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Akuiyiboetal. BMC Public Health (2022) 22:715
https://doi.org/10.1186/s12889-022-13139-3
RESEARCH
Eects ofbehaviour change communication
onhypertension anddiabetes related
knowledge, attitude andpractices inImo
andKaduna States: aquasi-experimental study
Selema Akuiyibo, Jennifer Anyanti, Babatunde Amoo*, Dennis Aizobu and Omokhudu Idogho
Abstract
Background: Behaviour change communication is a proven health communication strategy among used in promot-
ing changes in knowledge, attitudes, beliefs, and behaviours’, especially for communicable diseases. Few studies have
been conducted on its effectiveness for non-communicable diseases prevention and control. This study was con-
ducted as an evaluation assessment for a non-communicable disease focused intervention implemented in Imo and
Kaduna States, Nigeria.
Methods: A twelve-month long strategic behaviour change communication intervention on hypertension and
diabetes was implemented in selected communities across Imo and Kaduna States, Nigeria. This study adopted a
quasi-experimental design approach among adult residents aged at least 35 years to assess the effectiveness of the
intervention. Data was collected at baseline (prior to implementation of the interventions) and at the endline; among
study and control groups. A uniform study tool was used to collect information on awareness & lifestyle related factors
for Hypertension & Diabetes.
Results: The awareness of hypertension was 98.9% among the respondents in the study group compared to 94.4%
among the baseline respondents (χ2 = 20.276, p < 0.001). The history of blood pressure check was recorded among
86.8% of the study group compared to 79.0% of the baseline group (χ2 = 20.27, p < 0.001). In the last 6 months prior
to the study, 71.9% of the study group compared to 30.6% of the baseline group (χ2 = 243.34, p = 0.002) had blood
glucose check at least once. Daily alcohol consumers make up 36.8% of the baseline respondents, compared to 22.6%
in the study group (χ2 = 33.84, p < 0.001) and 30.6% of those in the control group compared to the 22.6% of the study
group (χ2 = 9.23, p = 0.002). The mean (± SD) knowledge score on hypertension and diabetes was 18.12 (± 8.36)
among the study group compared to 11.84 (± 6.90) among the baseline group (t = 15.29, p < 0.001), and compared to
10.97 (± 8.79) among the control group (t = 13.08, p < 0.001).
Conclusion: Significant changes in lifestyle practices, knowledge of hypertension and diabetes and risk perception
was observed following the implementation of community-based behaviour change communication interventions.
There is a need to increased access to health education and promotion interventions for non-communicable diseases.
Keywords: Hypertension, Behaviour change communication, Diabetes, Health promotion
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Open Access
*Correspondence: bamoo@sfhnigeria.org; amoobabatundey@gmail.com
Society for Family Health, Abuja, Nigeria
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Akuiyiboetal. BMC Public Health (2022) 22:715
Background
Cardiovascular diseases (CVDs) arethe leading cause of
deaths globally; responsible for almost 18 million deaths
every year [1]. People with hypertension and diabetes
have been identified, to be at high cardiovascular risk.
Hypertension alone accounts for about half of global
CVD morbidity and mortality [2]. By 2025, it is estimated
that a third of the world population will be hyperten-
sive, with increasing prevalence in developing nations
[3]. Between 2019 and 2020, more than 100 million new
persons were estimated to develop diabetes [4]. Although
the prevalence of both hypertension and diabetes are
higher among the older population, reports have shown
increasing risk among younger age group [4, 5]. In Nige-
ria, the prevalence of hypertension ranges between 27 to
38% among adult populations [6, 7] while around 4% are
estimated to be diabetic with higher diabetes prevalence
reported in some regions [8, 9].
