 35 years (OR = 3.59, 95% CI: 2.57–5.02) (Fig 7); with statistically significant heterogeneity among studies (I2 = 93.5%, P-value < 0.001). There is no small study effect (P-value = 0.485) and in random effects model, there was no single study excessively influence the pooled estimate of effect size (S3 Fig).

Fig 7. Forest plot for the association between age and hypertension.

Fig 7

Open in a new tab

A total of eighteen [22, 25, 27–29, 31, 32, 35, 40, 43, 45–47, 49–51, 55, 56] studies included to estimate the association between BMI and hypertension. The results of the test statistics indicate that significant heterogeneity was observed between studies (I2 = 95.41%, P-value < 0.001). Egger’s test evidenced that there was no publication bias (P-value = 0.176). Again, from random effects model, no individual studies excessively influence the pooled estimate of the effect size (S4 Fig). From the random effects model pooled estimate, the likelihood of developing hypertension among overweight and/or obese individuals was 3.34 times higher than the normal-weight individuals (OR = 3.34, 95% CI: 2.12–5.26) (Fig 8).

Fig 8. The association between body mass index and hypertension.

Fig 8

Open in a new tab

The pooled effects between khat chewing and hypertension was assessed using ten studies [22, 24, 33, 35, 36, 46, 48, 49, 55, 57]. Among the included studies, six [22, 24, 33, 36, 38, 48] of them reported that khat chewing has not a statistically significant association with hypertension. Based on Egger’s test there was no publication bias (P-value = 0.498). Besides, from random effects model there was no single study that excessively influences the pooled effect size (S5 Fig). Khat chewers have 42% more likelihood to develop hypertension than non-khat chewers (OR = 1.42, 95% CI: 1.10–1.85) (Fig 9), with moderate heterogeneity (I2 = 62.2%, P-value = 0.005).

Fig 9. The association between khat chewing and hypertension.

Fig 9

Open in a new tab

The association between alcohol consumption and hypertension was assessed using 14 studies [22, 24, 26, 27, 30, 34–36, 38, 55–57, 59]. Moderate heterogeneity was also observed from the random effects model (I2 = 64.04%) and there is no evidence of a single study that affects the pooled effects size in the sensitivity analysis (S6 Fig). Egger’s test evidenced that small study effect (P-value = 0.001). After non-parametric trim and fill analysis (Fig 10), alcohol consumption had a negative effect on hypertension. From the random-effects trim and fill analysis, alcohol drinkers were more likely to develop hypertension by half as compared to non-drinkers (OR = 1.50, 95% CI: 1.21–1.85).

Fig 10. Trim and fill analysis funnel plot for alcohol consumption.

Fig 10

Open in a new tab

A total of fifteen studies [22, 25, 26, 28, 29, 32, 33, 35, 41, 43, 45, 48, 49, 56, 59] were included to determine the association between physical activity and hypertension; of them, four studies had no statistically significant association with hypertension. From random effects model estimate, significant heterogeneity observed (I2 = 91.3%, P-value < 0.001). Egger’s test indicates that evidence of publication bias (P-value = 0.002). After non-parametric trim and fill analysis, physical exercise and hypertension has no significant association (OR = 1.24, 95% CI: 0.83–1.85).

As the results of eleven studies [22, 25, 29, 30, 33, 34, 43, 48–50, 55], family history of hypertension and hypertension had statistically significant association. The random effects model evidenced that statistically significant heterogeneity across studies (I2 = 83.3%, P-value < 0.001). From the sensitivity analysis random effects model estimate there is no single study that excessively influences pooled effect size (S7 Fig). Egger’s test showed that the presence of a small study effect (P-value = 0.016). After non-parametric trim and fill analysis pooled estimate (Fig 11), the pooled odds of developing hypertension among individuals who had a family history of hypertension were 2.56 times higher than their counterparts (OR = 2.56, 95% CI:1.64–3.99).

Fig 11. Trim and fill analysis funnel plot for a family history of hypertension.

Fig 11

Open in a new tab

Furthermore, the association between the family of diabetes mellitus and hypertension was identified using nine studies [22, 23, 29, 32, 33, 48, 55, 56, 59]; among them, four studies [22, 23, 48, 59] showed that there is no statistically significant association between family history of diabetes mellitus and hypertension. The random effects model estimate showed that statistically significant heterogeneity between studies (I2 = 89.9%, P-value < 0.001) and Egger’s test showed that there is no publication bias (P-value = 0.47). From random effects model sensitivity analysis, there is no single study that excessively affects the pooled effect size (S8 Fig). Form random effects model estimate individuals who had a family history of diabetes mellitus are 3.69 times more likely to develop hypertension than the reference category (OR = 3.69, 95% CI: 1.85–7.59) (Fig 12) (Table 4).

Fig 12. The association between family history of diabetes mellitus and hypertension.

Fig 12

Open in a new tab

Discussion

Non-communicable diseases are becoming a double burden of public health problem in developing countries [60]; besides hypertension prevalence is rising in developing countries in contrast to developed nations [61]. This systematic review and meta-analysis will give the update pooled estimates of hypertension in Ethiopia which gives invaluable information to policymakers, health planners, and the community itself.

This systematic review and meta-analysis revealed that the pooled prevalence of hypertension in Ethiopia was 21.81% (95% CI: 19.20–24.42), which was consistent with a study conducted in rural communities of Sub-Saharan Africa (22%), Kenya (22.8%), and a meta-analysis from Vietnam (21.1%) [62–64]. However, the finding of this meta-analysis was lower than the previous meta-analysis reports in LMICs (32.3%), among adults in Africa (57.0%), a meta-analysis study on undiagnosed hypertension in Sub-Saharan Africa (30%), Nigeria (28.9%), India (29.8%), Pakistan (26.34%), and a study in Nepal (25.1%) [65–71]. The prevalence of hypertension in this review was higher than a study conducted a previous systematic review in Ethiopia and a study conducted in Ghana [13, 72]. The possible reason for this discrepancy might be the time of the study, the age group of the population studied, the diagnosis criteria for hypertension, and the study setting.

From subgroup analysis by region, the highest prevalence of hypertension (25%) was observed in the capital city of Ethiopia, Addis Ababa. This is similar to subgroup analysis by the residence which is the prevalence of hypertension (23%) was higher in urban inhabitants. The possible justification might be, urbanization may be linked to low physical activity, consumption of unhealthy diet and stress which may again leads to the high burden of non-communicable diseases [73–76].

This review also identifies the determinant factors of hypertension. In random effects model pooled estimate, sex, age, body mass index, khat chewing, alcohol consumption, family history of hypertension, and family history of diabetes mellitus were significantly associated with hypertension.

From the random effects model estimate, the pooled odds of developing hypertension among males were 29% higher than females. This finding was similar with the studies conducted in Nepal, Varanasi India, Burkina Faso, Debrecen city of Hungary, and a meta-analysis study from Vietnam [62, 69, 77–80], whereas it is not similar to a study conducted at Uganda [81]. The possible reason might be males were more vulnerable to behavioral risk factors for hypertension.

The pooled effect of age greater than 35 years was 3.6 times higher than age less than 35 years to develop hypertension, which is similar to the community-based studies conducted in Uganda, Nepal, Benin, Varanasi city India, and another city of New Delhi, India [79–83]. As well, from meta-regression analysis showed that mean age and hypertension had a direct linear relationship. Age is one of the non-modifiable risk factors for hypertension. As a result, this is the fact that cardiovascular system is strongly affected by ageing; besides, ageing causes the structural and functional changes in the blood vessels that may lead to cardiovascular morbidity and mortality [84].

This review also evidenced that individuals being overweight and/or obese were venerable to hypertension. The likelihood of developing hypertension among overweight and/or obese individuals were three times higher than normal in their body mass index. This finding is similar to the previous studies conducted in different countries [63, 77–79, 81]. Besides, a study conducted in Japan evidenced that as 1 kg/m2 increase in body mass index increases the odds of developing hypertension by 23% among males and 35% among females [85]. This study strengths the fact that high body mass index increases blood cholesterol level which leads to hypertension [86]. Furthermore, this review evidenced that khat (Catha edulis) chewers were 42% more likely to develop hypertension than their counterparts which was similar to the studies conducted in Ethiopia, Yemen, and a meta-analysis study from Ethiopia [87–90]. Khat contains chemicals cathinone, cathine, and amphetamine. Cathinone is structurally related to amphetamine which increases levels of dopamine in the brain by acting on the catecholaminergic synapses [91] and increase blood pressure and heart rate [92, 93].

