Prevalence and Risk Factors of High Blood Pressure… E.Astutik, et al.

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ORIGINAL ARTICLE
Prevalence and Risk Factors of High Blood Pressure among Adults in
Banyuwangi Coastal Communities, Indonesia
Erni Astutik1*, Septa Indra Puspikawati2, Desak Made Sintha Kurnia Dewi3,
Ayik Mirayanti Mandagi4, Susy Katikana Sebayang3

OPEN ACCESS
Citation: Erni Astutik, Septa Indra ABSTRACT
Puspikawati, Desak Made Sintha Kurnia
Dewi, Ayik Mirayanti Mandagi, Susy BACKGROUND: Hypertension is a disease that still a problem in
Katikana Sebayang. Prevalence and Risk the world. Hypertension is a risk factor for heart disease and
Factors of High Blood Pressure among stroke mortality. Economic development and an emphasis on
Adults in Banyuwangi Coastal
Communities, Indonesia. Ethiop J coastal tourism may have an impact on public health conditions,
HealthSci. such as hypertension. This study aimed to determine risk factors
2020;30(6):941.doi:http://dx.doi.org/
10.4314/ejhs.v30i6.12
related to hypertension among adults in coastal communities in
Received: April 12, 2020 Indonesia.
Accepted: June 14, 2020 METHODS: This was a cross-sectional study of 123 respondents
Published: November 1, 2020
Copyright: © 2020 E. Astutik, et al. between the age of 18-59 years old selected by cluster sampling.
This is an open access article distributed This study was conducted among coastal communities in
under the terms of the Creative
Commons Attribution License, which
Banyuwangi District, East Java, Indonesia. Data was analyzed
permits unrestricted use, distribution, using multivariate logistic regression.
and reproduction in any medium, RESULTS: Our study showed that the prevalence of systolic and
provided the original author and source
are credited.
diastolic hypertension among residents of coastal communities
Funding: This study was funded by were as high as 33.33% and 31.71%, respectively. Increasing age
Universitas Airlangga, Surabaya, was associated with systolic and diastolic hypertension
Indonesia. Grant number
487/UN3.1.16/LT/2016 (ORsystolic=1.11; 95% CI=1.03-1.19, p=0.01 and ORdiastolic=1.07;
Competing Interests: The authors 95% CI=1.01-1.15, p=0.03) after controlling other variables.
declare that this manuscript was Respondents with the poorest and richer socio-economic status
approved by all authors in its form and
that no competing interest exists. had higher odds of having systolic and diastolic hypertension
Affiliation and Correspondence:
1
compared to respondents with the richest socio-economic status
Research Group for Health and
Wellbeing of Women and Children,
(ORsystolic-poorest =12.78; 95% CI=1.61-101.54, p=0.02; ORsystolic-
Department of Epidemiology, Faculty richer=10.74; 95% CI =1.55-74.37, p=0.02 and ORdiastolic-
of Public Health, Universitas poorest=10.36; 95% CI= 1.40-76.74, p=0.02;ORdiastolic-richer=6.45;
Airlangga, Surabaya, Indonesia
2
Research Group for Health and 95% CI=1.01-41.43, p=0.05) after controlling other variables.
Wellbeing of Women and Children, CONCLUSION: Being of older age and of the lower in
Department of Public Health socioeconomic status are significantly associated with increasing
Nutrition, Faculty of Public Health,
Universitas Airlangga, Banyuwangi risk for systolic and diastolic hypertension in these coastal
Campus, Indonesia
3
communities. More studies need to be done in these and other
Research Group for Health and
Wellbeing of Women and Children,
coastal village to help design appropriate health promotion and
Department of Biostatistics and counseling strategies for coastal community.
Population Studies, Faculty of Public KEYWORDS: Coastal community, Diastolic blood pressure,
Health, Universitas Airlangga,
Banyuwangi Campus, Indonesia Systolic blood pressure, Cardiovascular disease
4
Research Group of Tobacco Control,
Department of Epidemiology,
Universitas Airlangga, Faculty of
Public Health, Banyuwangi Campus,
Indonesia
*Email: [email protected]

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 942 Ethiop J Health Sci. Vol. 30, No. 6 November 2020