Generally, four major behavioural risk factors con-
tribute significantly to the high risk of hypertension
and diabetes among populations. ey include lifestyle
related practices such as tobacco use, unhealthy diet
and obesity, physical inactivity, and harmful use of alco-
hol. Knowledge of these risk factors is important in pro-
moting the adopting of positive lifestyle practices. For
instance, lifestyle modification has been reported to
have the potential to reduce the risk of diabetes by as
high as 70% [10]. In addition, early detection of hyper-
tension and diabetes through routine screening prac-
tices, counselling and adequate medication adherence
among already diagnosed individuals are also effective
strategies in preventing and controlling blood glucose
and pressure levels respectively [11, 12]
Misconceptions and poor knowledge about hyperten-
sion and diabetes still exists among Nigerians [13–16].
Also, the prevalence of unhealthy lifestyle practices in
the country are high; 25% of Nigerians are not physically
active, 13% practice harmful alcohol consumption and 6%
of the population are cigarette smokers [17], with higher
proportions reported in a study conducted in the eastern
part of the country [18]. Behaviour change communica-
tion (BCC) is a strategic and integrated communication
process involving a mix of advocacy and social mobili-
sation to influence and sustain changes in social norms,
attitude, values, knowledge and behaviours across differ-
ent levels in the society such as the individual, household,
community and national levels. Specifically, BCC has
been proven to be an effective intervention in preventing
and reducing the risk of communicable diseases such as
Malaria, HIV/AIDS and Covid-19 [19–23].
Since the risk factors for hypertension and diabetes
include unhealthy lifestyle practices, BCC could be an
effective strategy to improve knowledge and facilitate
attitudinal and behavioural change among individuals in
typical Nigerian communities. Only a few studies have
documented the effectiveness of BCC interventions in
the prevention, control and management of NCDs such
as hypertension and diabetes. In this study, we analysed
the effectiveness of an eight-month long BCC interven-
tion in selected communities of the Access-N project of
Society for Family Health across Imo and Kaduna States.
Findings from this study may provide an evidence-base
for the role of BCC in non-communicable diseases pro-
gramming and inform decision-making for community
level strategies towards reducing the risk of such diseases.
Methods
Study area
Imo and Kaduna States are in the south-eastern and
north-western regions of Nigeria, respectively. e two
states have an estimated population of 13.6 million inhab-
itants in 2016. Kaduna State is made up of 23 administra-
tive units referred to as local government areas (LGAs)
and Imo State, on the other hand, consists of 27 LGAs.
According to the National Health Facility Registry, there
are 1,197 health facilities in Imo State 43% of which are
privately owned. However, only about 23% of the 1419
health facilities in Kaduna State are owned by private
individuals.
In 2020, Society for Family Health implemented the
“Improving Access to Non-communicable diseases”
(Access-N) project over a twelve-month period. Access-
N Project focused on providing strategic behaviour
change communication intervention which aims to
empower communities to make informed and healthy
choices, increase disease knowledge, improve care seek-
ing behaviour, and facilitate access and linkage to avail-
able treatment options, products and services working in
the private and public health sectors for two key NCDs
namely – cardiovascular disease (hypertension) and type
2 diabetes in Imo and Kaduna States of Nigeria. e pro-
ject covered a total of fourteen (14) Local Government
areas (LGAs), seven (7) LGAs, in each of the implement-
ing states. In Imo state, Owerri North, Aboh Mbaise,
Obowo, Oru West, Oguta, Njaba and Ngor Okpala LGAs
were reached with Access-N interventions while in
Kaduna state, Kaduna North, Kaduna South, Sabon Gari,
Igabi, Zaria, Chikun and Kachia LGAs were reached.
The intervention
Access-N intervention empowered communities with
hypertension and diabetes information, the information
on determinants of these conditions, prevention infor-
mation and available treatment options. e project
employed an innovative and integrated demand genera-
tion approach in selected communities in the two States
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Akuiyiboetal. BMC Public Health (2022) 22:715
through Interpersonal Communication Agents (IPCAs)
trained to penetrate communities and create awareness,
increase knowledge and facilitate better understanding of
the promoted NCDs (hypertension and diabetes). In each
state, IPCAs conducted behaviour change communica-
tions through one-on-one, group and outreach sessions,
to address myths and misconceptions and barriers such
as low risk perceptions that hinder desired behaviour
change related to hypertension and diabetes risks. Con-
tacts with perceived risks were referred for further edu-
cation and diagnoses at selected health facilities within
the communities.
e trained agents point individuals to service deliv-
ery points where treatment services and products can be
accessed. ey also conducted outreaches in these com-
munities to increase uptake of services and products.