The pooled estimates of alcohol drinking and hypertension were statistically significant in random effects model estimate with moderate heterogeneity between studies. The odds of developing hypertension among drinkers were higher than by half as compared to non-drinkers. This finding was similar to the studies done in North American and France [94–96]. Another study evidenced that consuming three or more drinks of alcohol per day which approximately doubles the risk of developing hypertension [97]. Alcohol consumption affects the central nervous system which enhances cardiac output and has an effect on peripheral vascular effects [98].

Furthermore, family history of hypertension was a potential determinant factor for hypertension. Individuals who had a family history of hypertension have almost five times more chance to develop hypertension than individuals who had no family history of hypertension. This finding was similar to the previous studies conducted in China, Sri Lanka, and Mexico [99–101]. In addition, individuals who had a family history of diabetes mellitus were 3.7 times more likely to develop hypertension as compared to their counterparts. These factors are non-modifiable risk factors for hypertension. The possible association of family history of hypertension and diabetes mellitus with hypertension might be close blood relatives might have the same genes which may predispose to hypertension. Besides, close blood relatives might have experience of common behavioral practices that may predispose to hypertension.

This study follows some strengths and limitations. Our review adds considerable knowledge of the updated prevalence of hypertension in Ethiopia. All included studies use the same definition to declare hypertension. Subgroup analysis was performed to minimize statistical heterogeneity. Multiple factors were also included to identify the significant factors for hypertension. However, substantial statistically significant heterogeneity was observed across studies which undermine the pooled estimate of hypertension suggests that chance could be responsible for between-study variability. Sub-group analysis could not identify the source of heterogeneity. Though, meta-regression analysis suggested that mean age and region explain some source of heterogeneity.

Conclusions and recommendations

In conclusion, hypertension is becoming a major public health problem in Ethiopia. Nearly two out of ten individuals who are older than 18 years in Ethiopia are living with hypertension. The highest prevalence of hypertension was observed in Addis Ababa and the lowest was in Tigray region. Sex, age, overweight and/or obesity, chat chewing, alcohol consumption, family history of hypertension and family history of diabetes mellitus were statistically significant factors for hypertension. Based on the finding of this review, we recommend that health planners, policymakers, and the community itself should give prior attention to behavioral risk factors such as chat chewing, alcohol drinking and sedentary lifestyle.

Supporting information

S1 Table. Studies search strategies and entry terms from different electronic databases on the prevalence and determinants of hypertension.

(DOCX)

Click here for additional data file. (14.6KB, docx)
S1 Fig. Sensitivity analysis plot for the pooled prevalence of hypertension.

(TIF)

Click here for additional data file. (1.2MB, tif)
S2 Fig. Assessment of sensitivity analysis plot for factor sex.

(TIF)

Click here for additional data file. (326.9KB, tif)
S3 Fig. Assessment of sensitivity analysis plot for the factor age.

(TIF)

Click here for additional data file. (315KB, tif)
S4 Fig. Assessment of sensitivity analysis plot for factor among obese and/or overweight.

(TIF)

Click here for additional data file. (388.7KB, tif)
S5 Fig. Assessment of sensitivity analysis plot for factor Khat Chewing.

(TIF)

Click here for additional data file. (306.5KB, tif)
S6 Fig. Assessment of sensitivity analysis plot for factor alcohol consumption.

(TIF)

Click here for additional data file. (382.7KB, tif)
S7 Fig. Assessment of sensitivity analysis plot for factor family history of hypertension.

(TIF)

Click here for additional data file. (312.6KB, tif)
S8 Fig. Assessment of sensitivity analysis plot for factor alcohol consumption.

(TIF)

Click here for additional data file. (257.4KB, tif)
S1 Checklist

(DOC)

Click here for additional data file. (63.5KB, doc)
S1 File

(XLSX)

Click here for additional data file. (12.8KB, xlsx)

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

The author(s) received no specific funding for this work.