INTRODUCTION (Kampung Mandar, Ketapang, Grajagan,

Bangsring, Buluagung), East Java, Indonesia.
Globally, cardiovascular disease accounts for
Ethical permission was obtained from the
approximately 17 million deaths per year, of
Ethical Committee of the Faculty of Public
which 9.4 million deaths were due to
complications of hypertension (1). Hypertension Health, Universitas Airlangga in Surabaya.
Population and sampling: The study
is a risk factor for heart disease and stroke that is
population was communities living in 5 coastal
responsible for at least 45% of heart disease
villages, aged between 18-59 years. We used
mortality, and 51% of stroke mortality (1). The
cluster sampling methods with villages as
Indonesian Basic Health Research in 2018
clusters. There were 22 coastal villages of the
reported that the prevalence of hypertension in
52 villages in Banyuwangi District. Then, we
Indonesia was 34.1% of the total adult
selected 5 of the 22 coastal villages randomly
population, and in East Java Province, it was
for study location. After the cluster was selected,
13.5% (2). However, Banyuwangi, one of the
all mothers from the Family Welfare
districts in East Java Province, had a higher
Development Group and their husbands in the
prevalence of 33.3% in 2016 (3).
village were randomly selected (9). There were
Previous studies showed that the prevalence
156 respondents invited into the study, and 151
of hypertension tends to be higher in women, in
respondents agreed to participate (response
urban area, in those with low education and in
rate=96.8%). This sample size was sufficient to
those who are unemployed (4-6). Other studies
detect a 44% difference in the proportion of
found that there was a tendency of high
determinants of increased systolic and diastolic
incidence of hypertension in coastal
blood pressure with the confidence interval of
communities. The high prevalence of
95%, power of 90%, design effect of 2 and the
hypertension among coastal communities has
possibility of rejection of 25%.
previously been suggested to be due to high
Data collection: The data collected were
dietary salt consumed from salted dry fish, a
primary data. Structured questionnaires were
staple diet high in sodium and cholesterol (6-8).
filled in the village office after obtaining consent
The coastal communities of Banyuwangi
from the respondents. Data collection and
Regency are growing rapidly driven by
measurement of waist circumference were
economic development centered on coastal
conducted by trained data collectors consisting
tourism. This rapid pace of development may
of public health students. The data collectors
have a significant impact on the health
conditions such as obesity, diabetes and were trained by the researchers on interview
technique, questionnaires administration and
hypertension in the community. As happened in
measurement technique. They then underwent a
other regions in Indonesia and Asia, the
field testing in which the acceptability of the
prevalence of obesity, hypertension and diabetes
questionnaires and data collectors’ skills were
mellitus increases with the increase in the
assessed and errors were corrected. Waist
economy. The changing diet due to the need to
circumference was measured at respondents’
procure food for tourists may also cause an
navel using Medline non-stretchable measuring
increase in the prevalence of metabolic diseases
tape. Waist circumference was used to determine
such as hypertension in Banyuwangi. Hence,
abdominal obesity. Abdominal obesity was
this study aimed to determine the prevalence of
divided into yes (waist circumference ≥90 cm in
hypertension and the factors related to
men and ≥80 cm in women) and no (waist
hypertension among adult population living in
circumference <90 cm in men and <80 cm in
coastal communities of Banyuwangi District,
women) (10). Blood pressure measurements
East Java, Indonesia.
were taken by an experienced nurse. Systolic
METHODS and diastolic blood pressure were recorded as
the average of two measurements using blood
Study design: This is a cross-sectional study pressure monitor (Omron Hem-7130, Omron
conducted from September to November 2016 in Healthcare Co., Japan) while respondents were
5 coastal communities in Banyuwangi District

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 Prevalence and Risk Factors of High Blood Pressure… E. Astutik, et al. 943

sitting in constant ambient temperature. Weight Respondents scoring ≥ 6 were considered to