Outreaches were conducted at least once a month in each
of the seven implementing LGAs. e activities during
the outreaches included awareness creation, education
and sensitization, health talk, screening of community
members for blood glucose and blood pressure and refer-
rals to the nearest health facility. e primary aim of the
outreach was to increase disease awareness as well as
increase demand for NCD services at health facilities.
Study design
e study adopted a quasi-experimental design approach
among randomly selected adult residents aged at least
35years in selected Access-N implementing communi-
ties and control communities in Imo and Kaduna states.
e study was conducted at baseline prior to implemen-
tation of Access-N interventions and at the end of the
project intervention. In addition, a control group which
comprised of individuals resident in communities which
were not covered by the Access-N project and who were
not exposed to the project’s interventions, was included
in the study. e inclusion of the control group was to
adjust for the effect of time and exposure to hypertension
and diabetes information through other sources asides
the Access-N interventions between the baseline and
endline assessment periods. e findings from the base-
line survey has earlier been independently published [13].
Study population
e study was conducted among adult residents aged at
least 35years in selected communities of the seven (7)
implementing LGAs in Imo and Kaduna States prior to
the implementation of the project interventions (referred
to as baseline group). Eight months following the wrap
up of the Access-N project interventions, an endline
assessment of the interventions was conducted in the
project communities among residents who were exposed
to any of the project interventions over the course of
implementation (referred to as study or endline group)
and also among individuals who were resident in com-
munities other than the those reached by the project
interventions but are within the implementing LGAs of
the project (referred to as Control group).
Inclusion criteria
Imo and Kaduna states resident aged 35years and above
from whom informed consent was obtained and who are
willing to participate in the study.
Sample size estimation
e minimum sample size for this study was calculated
as follows:
Where N is the sample size, Z is the level of significance
that corresponds to the 95% confidence level which is
1.96, p is the prevalence of hypertension in Nigeria, and d
is the tolerance error (0.05). e awareness rate of hyper-
tension among adults 18years and above in Nigeria is
17.4% [6].
N = 1.962 × 0.174 × 0.826 / 0.052.
N = 220.85.
Adjusting for a 10% Non-response rate.
Nnew = n / (1 – 0.10).
= 220.85 / 0.9
= 245.4 ≈ 246.
Sample size is therefore estimated as 246 in each state.
us, the estimated minimum sample size is 492 for
both states at each phase of data collection.
Sampling technique
At baseline and end line, the selection of community resi-
dents was done using multi-stage sampling method as
described below:
Stage 1: Selection ofprimary sampling unit (PSU)
For this study, the fourteen (14) Access-N LGAs, seven
(7) from each state were used as the Primary Sampling
Units. e selected LGAs for this survey are as follows;
In Imo state; Owerri North, Aboh Mbaise, Ngor Okpala,
Oru West, Obowo, Oguta, and Njaba while in Kaduna
State they include, Kaduna North, Kaduna South, Sabon
Gari, Zaria, Igabi, Chikun and Kachia LGAs.
Stage 2: Selection ofcatchment area
A catchment area is defined as an area in the PSU (LGA)
where the project’s intervention was implemented. e
project adopted a hub and spoke model for participating
health facilities where a hub was a facility that can pro-
vide comprehensive hypertension and type 2 diabetes
N
=
(Z)
2
p(1−p
)
d
2
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Akuiyiboetal. BMC Public Health (2022) 22:715
services and a spoke was a lower cadre facility that could
provide screening services and facilitate referrals to the
hubs.
As designed by the Access-N project team, each LGA
was made up of a maximum of 5 partner facilities (1 hub
and 4 spokes) already identified and selected by the pro-
ject team. e hub was in a central location surrounded
by spokes within 5km distance of the hub. Communities,
dwelling structures around these facilities make up the
catchment area for this study.