References

  • 1.World Health Orgnaisation. Hypertension fact sheets. 2019. https://www.who.int/news-room/fact-sheets/detail/hypertension
  • 2.Olin BR, Pharm D. Hypertension: The Silent Killer: Updated JNC-8 Guideline Recommendations. 2018.
  • 3.Haldar RN. Global Brief on Hypertension: Silent Killer, Global Public Health Crisis. Indian J Phys Med Rehabil. 2013;24: 2–2. 10.5005/ijopmr-24-1-2 [DOI] [Google Scholar]
  • 4.Adeloye D, Basquill C. Estimating the prevalence and awareness rates of hypertension in Africa: A systematic analysis. PLoS One. 2014;9 10.1371/journal.pone.0104300 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.van de Vijver S, Akinyi H, Oti S, Olajide A, Agyemang C, Aboderin I, et al. Status report on hypertension in Africa—Consultative review for the 6th Session of the African Union Conference of Ministers of Health on NCD’s. Pan Afr Med J. 2013;16: 1–17. [DOI] [PMC free article] [PubMed]
  • 6.Ogah OS, Rayner BL. Recent advances in hypertension in sub-Saharan Africa. Heart. 2013;99: 1390–1397. 10.1136/heartjnl-2012-303227 [DOI] [PubMed] [Google Scholar]
  • 7.Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, et al. Global Ncd Target Reduce High Blood Pressure. Lancet. 2017;31: 190–215.1037//0033-2909.I26.1.78 [Google Scholar]
  • 8.Walker RW, McLarty DG, Kitange HM, Whiting D, Masuki G, Mtasiwa DM, et al. Stroke mortality in urban and rural Tanzania. Lancet. 2000;355: 1684–1687. 10.1016/s0140-6736(00)02240-6 [DOI] [PubMed] [Google Scholar]
  • 9.Dzudie A, Rayner B, Ojji D, Schutte AE, Twagirumukiza M, Damasceno A, et al. Roadmap to achieve 25% hypertension control in Africa by 2025. Cardiovasc J Afr. 2017;28: 262–273. 10.5830/CVJA-2017-040 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.WHO. NONCOMMUNICABLE DISEASES COUNTRY PROFILES 2018. Heart of Africa: Clinical Profile of an Evolving Burden of Heart Disease in Africa. 2016.
  • 11.Tefera YG, Abegaz TM, Abebe TB, Mekuria AB. The changing trend of cardiovascular disease and its clinical characteristics in Ethiopia: Hospital-based observational study. Vasc Health Risk Manag. 2017;13: 143–151. 10.2147/VHRM.S131259 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, et al. Global Ncd Target Reduce High Blood Pressure. Lancet. 2017;31: 190–215.1037//0033-2909.I26.1.78 [Google Scholar]
  • 13.Kibret KT, Mesfin YM. Prevalence of hypertension in Ethiopia: a systematic meta-analysis. Public Health Rev. 2015;36: 14 10.1186/s40985-015-0014-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Hoy D, Brooks P, Woolf A, Blyth F, March L, Bain C, et al. Assessing risk of bias in prevalence studies: Modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol. 2012;65: 934–939. 10.1016/j.jclinepi.2011.11.014 [DOI] [PubMed] [Google Scholar]
  • 15.DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7: 177–188. 10.1016/0197-2456(86)90046-2 [DOI] [PubMed] [Google Scholar]
  • 16.Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I 2 Index? Psychol Methods. 2006;11: 193–206. 10.1037/1082-989X.11.2.193 [DOI] [PubMed] [Google Scholar]
  • 17.Thompson SG, Smith TC, Sharp SJ. Investigating underlying risk as a source of heterogeneity in meta-analysis. Stat Med. 1997;16: 2741–2758. [DOI] [PubMed] [Google Scholar]
  • 18.Green S and H JP. Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Collaboration and John Wiley & Sons Ltd. Published; 2017. [Google Scholar]
  • 19.Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Br Med J. 1997;315: 629–634. 10.1136/bmj.315.7109.629 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Duval S, Tweedie R. A Nonparametric “Trim and Fill” Method of Accounting for Publication Bias in Meta-Analysis. J Am Stat Assoc. 2000;95: 89–98. 10.1080/01621459.2000.10473905 [DOI] [Google Scholar]
  • 21.Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6 10.1371/journal.pmed.1000097 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Kalssa Aschenaki, Ayele Gistane, Tamiso Alemu G T. Prevalence and Associated Factors of Hypertension among Civil Servants Working in Arba Minch Town, South Ethiopia. Int J Public Heal Sci. 2016;4: 375–383. 10.23880/mjccs-16000179 [DOI] [Google Scholar]
  • 23.Gebreyes YF, Goshu DY, Geletew TK, Argefa TG, Zemedu TG, Lemu KA, et al. Prevalence of high bloodpressure, hyperglycemia, dyslipidemia, metabolic syndrome and their determinants in Ethiopia: Evidences from the National NCDs STEPS Survey, 2015. PLoS One. 2018;13: 1–18. 10.1371/journal.pone.0194819 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Birlew T. Risk Factors for Hypertension among Adults. An Analysis of Survey Data on Chronic Non-Communicable Disease at Gilgel Gibe Field Research Center, South West Ethiopia. Sci J Public Heal. 2015;3: 281 10.11648/j.sjph.20150302.29 [DOI] [Google Scholar]
  • 25.Shukuri A, Tewelde T, Shaweno T. Prevalence of old age hypertension and associated factors among older adults in rural Ethiopia. Integr Blood Press Control. 2019;Volume 12: 23–31. 10.2147/IBPC.S212821 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Abebe SM, Berhane Y, Worku A, Getachew A. Prevalence and associated factors of hypertension: a crossectional community based study in northwest ethiopia. PLoS One. 2015;10: e0125210 10.1371/journal.pone.0125210 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Belachew A, Tewabe T, Miskir Y, Melese E, Wubet E, Alemu S, et al. Prevalence and associated factors of hypertension among adult patients in Felege-Hiwot Comprehensive Referral Hospitals, northwest, Ethiopia: a cross-sectional study. BMC Res Notes. 2018;11: 876 10.1186/s13104-018-3986-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Demisse AG, Greffie ES, Abebe SM, Bulti AB, Alemu S, Abebe B, et al. High burden of hypertension across the age groups among residents of Gondar city in Ethiopia: a population based cross sectional study. BMC Public Health. 2017;17: 647–649. 10.1186/s12889-017-4646-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Awoke A, Awoke T, Alemu S, Megabiaw B. Prevalence and associated factors of hypertension among adults in Gondar, Northwest Ethiopia: A community based cross-sectional study. BMC Cardiovasc Disord. 2012;12: 2–7. 10.1186/1471-2261-12-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Kiber M, Wube M, Temesgen H, Woyraw W, Belay YA. Prevalence of hypertension and its associated factors among adults in Debre Markos Town, Northwest Ethiopia: community based cross-sectional study. BMC Res Notes. 2019;12: 406 10.1186/s13104-019-4431-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Tadesse T, Alemu H. Hypertension and associated factors among university students in Gondar, Ethiopia: A cross-sectional study. BMC Public Health. 2014;14: 2–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Anteneh ZA, Yalew WA, Abitew DB. Prevalence and correlation of hypertension among adult population in Bahir Dar city, northwest Ethiopia: a community based cross-sectional study. Int J Gen Med. 2015;8: 175 10.2147/IJGM.S81513 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Kebede Gudina E, Michael Y, Assegid S. Prevalence of hypertension and its risk factors in southwest Ethiopia: A hospital-based cross-sectional survey. Integr Blood Press Control. 2013;6: 111–117. 10.2147/IBPC.S47298 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Asresahegn Asfaw H. Effect of Shift-Work on Hypertension Among Factory Workers in Ethiopia. Am J Clin Exp Med. 2015;3: 142 10.11648/j.ajcem.20150304.13 [DOI] [Google Scholar]
  • 35.Bissa S, Mossie A, Gobena T. Prevalence of Hypertension and Its Association with Substance Use among Adults Living in Jimma. World J Med Med Sci. 2014;2: 1–11. [Google Scholar]
  • 36.Bonsa F, Gudina EK, Hajito KW. Prevalence of hypertension and associated factors in Bedele Town, Southwest Ethiopia. Ethiop J Health Sci. 2014;24: 21–26. 10.4314/ejhs.v24i1.3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Muluneh AT, Haileamlak A, Tessema F, Alemseged F, Woldemichael K, Asefa M, et al. Population based survey of chronic non-communicable diseases at gilgel gibe field research center, southwest ethiopia. Ethiop J Health Sci. 2012;22: 7–18. [PMC free article] [PubMed] [Google Scholar]
  • 38.Negera Ebissa, Sileshi Tesfaye H RB. MAGNITUDE and ASSOCIATED FACTORS OF HYPERTENSION AMONG ADULTS IN ILLUBABORE ZONE OF OROMIA NATIONAL REGIONAL STATE, SOUTH WEST ETHIOPIA,2016/17. INDO Am J Pharm Sci. 2018;05: 11549–11555. [Google Scholar]
  • 39.Mara AM, Edris MM, Shikur A, Sintayew S. Magnitude of hypertension among adult residents in mizan-aman town, bench maji zone, Southwest Ethiopia–a descriptive cross-sectional study. MOJ Curr Res Rev. 2018;1: 148–152. 10.15406/mojcrr.2018.01.00023 [DOI] [Google Scholar]
  • 40.Esaiyas A, Teshome T, Kassa D. Prevalence of Hypertension and Associate Risk Factors among Workers at Hawassa University, Ethiopia: An Institution Based Cross Sectional Study. J Vasc Med Surg. 2018;6: 1–6. [Google Scholar]
  • 41.Asfaw LS, Ayanto SY, Gurmamo FL. Hypertension and its associated factors in Hosanna town, Southern Ethiopia: community based cross-sectional study. BMC Res Notes. 2018;11: 306 10.1186/s13104-018-3435-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Zekewos A, Egeno T, Loha E. The magnitude of hypertension and its risk factors in southern Ethiopia: A community based study. PLoS One. 2019;14: e0221726 10.1371/journal.pone.0221726 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Helelo TP, Gelaw YA, Adane AA. Prevalence and associated factors of hypertension among adults in durame town, Southern Ethiopia. PLoS One. 2014;9: 1–9. 10.1371/journal.pone.0112790 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Mengistu MD. Pattern of blood pressure distribution and prevalence of hypertension and prehypertension among adults in Northern Ethiopia: disclosing the hidden burden. BMC Cardiovasc Disord. 2014;14: 33 10.1186/1471-2261-14-33 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Gebrihet TA, Mesgna KH, Gebregiorgis YS, Kahsay AB, Weldehaweria NB, Weldu MG. Awareness, treatment, and control of hypertension is low among adults in Aksum town, northern Ethiopia: A sequential quantitative-qualitative study. PLoS One. 2017;12: 1–16. 10.1371/journal.pone.0176904 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Bayray A, Meles KG, Sibhatu Y. Magnitude and risk factors for hypertension among public servants in Tigray, Ethiopia: A cross-sectional study. PLoS One. 2018;13: e0204879 10.1371/journal.pone.0204879 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Zikru AB, Gebru HB, Kahsay AB. Prevalence and determinants of Hypertension among adult population in Mekelle city, Northern Ethiopia. Int J Innov Pharm Sci Res. 2014;2: 653–668. [Google Scholar]
  • 48.Asresahegn H, Tadesse F, Beyene E. Prevalence and associated factors of hypertension among adults in Ethiopia: a community based cross-sectional study. BMC Res Notes. 2017;10: 628–629. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Seifu W. Behavioral Risk Factors of Hypertension among Pastoral and Agro Pastoral Adult Communities, Eastern Ethiopia, Somali Regional State, 2016. J Trop Dis. 2017;5 10.4172/2329-891X.1000234 [DOI] [Google Scholar]
  • 50.Naba Tamene NO. Prevalence Of Hypertension And Associated Risk Factors Among Adult Population In Wolaita Sodo Town, Southern Ethiopia. Int J Med Res Pharm Sci. 2017;4: 96–105. 10.5281/zenodo.584031 [DOI] [Google Scholar]
  • 51.Bekele etabalew E, Tadesse T, Negaw R, Zewde T. Magnitude and associated factors of hypertension in Addis Ababa public health facilities, Ethiopia. MOJ Public Heal. 2018;7: 280–286. 10.15406/mojph.2018.07.00252 [DOI] [Google Scholar]
  • 52.Fikadu G, Lemma S. Socioeconomic Status and Hypertension among Teachers and Bankers in Addis Ababa, Ethiopia. Int J Hypertens. 2016;2016: 4143962–4143967. 10.1155/2016/4143962 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Nshisso LD, Reese A, Gelaye B, Lemma S, Berhane Y, Williams MA. Prevalence of hypertension and diabetes among Ethiopian adults. Diabetes Metab Syndr Clin Res Rev. 2012;6: 36–41. 10.1016/j.dsx.2012.05.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Abdissa SG, Feleke Y, Awol M. Prevalence of hypertension and pre-hypertension in Addis Ababa, Ethiopia: A survey done in recognition of World Hypertension Day, 2014. Ethiop J Heal Dev. 2015;29: 22–30. [Google Scholar]