was measured using the same digital scale (Seca have high score and thus having mental
869, Seca Asia Pacific), and height was emotional problem. Respondents were
measured by stature meter (Seca 213, Seca Asia considered obese if their waist circumferences
Pacific). Systolic blood pressure was divided were ≥90 cm for males and ≥80 cm for females
into ≥140 mmHg (high) and < 140 mmHg (low) (26,27). Ethnicity consisted of Javanese, Madura
(11, 12). Diastolic blood pressure was divided and others (Osing, Bali, Sasak and Bugis).
into ≥90 mmHg (high) and < 90 mmHg (low) Statistical analysis: Data were analyzed using
(11,12). All tools were calibrated prior to multivariable logistic regression in STATA 14.
testing. The questionnaires were tested for Covariate variables that had a relationship with
validity and reliability in Kepatihan village, systolic and diastolic blood pressure with p-
Banyuwangi Sub-district, Banyuwangi, on 1 value of <0.25 were included in the initial
October 2016, and the test resulted in good multivariable analysis to allow for a possibility
validity and reliability with Cronbach alpha of that insignificant covariates in the univariable
0.72. analysis might become significant when adjusted
Data analysis: We analyzed data from by other variables. Backward method was used
respondents aged 18-59 years old. Covariates to select variables to be retained in the final
tested were age (13,14), sex (14,15), education model. Confounding assessment was done by
level (16), occupation (16), abdominal obesity reentering covariate variables into the model one
(16), Body Mass Index (BMI) (14,15,17,18), by one, starting from variables that have the
socio-economic status (15,19,20), mental- greatest p-value. If the difference in Odds Ratio
emotional status (21), family health history (14), (OR) of the factors between before and after the
smoking status (16), family member smoking covariate was included was greater than 10%,
status, ethnic group (17,22) and location (23). the variable was declared confounding and must
Age was defined as the last anniversary of the remain in the model.
respondent at the time of the study. Sex was Ethical clearance: The study was approved by
divided into male and female. The level of Ethics Committee, Universitas Airlangga,
education consisted of lower education (no Indonesia with a decision letter numbered 512-
schooling, no primary school and primary KEPK.
school), middle level education (high school)
and higher education (graduated from high RESULTS
school and college). Occupation level was Of the 151 participants who provided data, we
categorized as currently working or not; socio- excluded data from 16 respondents who were
economic status was categorized into equally older than 59 years. Of the 135 remaining
distributed quintiles (poorest, poorer, middle, observations, 14 were excluded from analysis
richer and richest) from wealth index derived due to incomplete information (2 observations
from Principal Component Analysis of had missing outcome data and 12 observations
household ownership of radio, goat, chicken and had missing covariate information). This
rice field (24). Smoking habits for both resulted in 123(81.46%) observations ready for
respondents and members of their household analysis.
were divided into smoking and not smoking. The mean age of respondents was 41.82
Respondents were considered to have family ±9.08 years, and the mean BMI was 27.28 ±6.67
health history if a member of their family had a kg/m2. There were 33.33% of respondents who
history of one of the following diseases: diabetes had systolic hypertension and 31.71% who had
mellitus, seizures, obesity, heart disease, diastolic hypertension. The majority of the
recurrent headache, stroke and high blood respondents were females (69.92%), had higher
pressure. Mental-emotional condition was education (54.47%), were employed (65.85%),
measured using Self-Reporting Questionnaire and married (97.56%). There were 96
(SRQ) consisting of 20 questions (25). respondents (78.05%) with abdominal obesity,

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 944 Ethiop J Health Sci. Vol. 30, No. 6 November 2020

and 72.36% had lower mental-emotional status. 83.74% of respondents did not smoke. The
In addition, 47.97% of the respondents had at majority of the respondents belonged to
least one family member who smoked while Javanese ethnicity (63.41%) (Table 1).
Table 1: Characteristics of respondents of the study
Variables N % or Mean±SD
Age 41.82±9.08
BMI (kg/m2) 27.28±6.67
Systolic Blood Pressure (mmHg) ≥140 41 33.33
<140 82 66.67
Diastolic Blood Pressure (mmHg) ≥90 39 31.71
<90 84 68.29
Sex Male 37 30.08
Female 86 69.92
Education Lower Education 26 21.14
Middle Education 30 24.39
Higher Education 67 54.47
Occupation Not working 42 34.15
Working 81 65.85
Abdominal obesity (cm) <90 for men or <80 for women 27 22.95
≥90 for men or ≥80 for women 96 78.05
Socio-economic status Poorest 23 18.70
Poorer 21 17.07
Middle 28 22.76
Richer 26 21.14
Richest 25 20.33
Married status Married 120 97.56
Died/divorce 3 2.44
Mental emotional status Low 89 72.36
High 34 27.64
Family history No 71 57.72
Yes 52 42.28
Family members smoking status No 64 52.03
Yes 59 47.97
Smoking status No 103 83.74
Yes 20 16.26
Ethnic group Javanese 78 63.41
Madura 36 29.27
Others 9 7.32
Location Kampung Mandar 19 15.45
Ketapang 24 19.51
Bangsring 28 22.76
Grajagan 30 24.39
Buluagung 22 17.89

Based on multivariable analysis, factors variables (Table 2: OR= 1.11; 95% CI = 1.03-
associated with both systolic and diastolic 1.19, p=0.01), while the odds of getting diastolic
hypertension were age and socio-economic hypertension increased 1.07 for every one-year
status after adjustment for abdominal obesity, increase in age after controlling for other
family history and location variables (Tables 2 variables (Table 3: OR= 1.07; 95% CI = 1.01-
and 3). The odds of getting systolic blood 1.15, p=0.03). Respondents belonging to the
hypertension increased 1.11 for every one-year poorest socio-economic status had 12.78 times
increase in age after controlling for other greater odds of getting systolic hypertension