Stage 3: Selection ofdwelling structure/households
e Access-N participating facilities were identified
as the starting point in each LGA. A direction (North,
South, West, or East) of the starting point was randomly
selected and data collection took place in that direction
until the last house on that street was reached and then
data collection continued in the next street until the tar-
get sample size in the catchment area of the LGA was
met.
e day’s code was used to determine the first dwell-
ing structure to begin with. A dwelling structure is a dis-
tinct floor of a residential building. Hence a single storied
building comprised of two dwelling structures while a
bungalow contains a single dwelling structure.
e first dwelling structure was selected using the day’s
code method (the summation of the digits of the day’s
date to get a single digit e.g. on the first day of the month,
the day code is 01, 0 + 1 = 1, the first house). e corre-
sponding house will be the first dwelling structure where
an interview will be conducted. If the structure has more
than one household (a group of people who usually live
together), the household to begin from was randomly
selected by balloting.
Every fifth house was visited in a low-density area
and ten buildings in a densely populated area to ensure
wide coverage of the catchment area. Once a successful
call (interview) was made, the interviewer left the entire
dwelling structure completely and observed the required
sampling gap. is meant that, only one household in a
dwelling structure was selected and one respondent in a
household, no matter the size of the dwelling structure.
is was because the households were homogenous in
nature and also to ensure wider spread of interviews in
each catchment area and PSU.
Stage 4: Selection ofrespondents
Not more than two eligible respondents (male or female
aged 35 years and above) were randomly interviewed
depending on the population density of a household
except in a clustered location. While no gender quotas
were set, calls were alternated between males and female
to prevent a skew towards any gender.
In a clustered location, such as a marketplace or
a restaurant/bar, 10% of the total estimated popula-
tion of eligible respondents was randomly selected and
interviewed.
Study tool
A uniform study tool was used among the three groups
interviewed in this study. Data was collected using
self-administered, semi-structured questionnaires and
through personal interview for respondents that are not
literate. e questionnaires were designed in English lan-
guage for ease of administration for literate respondents
or interpreted to the respondent’s indigenous language
and completed with the aid of the interviewer for those
who were not able to complete it by themselves. e
knowledge, awareness and lifestyle related factors for
hypertension and diabetes questions were adapted from
WHO STEPS survey tool [24].
e questionnaire was divided into four broad sec-
tions which included: A) Background Characteristics of
respondent, B) Awareness, Lifestyle-related & screening
practices for Hypertension & Diabetes C) Awareness of
risk factors, complication and prevention measures for
hypertension and diabetes and D) Medication Adher-
ence among Hypertension and Diabetes patients. Sec-
tion B included questions on smoking practices, alcohol
consumption, exercising, fruits & added salt consump-
tion and screening for blood pressure and blood glucose.
In section C, the respondents were asked to identify the
risk factors, possible complications, and the measures for
preventing raised blood glucose and pressure levels while
for section D, the respondents who have been previously
diagnosed for hypertension and diabetes were asked
about their medication adherence for their prescribed
anti-hypertensive and anti-diabetic medications.
Data management andanalysis
Questionnaires were checked for errors or omissions at
the end of each day and data was subsequently entered
and stored in a password secured computer to ensure
confidentiality. Following review of the data, only indi-
viduals with adequate responses to the questions in the
study tool were included in the analysis (hence the differ-
ence in sample size across the study groups). SPSS ver-
sion 20.0 was used for the analysis of the data collected.
e frequency distribution and proportions of all the var-
iables in the broad sections listed above were determined
across study groups. Chi-square test was used to com-
pare proportions and investigate statistical significance
between the baseline and study groups, and the study and
control groups for attitude and practices related ques-
tions while an independent T-test was used to compare
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Akuiyiboetal. BMC Public Health (2022) 22:715
the difference in knowledge across the groups. P-values
less than 0.05 were considered as statistically significant.
e respondents who knew the meaning of hyper-
tension and/or diabetes were classified as being aware
of either or both two conditions while those who had
checked their blood pressure and/or blood glucose lev-
els were regarded to have a history of check for either
or both conditions. Correct responses to the each of the
items in Section D of the study tool were assigned a score
of 1 while incorrect responses were assigned a score of 0.