  • 55.Angaw K, Dadi AF, Alene KA. Prevalence of hypertension among federal ministry civil servants in Addis Ababa, Ethiopia: a call for a workplace-screening program. BMC Cardiovasc Disord. 2015;15: 76 10.1186/s12872-015-0062-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Abebe S, Yallew WW. Prevalence of hypertension among adult outpatient clients in hospitals and its associated factors In Addis Ababa, Ethiopia: a hospital based cross-sectional study. BMC Res Notes. 2019;12: 1–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57.Berhanu Tolera Agama AA. Assessment of prevalence and associated factors of hypertension among outpatient attendants at health centers in Akaki Kality sub-city, Addis Ababa, Ethiopia. Addis Ababa University. 2017.
  • 58.Tesfaye F, Byass P, Wall S. Populationbased prevalence of high blood pressure among adults in Addis Ababa: Uncovering a silent epidemic. BMC Cardiovasc Disord. 2009;9 10.1186/1471-2261-9-39 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Roba HS, Beyene AS, Mengesha MM, Ayele BH. Prevalence of Hypertension and Associated Factors in Dire Dawa City, Eastern Ethiopia: A Community-Based Cross-Sectional Study. Int J Hypertens. 2019;2019: 9878437–9878439. 10.1155/2019/9878437 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Bygbjerg IC. Double burden of noncommunicable and infectious diseases in developing countries. Science. 2012. pp. 1499–1501. 10.1126/science.1223466 [DOI] [PubMed] [Google Scholar]
  • 61.Mohsen Ibrahim M. Hypertension in Developing Countries: A Major Challenge for the Future. Curr Hypertens Rep. 2018;20 10.1007/s11906-018-0839-1 [DOI] [PubMed] [Google Scholar]
  • 62.Meiqari L, Essink D, Wright P, Scheele F. Prevalence of Hypertension in Vietnam: A Systematic Review and Meta-Analysis. Asia-Pacific J Public Heal. 2019;31: 101–112. 10.1177/1010539518824810 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.De Ramirez SS, Enquobahrie DA, Nyadzi G, Mjungu D, Magombo F, Ramirez M, et al. Prevalence and correlates of hypertension: A cross-sectional study among rural populations in sub-Saharan Africa. J Hum Hypertens. 2010;24: 786–795. 10.1038/jhh.2010.14 [DOI] [PubMed] [Google Scholar]
  • 64.Joshi MD, Ayah R, Njau EK, Wanjiru R, Kayima JK, Njeru EK, et al. Prevalence of hypertension and associated cardiovascular risk factors in an urban slum in Nairobi, Kenya: A population-based survey. BMC Public Health. 2014;14: 1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Ataklte F, Erqou S, Kaptoge S, Taye B, Echouffo-Tcheugui JB, Kengne AP. Burden of undiagnosed hypertension in sub-saharan africa: A systematic review and meta-analysis. Hypertension. 2015;65: 291–298. 10.1161/HYPERTENSIONAHA.114.04394 [DOI] [PubMed] [Google Scholar]
  • 66.Bosu WK, Reilly ST, Aheto JMK, Zucchelli E. Hypertension in older adults in Africa: A systematic review and meta-analysis. PLoS One. 2019;14: 1–25. 10.1371/journal.pone.0214934 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 67.Sarki AM, Nduka CU, Stranges S, Kandala NB, Uthman OA. Prevalence of hypertension in low- and middle-income countries: A systematic review and meta-analysis. Med (United States). 2015;94: 1–16. 10.1097/MD.0000000000001959 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Adeloye D, Basquill C, Aderemi A V., Thompson JY, Obi FA. An estimate of the prevalence of hypertension in Nigeria: A systematic review and meta-analysis. J Hypertens. 2015;33: 230–242. 10.1097/HJH.0000000000000413 [DOI] [PubMed] [Google Scholar]
  • 69.Pyakurel P, Yadav DK, Thapa J, Thakur N, Sharma P, Koirala N, et al. Prevalence and associated risk factor of hypertension among individuals of age 18–59 years in South-eastern Nepal: A cross-sectional study. Nepal Hear J. 2019;16: 19–26. 10.3126/njh.v16i1.23894 [DOI] [Google Scholar]
  • 70.Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al. Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014;32: 1170–1177. 10.1097/HJH.0000000000000146 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 71.Shah N, Shah Q, Shah AJ. The burden and high prevalence of hypertension in Pakistani adolescents: A meta-analysis of the published studies. Arch Public Heal. 2018;76: 1–10. 10.1186/s13690-018-0265-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 72.Sanuade OA, Boatemaa S, Kushitor MK. Hypertension prevalence, awareness, treatment and control in Ghanaian population: Evidence from the Ghana demographic and health survey. PLoS One. 2018;13: 1–18. 10.1371/journal.pone.0205985 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 73.Allender S, Wickramasinghe K, Goldacre M, Matthews D, Katulanda P. Quantifying urbanization as a risk factor for noncommunicable disease. J Urban Heal. 2011;88: 906–918. 10.1007/s11524-011-9586-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 74.Htet AS, Bjertness MB, Sherpa LY, Kjøllesdal MK, Oo WM, Meyer HE, et al. Urban-rural differences in the prevalence of non-communicable diseases risk factors among 25–74 years old citizens in Yangon Region, Myanmar: A cross sectional study. BMC Public Health. 2016;16: 1–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 75.Goryakin Y, Rocco L, Suhrcke M. The contribution of urbanization to non-communicable diseases: Evidence from 173 countries from 1980 to 2008. Econ Hum Biol. 2017;26: 151–163. 10.1016/j.ehb.2017.03.004 [DOI] [PubMed] [Google Scholar]
  • 76.Allender S, Lacey B, Webster P, Rayner M, Deepa M, Scarborough P, et al. Level of urbanization and noncommunicable disease risk factors in Tamil Nadu, India. Bull World Health Organ. 2010;88: 297–304. 10.2471/BLT.09.065847 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 77.Jenei Z, Páll D, Katona É, Kakuk G, Polgár P. The epidemiology of hypertension and its associated risk factors in the city of Debrecen, Hungary. Public Health. 2002;116: 138–144. 10.1038/sj.ph.1900840 [DOI] [PubMed] [Google Scholar]
  • 78.Soubeiga JK, Millogo T, Bicaba BW, Doulougou B, Kouanda S. Prevalence and factors associated with hypertension in Burkina Faso: A countrywide cross-sectional study. BMC Public Health. 2017;17: 1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 79.Singh Shikha, Shankar Ravi and S GP. Prevalence and Associated Risk Factors of Hypertension: A Cross-Sectional Study in Urban Varanasi. Hinndawi. 2017;2017 10.1155/2017/5491838 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 80.Das Gupta R, Bin Zaman S, Wagle K, Crispen R, Hashan MR, Al Kibria GM. Factors associated with hypertension among adults in Nepal as per the Joint National Committee 7 and 2017 American College of Cardiology/American Heart Association hypertension guidelines: a cross-sectional analysis of the demographic and health survey 20. BMJ Open. 2019;9: e030206 10.1136/bmjopen-2019-030206 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 81.Wamala JF, Karyabakabo Z, Ndungutse D, Guwatudde D. Prevalence factors associated with hypertension in Rukungiri District, Uganda—A community-based study. Afr Health Sci. 2009;9: 153–160. [PMC free article] [PubMed] [Google Scholar]
  • 82.Houinato DS, Gbary AR, Houehanou YC, Djrolo F, Amoussou M, Segnon-Agueh J, et al. Prevalence of hypertension and associated risk factors in Benin. Rev Epidemiol Sante Publique. 2012;60: 95–102. 10.1016/j.respe.2011.09.010 [DOI] [PubMed] [Google Scholar]
  • 83.Kishore J, Gupta N, Kohli C, Kumar N. Prevalence of Hypertension and Determination of Its Risk Factors in Rural Delhi. Int J Hypertens. 2016;2016 10.1155/2016/7962595 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 84.Kannel WB, Vasan RS. Is Age Really a Non-Modifiable Cardiovascular Risk Factor? Am J Cardiol. 2009;104: 1307–1310. 10.1016/j.amjcard.2009.06.051 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 85.Oda E, Kawai R. Body mass index is more strongly associated with hypertension than waist circumference in apparently healthy Japanese men and women. Acta Diabetol. 2010;47: 309–313. 10.1007/s00592-010-0203-7 [DOI] [PubMed] [Google Scholar]
  • 86.Brown CD, Higgins M, Donato KA, Rohde FC, Garrison R, Obarzanek E, et al. Body Mass Index and the Prevalence of Hypertension and Dyslipidemia. Obes Res. 2000;8 10.1038/oby.2000.79 [DOI] [PubMed] [Google Scholar]
  • 87.Mega TA, Dabe NE. Khat (Catha Edulis) as a Risk Factor for Cardiovascular Disorders: Systematic Review and Meta-Analysis. Open Cardiovasc Med J. 2017;11: 146–155. 10.2174/1874192401711010146 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 88.Al-Motarreb A, Al-Habori M, Broadley KJ. Khat chewing, cardiovascular diseases and other internal medical problems: The current situation and directions for future research. J Ethnopharmacol. 2010;132: 540–548. 10.1016/j.jep.2010.07.001 [DOI] [PubMed] [Google Scholar]
  • 89.Getahun W, Gedif T, Tesfaye F. Regular Khat (Catha edulis) chewing is associated with elevated diastolic blood pressure among adults in Butajira, Ethiopia: A comparative study. BMC Public Health. 2010;10: 4–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 90.Birhane BW. The Effect of Khat (Catha edulis) Chewing on Blood Pressure among Male Adult Chewers, Bahir Dar, North West Ethiopia. Sci J Public Heal. 2014;2: 461 10.11648/j.sjph.20140205.23 [DOI] [Google Scholar]
  • 91.Patel NB. Mechanism of action of cathinone: The active ingredient of khat (Catha edulis). East Afr Med J. 2000;77: 329–332. 10.4314/eamj.v77i6.46651 [DOI] [PubMed] [Google Scholar]
  • 92.Brenneisen R, Fisch H, Koelbing U, Geisshusler S, Kalix P. Amphetamine-like effects in humans of the khat alkaloid cathinone. Br J Clin Pharmacol. 1990;30: 825–828. 10.1111/j.1365-2125.1990.tb05447.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 93.Balint EE, Falkay G, Balint GA. Khat—A controversial plant. Wien Klin Wochenschr. 2009;121: 604–614. 10.1007/s00508-009-1259-7 [DOI] [PubMed] [Google Scholar]
  • 94.Aladin A, Chevli P, Ahmad MI, Rasool S, Herrington D. Alcohol Consumption and Risk of Hypertension. J Am Coll Cardiol. 2019;73: 12 10.1016/s0735-1097(19)33774-x [DOI] [Google Scholar]
  • 95.Lang T, Degoulet P, Aime F, Devries C, Jacquinet-Salord MC, Fouriaud C. Relationship between alcohol consumption and hypertension prevalence and control in a French population. J Chronic Dis. 1987;40: 713–720. 10.1016/0021-9681(87)90108-1 [DOI] [PubMed] [Google Scholar]
  • 96.Saremi A, Hanson RL, Tulloch-Reid M, Williams DE, Knowler WC. Alcohol Consumption Predicts Hypertension but Not Diabetes. J Stud Alcohol. 2004;65: 184–190. 10.15288/jsa.2004.65.184 [DOI] [PubMed] [Google Scholar]
  • 97.Cushman WC. Alcohol Consumption and Hypertension. J Clin Hypertens. 2001;III 10.1111/j.1524-6175.2001.00443.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 98.Howes LG, Reid JL. The effects of alcohol on local, neural and humoral cardiovascular regulation. Clin Sci. 1986;71: 9–15. 10.1042/cs0710009 [DOI] [PubMed] [Google Scholar]
  • 99.Rodríguez-Moran M, Aradillas-García C, Simental-Mendia LE, Monreal-Escalante E, De La Cruz Mendoza E, Dávila Esqueda ME, et al. Family history of hypertension and cardiovascular risk factors in prepubertal children. Am J Hypertens. 2010;23: 299–304. 10.1038/ajh.2009.257 [DOI] [PubMed] [Google Scholar]
  • 100.Ranasinghe P, Cooray DN, Jayawardena R, Katulanda P. The influence of family history of Hypertension on disease prevalence and associated metabolic risk factors among Sri Lankan adults Chronic Disease epidemiology. BMC Public Health. 2015;15: 1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 101.Liu M, He Y, Jiang B, Wang J, Wu L, Wang Y, et al. Association between family history and hypertension among Chinese elderly. Med (United States). 2015;94: 1–6. 10.1097/MD.0000000000002226 [DOI] [PMC free article] [PubMed] [Google Scholar]