In total, the maximum obtainable score for hypertension
knowledge was 17 as there were six items on hyperten-
sion risk factors, six items on hypertension prevention
measures and five items on hypertension complications.
On the other hand, the maximum obtainable score for
diabetes knowledge was 18 as there were six question
each on diabetes risk factors, prevention measure and
complications.
Ethical approval
Ethical approval was obtained from the Institutional
Review Board of the Nigerian Institute of Medical
Research (Protocol No: IRB/20/015). Participation was
voluntary after each respondent had received detailed
information on the purpose of the study and a written
informed consent was obtained before questionnaires
were administered. In addition, informed consent was
obtained from a legal guardian for involved illiterate par-
ticipants in the study.
Results
A total of 824 respondents were included in the baseline
group while 624 and 500 respondents were included in
the study and control groups, respectively. Among the
baseline, study and control groups, comparable propor-
tions of the respondents were distributed across charac-
teristics. More females and younger respondents were
in each group. Married individuals, Christians and those
with a secondary education level were spread across the
baseline, study and control groups as shown in Table1.
Awareness andscreening prole forhypertension
anddiabetes
e awareness of hypertension was 98.9% among the
respondents in the study group compared to 94.4%
among the baseline respondents (χ2 = 20.27, p < 0.001).
Among the control group, 84.8% were aware of hyperten-
sion while only 81.6% of them had ever heard of diabetes
(χ2 = 81.60, p-value < 0.001) as shown in Table2. Aware-
ness of diabetes was 90.5% among the baseline group
compared to 97.1% in the endline group (χ2 = 25.22,
p < 0.001). Also, the history of blood pressure check was
recorded among 86.8% of the study group compared to
79.0% of the baseline group (χ2 = 14.95, p < 0.001). In the
last 6months prior to the study, 452 (71.9%) of the study
group compared to 252 (30.6%) of the baseline group
(χ2 = 243.34, p < 0.001) had blood glucose check at least
once.
Hypertension anddiabetes related risk andprevention
practices
Daily alcohol consumers were 303 (36.8%) among the
baseline respondents, compared to 142 (22.6%) in the
Table 1 Background characteristics of respondents
Variable Baseline (%) Study
group (%) Control (%)
Age (Years)
35 – 44 44.5 33.4 36.2
45 – 54 29.1 29.7 28.0
55 – 64 17.2 23.1 20.4
65 & above 9.1 13.8 15.4
Gender
Male 49.2 42.9 47.2
Female 50.8 57.1 52.8
State of Residence
Imo 57.2 53.1 55.4
Kaduna 42.8 46.9 44.6
Marital Status
Single 10.6 8.1 10.0
Married 79.0 78.7 75.2
Divorced 2.1 1.1 1.4
Widowed 7.9 10.5 11.0
Separated 0.5 1.6 2.4
Religion
Christianity 67.8 53.1 60.6
Islam 31.6 39.3 34.0
Others 0.6 7.6 5.4
Highest level of Education
No Education 10.6 11.3 14.8
Primary 19.1 16.9 18.6
Secondary 38.8 46.9 41.6
Tertiary 29.4 25.0 25.0
Qur’anic school 2.2 0.0 0.0
Employment Status
Unemployed 15.2 27.7 25.0
Employed 84.3 72.3 75.0
Average Monthly Income (Naira)
Below N50,000 67.2 74.7 72.2
N50,000—< N100,000 27.4 22.7 26.2
N100,000—< N200,000 4.6 2.1 1.6
N200,000 & Above 0.7 0.5 0.0
TOTA L 824 629 500
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Akuiyiboetal. BMC Public Health (2022) 22:715
study group (χ2 = 33.82, p < 0.001) and 152 (30.6%) of
those in the control group compared to 142 respond-
ents in the endline group (χ2 = 9.23, p = 0.022). Among
the study respondents, daily exercisers made up 73.2%
compared to 74.2% of the baseline respondents (χ2 = 0.18,
p = 0.672) while 64.2% of the control groups were daily
exercisers (Table3). Daily fruit consumers were 7.9% in
the baseline group compared to 20.8% in the study group
(χ2 = 51.17, p < 0.001) and 15.2% in the control group
compared to the study group (χ2 = 5.89, p = 0.015).