Decision Letter 0

R Jay Widmer

11 Jun 2020

PONE-D-19-34928

Prevalence and determinants of hypertension in Ethiopia. Systematic review and meta-analysis

PLOS ONE

Dear Dr. Tiruneh,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Multiple reviewers have made comments on this manuscript, and are interested in the theme. However, serious concerns have arisen, and each of these must be handled individually. Please indicate how each of these points have been addressed to improve the quality of the paper. 

==============================

Please submit your revised manuscript by Jul 26 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Jay Widmer

Academic Editor

PLOS ONE

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please upload a copy of Figure 1, to which you refer in your text on page 6. If the figure is no longer to be included as part of the submission please remove all reference to it within the text.

3. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

4. Please correct your reference to "p=0.000" to "p<0.001" or as similarly appropriate, as p values cannot equal zero.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Language:

Please have the paper read and corrected by native English. Currently, language needs to be reviewed

Introduction:

Hypertension is defined and diagnosed if the systolic blood pressure readings ≥ 140 mmHg and/or the diastolic blood pressure readings ≥ 90 mmHg (1,2)

• This definition with numbers is controversial (See AHA/ACC guidelines) and does not add anything in the introduction. Authors should either adopt a conceptual definition or cancel it. The introduction could simply start by acknowledging the magnitude of the problem

Methods

• Definition of hypertension with numbers comes back and is inappropriate for such a systematic review. Authors did not defined hypertension but instead relied on definition given across studies and the variation of these defintions should be presented in tables because it could affect the results/prevalence

• Inclusion criteria. Given the differences in methodology and the large time interval between the first and the latest study, the variation of the definition of hypertension across studies, the sampling method etc…it would have been more rigorous to add a criteria like a minimum sample size to reduce study bias. Should authors have considered sample size across studies, arbitrarily I would think a minimum sample size of 1000 would be advisable. Would the results be different? Currently 308 to 9788 with HT prevalence ranging from 9 to 41%. Heterogeneity handling alone cannot control all these bias.

Results section

This systematic review and meta-analysis include published articles on the prevalence and determinates of hypertension in Ethiopia. We used PubMed, Hinari, Google Scholar, and grey literature search to find potential studies for this systematic review and meta-analysis.

• Repetition of the aim and method, not necessary

Figures

Figure 1 not provided

Choose between 5 and 7

Don’t see the added value of 10 and 11

Titles: a figure beind a stand alone, titles should be comprehensive enough. Indicating year is not really informative here. Eg, figure 1 could read : Prevalence of hypertension among people with hypertension in Ethiopia. Blue boxes represent the effect estimates (prevalence) and the horizontal bars about are for the 95% confidence intervals (CIs). The size of the boxes is proportional to the inverse variance. The diamond is for the pooled effect estimate and 95% CI, and the plain red vertical line centered on the diamond has been added to assist visual interpretation. Effect estimates are provided as proportions.

Discussion

• This pooled prevalence is low when compared to continental (Ataklte F, et al. Burden of undiagnosed hypertension in sub-saharan Africa: a systematic review and meta-analysis. Hypertension 2015; 65: 291–98.) pooled prevalence and shall be discussed.

Limitations are several:

• Studying just the prevalence, not awareness and treatment to define a response strategy to hypertension burden would be limited, one really needs to know all these components to define a response

• Non comprehensive search strategy (language bias, Only English was consider) might not have traced all studies.

• Substantial heterogeneity across the studies, this has surely affected the pooled prevalence

• Differences in individual studies’ methodology and population structures

• Methods for assessing hypertension prevalence across studies. How could any of the study use a standardize method like the WHO-STEP???

• Information on the use of antihypertensive medications is crucial because it could have affected the 140/90.

• Did authors search for unpublished data to reduce publication bias?.

Referencing

• References selection is too comprehensive but not always pertinent. Authors should read references and select the best ones, not exceeding 50 references for such a paper

• A key paper in the field is not cited: Ataklte F, Erqou S, Kaptoge S, Taye B, Echou o-Tcheugui JB, Kengne AP. Burden of undiagnosed hypertension in sub-saharan Africa: a systematic review and meta-analysis. Hypertension 2015;

65: 291–98.

Reviewer #2: General comment

This systematic review and meta-analysis is interesting in view of a rising burden of hypertension in LMICs and increasing number of publications. The analysis was handled very well and results presented appropriately. However, the written part especially in the introduction and discussions is rather sloppy. A lot of this is due to language difficulties which I’m sure can be addressed by hiring a native English speaker to edit.

I have specific comments for each section as follows:

Introduction

Apart from the common grammatical errors; the presentation of the literature on the burden needs to be re-organized in paragraphs into four main themes.

1-The Big picture (Burden of hypertension)

2- The specific problem (Literature about hypertension systematic reviews in Ethiopia and what the burden is)

3- The GAP (need to show the missing information in previous systematic reviews) and how this one fills the gap.

4- How this review fills the gap. One obvious reason is updating the previous reviews (I found 2 of them all published in 2015) and also state what you do to handle the review differently.

In the current form the is a mix of literature and sometimes contradicting information from two sources is posted but not explained example

For example the articles cited below speak about the same thing but are not brought together in a coherent way.

“Approximately 970 million people worldwide have high blood pressure and 1.56 billion adults will be living with hypertension by 2025 (3)”

“Globally around 1.13 billion people live with hypertension, which is two-thirds of them from low and middle-income countries (5).”

The statement that no systematic reviews were available to the knowledge of the authors is not true. I came across two systematic reviews on hypertension in Ethiopia and no mention of these were made apart from one that appeared in the discussion. The authors need to be honest about the scientific premise and show what gaps were in the previous review to warrant their review. See below the two reviews I came across

1-Kibret, K. T., & Mesfin, Y. M. (2015). Prevalence of hypertension in Ethiopia: a systematic meta-analysis. Public Health Reviews, 36(1), 14

2- Molla, M. (2015). Systematic reviews of prevalence and associated factors of hypertension in Ethiopia: finding the evidence. Sci J Public Health, 3(4), 514-9.

Methods

Just checking on the sensitivity of the search criteria: a synonym for high blood pressure “raised blood pressure” should have been indicated in the search terms. It is possible some articles could have been missed if they only used this terminology.

Inclusion criteria

Why did you choose 2000 as the earliest year to limit your search? Please give the rationale for selecting articles from this year.

Quality assessment

The statement below is confusing. Please clarify

“Based on the score of the quality assessment tool the highest score from nine questions declared low risk of bias” this is not clear. This would mean the highest score had the minimum risk yet the proceeding statement says the opposite

Results

You are silent about grey literature in your reporting yet you did mention an attempt to search for this in the methods section. Pease clarify if any grey literature was found and how it was handled.

Discussion

In the discussion section, a good attempt is made to interpret the findings but the language makes it rather sloppy. Need to hire the services of a native English speaker for language edits.

The comment in the limitation section about social desirability of the study is erroneous. The phrase social desirability bias is not appropriately used. I do not think cross sectional studies lead to social desirability. This could as well happen in longitudinal studies.

“Social desirability bias refers to the tendency of research subjects to give socially desirable responses instead of choosing responses that are reflective of their true feelings. The bias in responses due to this personality trait becomes a major issue when the scope of the study involves socially sensitive issues such as politics, religion, and environment, or personal issues such as drug use, cheating, and smoking. This is usually resolved by use of a well‐trained interviewer or collection of data through methods that do not require presence involvement of an interviewer can help avoid this bias to some extent. Properly identified options to questions vulnerable to social desirability effect is another means of tackling this issue”

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachment

Submitted filename: Review_comments.docx

Click here for additional data file. (13.8KB, docx)
PLoS One. 2020 Dec 31;15(12):e0244642. doi: 10.1371/journal.pone.0244642.r002

Author response to Decision Letter 0

23 Jul 2020

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Noted, thank you! We had tried to make it fine according to PLOS One requirements.

2. Please upload a copy of Figure 1, to which you refer in your text on page 6. If the figure is no longer to be included aspart of the submission please remove all reference to it within the text.

Noted it was updated!

3. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Yes, updated accordingly.

4. Please correct your reference to "p=0.000" to "p<0.001" or as similarly appropriate, as p values cannot equal zero.

Noted, Thank you! It was updated according to the comment.

Reviewers' comments:

Reviewer #1: Language:

Please have the paper read and corrected by native English. Currently, language needs to be reviewed

Thank you! We had tried to correct the English language intensively by reading again and again.

Introduction:

Hypertension is defined and diagnosed if the systolic blood pressure readings ≥ 140 mmHg and/or the diastolic blood pressure readings ≥ 90 mmHg (1,2)

• This definition with numbers is controversial (See AHA/ACC guidelines) and does not add anything in the introduction. Authors should either adopt a conceptual definition or cancel it. The introduction could simply start by acknowledging the magnitude of the problem

Noted, Thank you! Accepted accordingly.

Methods

• Definition of hypertension with numbers comes back and is inappropriate for such a systematic review. Authors did not defined hypertension but instead relied on definition given across studies and the variation of these definitions should be presented in tables because it could affect the results/prevalence

Yes! Accepted accordingly.

• Inclusion criteria. Given the differences in methodology and the large time interval between the first and the latest study, the variation of the definition of hypertension across studies, the sampling method etc…it would have been more rigorous to add a criteria like a minimum sample size to reduce study bias. Should authors have considered sample size across studies, arbitrarily I would think a minimum sample size of 1000 would be advisable. Would the results be different? Currently 308 to 9788 with HT prevalence ranging from 9 to 41%. Heterogeneity handling alone cannot control all these bias.

Thank you for the comment. We had tried to handle the heterogeneity even with sample size category by a cut point greater than 500, 1000; But the heterogeneity still their; finally, we state as limitation of the study. Besides, to include studies sample size less than 1000 might be mandatory since the maximum sample size for prevalence studies is 384 at a proportion value 50%.

Results section

This systematic review and meta-analysis include published articles on the prevalence and determinates of hypertension in Ethiopia. We used PubMed, Hinari, Google Scholar, and grey literature search to find potential studies for this systematic review and meta-analysis.

• Repetition of the aim and method, not necessary

Thank you! corrected accordingly.

Figures

Figure 1 not provided

Thank you, corrected accordingly.

Choose between 5 and 7

Don’t see the added value of 10 and 11

Titles: a figure behind a standalone, titles should be comprehensive enough. Indicating year is not really informative here. Eg, figure 1 could read: Prevalence of hypertension among people with hypertension in Ethiopia. Blue boxes represent the effect estimates (prevalence) and the horizontal bars about are for the 95% confidence intervals (CIs). The size of the boxes is proportional to the inverse variance. The diamond is for the pooled effect estimate and 95% CI, and the plain red vertical line centered on the diamond has been added to assist visual interpretation. Effect estimates are provided as proportions.

Thank you! Corrected accordingly.