Knowledge ofrisk factors, complications andpreventive
measures forhypertension anddiabetes
e mean knowledge score (± SD) on hypertension
risk factors was 3.18 (± 1.82) among the study group
compared to 1.85 (± 1.41) among the baseline group
(t = 15.13, p-value < 0.001) and compared to a mean
score of 1.90 (± 1.85) among the control group (t = 11.66,
p-value < 0.001) (Table 4). Similarly, the mean knowl-
edge score on diabetes complication was 2.85 (± 1.68)
among the study group compared to 2.12 (± 1.55) among
the baseline group (t = 8.54, p = 0.001) and compared to
a mean score of 1.80 (± 1.55) among the control group
(t = 10.94, p < 0.001). e overall mean knowledge score
for hypertension and diabetes was 18.12 (± 8.36) among
the study group compared to 11.84 (± 6.90) among
the baseline group (t = 15.29, p < 0.001) and compared
to 10.97 (± 8.79) among the control group (t = 13.08,
p < 0.001).
Medication Adherence amongHypertension andDiabetes
Patients
Among persons diagnosed with hypertension, 80.4% in
the endline group compared to 76.5% in the baseline and
56.9% in the control groups respectively adhere to their
medication as prescribed by a healthcare provider. On
the other hand, 76.5% of persons diagnosed with diabetes
in the endline group compared to 80.0% in the baseline
and 75.0% in the control groups adhere to their diabetes
medication (Fig.1).
Discussion
e Access-N project’s BCC strategy was designed
based on the health belief model, socio-cognitive and
the diffusion of innovation theories. Our findings gen-
erally showed that the awareness of both hypertension
and diabetes were significantly higher among the study
group compared to both baseline and control groups. As
observed in this study (especially among the baseline and
control groups), and in other studies, the level of hyper-
tension and diabetes awareness in Nigeria is quite high. In
spite of this, the BCC strategy adopted by the Access-N
Table 2 Awareness and screening profile for hypertension and diabetes
* p-value1—showing Chi-square test (χ2) comparison signicance between baseline and endline groups
* p-value2—showing Chi-square test (χ2) comparison signicance between endline and control groups
Variable Baseline group (%) Study group (%) χ2 (p-value1) Study group (%) Control group (%) χ2 (p-value2)
Awareness of hypertension 778 (94.4) 622 (98.9) 20.27 (< 0.001) 622 (98.9) 424 (84.8) 81.60 (< 0.001)
Awareness of diabetes 746 (90.5) 611 (97.1) 25.22 (< 0.001) 611 (97.1) 408 (81.9) 76.36 (< 0.001)
History of blood pressure check 651 (79.0) 546 (86.8) 14.95 (< 0.001) 546 (86.8) 365 (73.0) 34.07 (< 0.001)
History of blood glucose check 471 (57.2) 538 (85.5) 135. 32 (< 0.001) 538 (85.5) 389 (77.8) 11.34 (0.001)
Last blood pressure check within
6 months 458 (55.6) 499 (79.3) 89.49 (< 0.001) 499 (79.3) 261 (52.2) 93.21 (< 0.001)
Last blood glucose check within
6 months 252 (30.6) 452 (71.9) 243. 34 (< 0.001) 452 (71.9) 338 (68.4) 2.27 (0.132)
Table 3 Hypertension and diabetes related risk and prevention practices
* p-value1—showing Chi-square test (χ2) comparison signicance between baseline and endline groups
* p-value2—showing Chi-square test (χ2) comparison signicance between endline and control groups
Variable Baseline group (%) Study group (%) χ2 (p-value1) Endline (%) Control (%) χ2 (p-value2)
Daily alcohol consumers 303 (36.8) 142 (22.6) 33.84 (< 0.001) 142 (22.6) 152 (30.6) 9.23 (0.002)
Daily smokers 66 (8.0) 39 (6.2) 1.74 (0.187) 39 (6.2) 58 (11.6) 10.4 (0.001)
Daily exercisers 611 (74.2) 458 (73.2) 0.18 (0.672) 458 (73.2) 319 (64.2) 10.48 (0.001)
Daily fruit consumers 65 (7.9) 131 (20.8) 51.17 (< 0.001) 131 (20.8) 76 (15.2) 5.89 (0.015)
Occasional consumers of
food with added salt 174 (21.1) 98 (15.6) 7.19 (0.007) 98 (15.6) 497 (28.6) 27.51 (< 0.001)
Page 7 of 9
Akuiyiboetal. BMC Public Health (2022) 22:715
project further contributed to a notable increase in the
level of hypertension and diabetes awareness among the
study group. Health education in the form of awareness
creation for hypertension and diabetes has proven to
improve screening service uptake [25]. Similarly in this
study, the observed higher awareness of both conditions
among the study groups could also be attributed to the
increase in the proportion of the respondents who have
a history of blood pressure or glucose check in the study
group compared to the other groups.
e health belief model theory posits that the self-
perceived threat or susceptibility to a health risk will
motivate adoption of positive preventative action [26].
rough the BCC strategies of the Access-N project, per-
sons reached by the project were able to properly assess
the health implications of some of their lifestyle practices
that could predispose them to risks of developing high
blood pressure and/or high glucose levels. is further
led to the gradual adoption of positive lifestyle behaviour
such as increased fruit intake and reduced negative prac-
tices such as daily alcohol intake, smoking, etc., observed
among the intervention group. Decreases in exercising
could be attributed to the COVID19 pandemic which
could have reduced the frequency and numbers of out-
door activities in the study locations due to social dis-
tancing measures. Also, decreases in fruit intakes could
be attributed to lack of purchasing power as a result of
inflation which worsened because of the COVID-19 pan-
demic. Although, the goal of public health transcends the
initiation of positive behaviours alone, it further seeks to
Table 4 Respondents knowledge ofr factors, complications and preventive measures for hypertension and diabetes
Score Baseline
group
Mean ± SD
Study group Mean ± SD T-test (p-value1) Study group Mean ± SD Control
group
Mean ± SD
T-test (p-value2)
Hypertension risk factors 1.85 ± 1.41 3.18 ± 1.82 15.13 (< 0.001) 3.18 ± 1.82 1.90 ± 1.85 11.66 (< 0.001)
Diabetes risk factors 1.52 ± 1.18 2.82 ± 1.80 15.77 (< 0.001) 2.82 ± 1.80 1.62 ± 1.71 11.43 (< 0.001)
Hypertension complica-
tions 2.03 ± 1.24 2.49 ± 1.41 6.45 (0.001) 2.49 ± 1.41 1.68 ± 1.27 10.08 (< 0.001)
Diabetes complications 2.12 ± 1.55 2.85 ± 1.68 8.54 (< 0.001) 2.85 ± 1.68 1.80 ± 1.55 10.94 (< 0.001)
Hypertension prevention
and management 2.36 ± 1.62 3.46 ± 1.82 12.00 (< 0.001) 3.46 ± 1.82 2.07 ± 1.82 12.84 (< 0.001)
Diabetes prevention and
management 1.95 ± 1.40 3.31 ± 1.62 16.64 (< 0.001) 3.31 ± 1.62 2.02 ± 1.59 13.41 (< 0.001)
Total Hypertension and
Diabetes Knowledge
Score
11.84 ± 6.90 18.12 ± 8.36 15.29 (< 0.001) 18.12 ± 8.36 10.97 ± 8.79 13.08 (< 0.001)
Fig. 1 Medication Adherence among Persons diagnosed with Hypertension and Diabetes
Page 8 of 9
Akuiyiboetal. BMC Public Health (2022) 22:715
maintain such behaviours. e initiation of these behav-
iours within this short period of implementing Access-
N intervention shows the potentials for self-efficacy and
further suggests that a continued exposure to BCC inter-
vention would be helpful in ensuring that such behav-
iours are maintained.