Discussion

o This pooled prevalence is low when compared to continental (Ataklte F, et al. Burden of undiagnosed hypertension in sub-saharan Africa: a systematic review and meta-analysis. Hypertension 2015; 65: 291–98.) pooled prevalence and shall be discussed.

Thank you! Corrected and cited.

Limitations are several:

o Studying just the prevalence, not awareness and treatment to define a response strategy to hypertension burden would be limited, one really needs to know all these components to define a response

o Non comprehensive search strategy (language bias, Only English was consider) might not have traced all studies.

o Substantial heterogeneity across the studies, this has surely affected the pooled prevalence

o Differences in individual studies’ methodology and population structures

o Methods for assessing hypertension prevalence across studies. How could any of the study use a standardize method like the WHO-STEP???

o Information on the use of antihypertensive medications is crucial because it could have affected the 140/90.

o Did authors search for unpublished data to reduce publication bias?

Noted, accepted thank you! We, act accordingly the comment.

Referencing

• References selection is too comprehensive but not always pertinent. Authors should read references and select the best ones, not exceeding 50 references for such a paper

• A key paper in the field is not cited: Ataklte F, Erqou S, Kaptoge S, Taye B, Echou o-Tcheugui JB, Kengne AP. Burden of undiagnosed hypertension in sub-saharan Africa: a systematic review and meta-analysis. Hypertension 2015; 65: 291–98.

Noted!

Reviewer #2: General comment

This systematic review and meta-analysis is interesting in view of a rising burden of hypertension in LMICs and increasing number of publications. The analysis was handled very well and results presented appropriately.

Noted, Thank you!

However, the written part especially in the introduction and discussions is rather sloppy. A lot of this is due to language difficulties which I’m sure can be addressed by hiring a native English speaker to edit.

Noted, we have read again and again to improve the quality of the English writing roblem, as well we had invited for English editors in our University.

I have specific comments for each section as follows:

Introduction

Apart from the common grammatical errors; the presentation of the literature on the burden needs to be re-organized in paragraphs into four main themes.

1. The Big picture (Burden of hypertension).

2. The specific problem (Literature about hypertension systematic reviews in Ethiopia and what the burden is)

3. The GAP (need to show the missing information in previous systematic reviews) and how this one fills the gap.

4. How this review fills the gap. One obvious reason is updating the previous reviews (I found 2 of them all published in 2015) and state what you do to handle the review differently.

Noted, thank you very much for this wonderful comment and it was updated accordingly.

In the current form the is a mix of literature and sometimes contradicting information from two sources is posted but not explained example

For example the articles cited below speak about the same thing but are not brought together in a coherent way. “Approximately 970 million people worldwide have high blood pressure and 1.56 billion adults will be living with hypertension by 2025 (3)”

“Globally around 1.13 billion people live with hypertension, which is two-thirds of them from low and middle-income countries (5).”

Noted, Thank you! Corrected accordingly.

The statement that no systematic reviews were available to the knowledge of the authors is not true. I came across two systematic reviews on hypertension in Ethiopia and no mention of these were made apart from one that appeared in the discussion. The authors need to be honest about the scientific premise and show what gaps were in the previous review to warrant their review. See below the two reviews I came across

1-Kibret, K. T., & Mesfin, Y. M. (2015). Prevalence of hypertension in Ethiopia: a systematic meta-analysis. Public Health

Reviews, 36(1), 14

2- Molla, M. (2015). Systematic reviews of prevalence and associated factors of hypertension in Ethiopia: finding the evidence. Sci J Public Health, 3(4), 514-9.

Noted, Thank you! Yes, there are two reviews by the year 2015. But these two reviews did not account factors that affect the pooled prevalence of hypertension, as well as 20 (52.60%) studies, had been published after 2016. Therefore, this review gives updated information for interventions.

Methods

Just checking on the sensitivity of the search criteria: a synonym for high blood pressure “raised blood pressure” should have been indicated in the search terms. It is possible some articles could have been missed if they only used this terminology.

Noted, thank you! The searching strategies was performed accordingly in the MeSH terms using the key terms of hypertension. Therefore, the synonym was performed accordingly the MeSH terms by hypertension.

Inclusion criteria

Why did you choose 2000 as the earliest year to limit your search? Please give the rationale for selecting articles from this year.

Noted, thank you! We interested updated information in the last two decades simply. As well as no relevant studies before 2009 for this review.

Quality assessment

The statement below is confusing. Please clarify

“Based on the score of the quality assessment tool the highest score from nine questions declared low risk of bias” this is not clear. This would mean the highest score had the minimum risk yet the proceeding statement says the opposite

Noted, and updated accordingly!

Results

You are silent about grey literature in your reporting yet you did mention an attempt to search for this in the methods section. Pease clarify if any grey literature was found and how it was handled.

Noted, Thank you! Yes, we had include one grey literature (Birhanu Tolera (58)) and it was extracted the same way as the other studies.

Discussion

In the discussion section, a good attempt is made to interpret the findings but the language makes it rather sloppy. Need to hire the services of a native English speaker for language edits.

Noted thank you corrected accordingly.

The comment in the limitation section about social desirability of the study is erroneous. The phrase social desirability bias is not appropriately used. I do not think cross sectional studies lead to social desirability. This could as well happen in longitudinal studies.

“Social desirability bias refers to the tendency of research subjects to give socially desirable responses instead of choosing responses that are reflective of their true feelings. The bias in responses due to this personality trait becomes a major issue when the scope of the study involves socially sensitive issues such as politics, religion, and environment, or personal issues such as drug use, cheating, and smoking. This is usually resolved by use of a well‐trained interviewer or collection of data through methods that do not require presence involvement of an interviewer can help avoid this bias to some extent. Properly identified options to questions vulnerable to social desirability effect is another means of tackling this issue”

Thank you very much for the detail elaboration. Yes, we are go through the limitation and correct according to the comment and that was account.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (27.4KB, docx)

Decision Letter 1

R Jay Widmer

13 Aug 2020

PONE-D-19-34928R1

Prevalence and determinants of hypertension in Ethiopia. Systematic review and meta-analysis

PLOS ONE

Dear Dr. Tiruneh,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 27 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Jay Widmer

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The language edits are not satisfactory. I doubt if the authors sought services of a native English speaker. I noted several grammatical errors. It appears to me more errors were introduced during the revisions. I have cited some of them here but this is not an exhaustive list. There will be need for a thorough check. I strongly recommend hiring a language editor.

Introduction

Lines 58-60- According to the World Health Organization (WHO) report in 2019, globally more than 1.13 billion people live with hypertension, of this two-thirds of them from Low and Middle-Income Countries (LMICs)

Lines 63-64. According to a systematic study, the overall pooled prevalence of hypertension in Africa raised from 19.7% in 1990, 27.4% in 2000 and 30.8% in 2010 [5].

Line 65: people live with hypertension and it will be projected 3 out of 4 people by the end of 2025

Lines 76-77: increment of non-communicable diseases will lead to greater dependency and rise the costs of health care for patients and their families unless public health interventions.

Line 82: Besides, more than half of the studies published after the previous study conducted.

Discussion

Line 305: Non-communicable disease was a double burden of public health problem in developing countries

Line 330: This finding was consistence with a study conducted in Nepal

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 Dec 31;15(12):e0244642. doi: 10.1371/journal.pone.0244642.r004

Author response to Decision Letter 1

15 Sep 2020

Response to Reviewers’

Prevalence and determinants of hypertension in Ethiopia: Systematic review and meta-analysis

Sofonyas Abebaw Tiruneh1, Yeaynmarnesh Asmare Bukayaw2, Seblewongel Tigabu Yigizaw2, Dessie Abebaw Angaw2

The authors, extend great thanks for the editors and reviewers as the stand of this review. The comments raised by the reviewers are vital and defiantly it will improve the quality of the manuscript.

Stay Safe!!!

The Authors.

Reviewer #2: The language edits are not satisfactory. I doubt if the authors sought services of a native English speaker. I noted several grammatical errors. It appears to me more errors were introduced during the revisions. I have cited some of them here but this is not an exhaustive list. There will be need for a thorough check. I strongly recommend hiring a language editor.

Introduction

Lines 58-60- According to the World Health Organization (WHO) report in 2019, globally more than 1.13 billion people live with hypertension, of this two-thirds of them from Low and Middle-Income Countries (LMICs)

Lines 63-64. According to a systematic study, the overall pooled prevalence of hypertension in Africa raised from 19.7% in 1990, 27.4% in 2000 and 30.8% in 2010 [5].

Line 65: people live with hypertension and it will be projected 3 out of 4 people by the end of 2025

Lines 76-77: increment of non-communicable diseases will lead to greater dependency and rise the costs of health care for patients and their families unless public health interventions.

Line 82: Besides, more than half of the studies published after the previous study conducted.

Discussion

Line 305: Non-communicable disease was a double burden of public health problem in developing countries

Line 330: This finding was consistence with a study conducted in Nepal

We noted all the concerns and we have tried to our maximum effort to improve the quality of English writing.

We also invited the English exert river in our institution.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (17.9KB, docx)

Decision Letter 2

R Jay Widmer

23 Sep 2020

PONE-D-19-34928R2

Prevalence and determinants of hypertension in Ethiopia. Systematic review and meta-analysis

PLOS ONE

Dear Dr. Tiruneh,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

The reviewers feel that the editorial changes were not satisfactory to merit publication. Particularly, the authors should pay particular attention to each and every sentence to be sure it has been properly proofed and vetted by a native English speaker for correct grammar and syntax. Without these changes we will be unable to publish this work that has some merit according to the reviewers and editorial staff. Please make these changes at your earliest convenience and resubmit. Thank you.

==============================

Please submit your revised manuscript by Nov 07 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Jay Widmer

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 Dec 31;15(12):e0244642. doi: 10.1371/journal.pone.0244642.r006

Author response to Decision Letter 2

20 Oct 2020

Editors request

The reviewers feel that the editorial changes were not satisfactory to merit publication. Particularly, the authors should pay particular attention to each and every sentence to be sure it has been properly proofed and vetted by a native English speaker for correct grammar and syntax. Without these changes we will be unable to publish this work that has some merit according to the reviewers and editorial staff. Please make these changes at your earliest convenience and resubmit.

Authors response

The authors, extend great thanks for the editors and reviewers as the stand of this review. The comments raised by the editors are valuable and defiantly it will improve the quality of the manuscript. We have addressed the English and grammar problems as per the editor request.

Since all authors are from low-income country, we cannot able to proofread the manuscript by fluent in English by payment especially native by English. But we have tried to improve the grammar and punctuation problems through read again and again. Besides, we had invited the manuscript for senior English editors at the University of Gondar and Debre Tabor University, Ethiopia. Those two English experts Lectures review our manuscript by free cost.

We hope that the English write up problem improves and will meet the minimum publication criteria of PLOS ONE journal. We look forwarding your excellent comments as usual.

The authors,

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (18KB, docx)

Decision Letter 3

R Jay Widmer

10 Nov 2020

PONE-D-19-34928R3

Prevalence and determinants of hypertension in Ethiopia. Systematic review and meta-analysis

PLOS ONE

Dear Dr. Tiruneh,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

The edits are not acceptable as written, and careful attention to correcting the text to ensure readability in the English language is required for further consideration for publication. 

==============================

Please submit your revised manuscript by Dec 25 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

R. Jay Widmer

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

The scientific merit has certainly been met, however the language simply is illegible by current English standards. This will be the authors final chance to amend the paper so that all grammatical mistakes are corrected and the paper flows in a smooth and readable fashion. For example the second sentence of the abstract reads, "A comprehensive electronic databases". There is a lack of subject/verb agreement, and this phrase is uninterpretable by the reader. Please make this final effort to correct the paper, and we look forward to a thoroughly reviewed next draft. Thank you for your attention to these details.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I very much appreciate the efforts to address all my comments. However,

1. You probably did not get my comment on the introduction, I would suggest you simply cancel the first sentence of the introduction, it is controversial and adds nothing.

2. The language edits are really far below what is acceptable. My suggestion would be that you have the paper read by a scientific writer.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 Dec 31;15(12):e0244642. doi: 10.1371/journal.pone.0244642.r008

Author response to Decision Letter 3

12 Dec 2020

Response Letter to editors and reviewers

Prevalence of hypertension and its determinants in Ethiopia: A systematic review and meta-analysis

Sofonyas Abebaw Tiruneh1*, Yeaynmarnesh Asmare Bukayaw2, Seblewongel Tigabu Yigizaw2, Dessie Abebaw Angaw2

We authors appreciate to the editors and reviewers for this manuscript as the position fourth review. The comments raised by the editors and reviewers are vital and defiantly it will improve the quality of the manuscript. We have addressed all the issues raised by the editors and reviewer's and believed that the revised version of the manuscript is satisfactory and will meet the minimum journal publication requirements. We have updated the manuscript accordingly.

Stay Safe!!!

The Authors.

Additional Editor Comments (if provided):

The scientific merit has certainly been met, however, the language simply is illegible by current English standards. This will be the authors final chance to amend the paper so that all grammatical mistakes are corrected and the paper flows in a smooth and readable fashion. For example the second sentence of the abstract reads, "A comprehensive electronic databases". There is a lack of subject/verb agreement, and this phrase is uninterpretable by the reader. Please make this final effort to correct the paper, and we look forward to a thoroughly reviewed next draft. Thank you

for your attention to these details.

Noted: Thank you! We have made our final attempt as our maximum effort.

Review Comments to the Author

Reviewer #1: I very much appreciate the efforts to address all my comments. However,

1. You probably did not get my comment on the introduction, I would suggest you simply cancel the first sentence of the introduction, it is controversial and adds nothing.

2. The language edits are really far below what is acceptable. My suggestion would be that you have the paper read by a scientific writer.

Noted thank you, We appreciate your comment and We had corrected in the recent version of the manuscript

Attachment

Submitted filename: Response Letter to Reviewer.R4.docx

Click here for additional data file. (16KB, docx)

Decision Letter 4

R Jay Widmer

15 Dec 2020

Prevalence of hypertension and its determinants in Ethiopia: A systematic review and meta-analysis

PONE-D-19-34928R4

Dear Dr. Tiruneh,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

R. Jay Widmer

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors are to be congratulated on this work and for such a well written manuscript.

Acceptance letter

R Jay Widmer

18 Dec 2020

PONE-D-19-34928R4

Prevalence of hypertension and its determinants in Ethiopia: A systematic review and meta-analysis

Dear Dr. Tiruneh:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. R. Jay Widmer

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Studies search strategies and entry terms from different electronic databases on the prevalence and determinants of hypertension.

    (DOCX)

    Click here for additional data file. (14.6KB, docx)
    S1 Fig. Sensitivity analysis plot for the pooled prevalence of hypertension.

    (TIF)

    Click here for additional data file. (1.2MB, tif)
    S2 Fig. Assessment of sensitivity analysis plot for factor sex.

    (TIF)

    Click here for additional data file. (326.9KB, tif)
    S3 Fig. Assessment of sensitivity analysis plot for the factor age.

    (TIF)

    Click here for additional data file. (315KB, tif)
    S4 Fig. Assessment of sensitivity analysis plot for factor among obese and/or overweight.

    (TIF)

    Click here for additional data file. (388.7KB, tif)
    S5 Fig. Assessment of sensitivity analysis plot for factor Khat Chewing.

    (TIF)

    Click here for additional data file. (306.5KB, tif)
    S6 Fig. Assessment of sensitivity analysis plot for factor alcohol consumption.

    (TIF)

    Click here for additional data file. (382.7KB, tif)
    S7 Fig. Assessment of sensitivity analysis plot for factor family history of hypertension.

    (TIF)

    Click here for additional data file. (312.6KB, tif)
    S8 Fig. Assessment of sensitivity analysis plot for factor alcohol consumption.

    (TIF)

    Click here for additional data file. (257.4KB, tif)
    S1 Checklist

    (DOC)

    Click here for additional data file. (63.5KB, doc)
    S1 File

    (XLSX)

    Click here for additional data file. (12.8KB, xlsx)
    Attachment

    Submitted filename: Review_comments.docx

    Click here for additional data file. (13.8KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (27.4KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (17.9KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (18KB, docx)
    Attachment

    Submitted filename: Response Letter to Reviewer.R4.docx

    Click here for additional data file. (16KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its Supporting information files.

    Articles from PLoS ONE are provided here courtesy of PLOS

    RESOURCES