At the core of the Access-N BCC strategy is health edu-
cation on hypertension and diabetes risk factors, preven-
tive measures, and complications. Research has shown
that health education intervention on hypertension-
related knowledge is effective in improving knowledge
about the condition and influencing adoption of self-care
practices [27]. In this study, we observed also remarkable
increase in hypertension knowledge (as high as 30% for
diabetes risk factors) among the study group when com-
pared to the other groups. Whilst knowledge may not
be sufficient to result in behaviour change, it is a criti-
cal component in motivating behaviour change. Change
in behaviour is better assured if health education targets
personal relevance [28]. e adopted BCC strategy by the
Access-N did not only aimed to improve knowledge, it
also focused on personal risks and likely complications
that could result from hypertension and diabetes. us,
the increased knowledge observed among the study
group could be further attributed to the increased adop-
tion of some positive behaviours observed in this study.
Behaviours are formed as a result of interactions
between individual characteristics, and other social,
political and economic factors. us, a holistic approach
is required in driving behaviour change [29, 30]. In this
study, we observed that among the hypertension and
diabetes patients, BCC was not significantly effective in
fostering medication adherence, especially among the
diabetes patients. Other non-knowledge related fac-
tors such as perceived feeling of wellness, high cost of
prescribed medications, perceived medication efficacy,
could be responsible for non-medication adherence [31].
In choosing the right intervention for addressing non-
adherence, there is a need to understand major causal
factors. is will assist in designing motivations for
adherence using appropriate behaviour change model or
product design interventions.
Study limitations
Our study is not without limitations. The respond-
ents across groups, (specifically the baseline and study
groups) were not matched and had different sample
sizes. Thus, confounding variables might have con-
tributed to some of the changes observed in this study.
However, we ensured that the distribution of char-
acteristics among the respondents across groups are
very similar. Also, a control group was not included
during the baseline assessment. The inclusion of a
baseline control group would have better explained
comparisons and attributions of the observed changes
to the intervention. However, we independently made
comparisons between the study and both the baseline
and the control groups, respectively in order to adjust
for the effect of any other exposure that could be
responsible for the outcomes assessed. Despite these
shortcomings, we believe that the findings from this
study are valid and could be useful to make recom-
mendations for hypertension and diabetes prevention
and control.
Conclusions
Strategic behaviour change communication was found
to be quite effective in promoting the adopting of posi-
tive lifestyle practices essential for hypertension and
diabetes control. In addition, significant improvement
in knowledge was also observed as a result of the inter-
vention. In order to reduce the burden of hyperten-
sion and diabetes in the population, there is a need to
increase and improve access to quality information on
hypertension and diabetes prevention, treatment and
control among adults through a mix of cost-effective
community-based health promotion strategies.
Acknowledgements
The authors wish to acknowledge the efforts of the Access-N project team
members whose contributions were critical to the success of the project.
Authors’ contributions
SA, JA and OI conceived the study. SA, BA and DA initiated the study design
while SA, JA and DA helped with implementation. BA provided statistical
expertise in conducting the primary statistical analysis. SA and BA drafted the
manuscript. All authors contributed to refinement of the study protocol and
approved the final manuscript.
Funding
This study was fully funded by the authors’ affiliated organisation.
Availability of data and materials
All available data can be obtained by contacting the corresponding author.
Access to anonymised data may be granted following review.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of
Helsinki and approved by the Nigerian Institute of Medical Research (NIMR)
Institutional Review Board (Protocol No: IRB/20/015, Date: 16th March 2020).
Participation was voluntary after each respondent had received detailed
information on the purpose of the study and a written informed consent was
obtained before questionnaires were administered. In addition, informed
consent was obtained from a legal guardian for involved illiterate participants
in the study.
Consent for publication
Informed consent, detailing proposed publication of the study findings, was
obtained from all the respondents involved in the study.
Competing interests
The authors declare no competing interests.
Page 9 of 9
Akuiyiboetal. BMC Public Health (2022) 22:715
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