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 Prevalence and Risk Factors of High Blood Pressure… E. Astutik, et al. 945

compared to the richest socio-economic status had 10.74 times greater odds of getting systolic
after controlling for other variables (Table hypertension compared to the richest socio-
2:ORsystolic= 12.78; 95% CI = 1.61-101.54, economic status after controlling for other
p=0.02). Respondents whose socio-economic variables (Table 2: ORsystolic= 10.74; 95% CI =
status was the poorest had nearly 10.36 times 1.55-74.37, p=0.02). Respondents whose socio-
greater odds for obtaining diastolic hypertension economic status was the richer had nearly 6.45
compared to respondents from the richest times greater odds for obtaining diastolic
quintile after controlling for other variables hypertension compared to respondents from the
(Table 3: ORdiastolic= 10.36; 95% CI = 1.40- richest quintile after controlling for other
76.74, p=0.02). In addition, respondents variables (Table 3:ORdiastolic= 6.45; 95% CI =
belonging to the richer socio-economic status 1.01-41.43, p=0.05).
Table 2: Factors related to systolic blood pressure
Univariate (N=123 ) Multivariate (N=123 )
Variables a 95% CI P b 95% CI P
OR AOR
Lower Upper Value Lower Upper Value
Age 1.14 1.07 1.21 0.00 1.11 1.03 1.19 0.01
BMI
1.01 0.96 1.07 0.73
(kg/m2)
Sex Male Ref
Female 1.06 0.47 2.41 0.89
Education Lower Education Ref
level Middle Education 1.17 0.45 3.03 0.75
Higher Education 1.13 0.31 4.07 0.86
Occupation Not working Ref
Working 1.39 0.62 3.13 0.42
Abdominal <90 for men or <80
Ref Ref
obesity for women
(cm) ≥90 for men or ≥80 3.61 1.15 11.26 0.03 2.51 1.61 11.83 0.24
for women
Socio- Richest Ref Ref
economic Richer 11.45 2.24 59.09 0.00 10.74 1.55 74.37 0.02
status Middle 3.83 0.72 20.55 0.12 3.36 0.46 24.31 0.23
Poorer 3.59 0.62 20.87 0.15 3.76 0.44 32.21 0.23
Poorest 17.89 3.37 95.03 0.00 12.78 1.61 101.54 0.02
Mental Low Ref
emotional High 0.42 0.16 1.07 0.07
status
Family Yes Ref Ref
history
1.95 0.89 4.29 0.10 2.43 0.88 6.75 0.09
No
Family No Ref
members
smoking Yes 0.67 0.32 1.44 0.31
status
Smoking No Ref
status Yes 0.62 0.21 1.85 0.39
Location Kampung Mandar Ref Ref
Ketapang 0.35 0.10 1.22 0.10 0.55 0.12 2.54 0.45
Bangsring 0.05 0.01 0.25 0.01 0.09 0.01 0.69 0.02
Grajagan 0.29 0.09 0.97 0.09 0.33 0.07 1.59 0.17
Buluagung 0.33 0.09 1.19 0.09 0.68 0.13 3.59 0.65
Ethnic Javanese Ref

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 946 Ethiop J Health Sci. Vol. 30, No. 6 November 2020

group
Madura 0.46 0.18 1.13 0.09
Others 0.80 0.19 3.44 0.76
a
Odds Ratio, bAdjusted Odds Ratio

Table 3: Factors related to diastolic blood pressure

Variables Univariate (N=123 ) Multivariate (N=123 )
a 95% CI P b 95% CI P
OR AOR
Lower Upper Value Lower Upper Value
Age 1.11 1.05 1.19 0.00 1.07 1.01 1.15 0.03
BMI (kg/m2) 0.99 0.93 1.05 0.78
Sex Male Ref
Female 0.80 0.35 1.81 0.59
Education Lower Education Ref
Middle Education 0.82 0.32 2.11 0.69
Higher Education 0.94 0.27 3.36 0.93
Occupation Not working Ref
Working 2.16 0.91 5.12 0.08
Abdominal <90 for men or <80 Ref Ref
obesity (cm) for women
≥90 for men or ≥80 3.30 1.05 10.32 0.04 1.95 0.49 7.76 0.34
for women
Socio- Richest Ref Ref
economic Richer 8.43 1.63 43.52 0.01 6.45 1.01 41.43 0.05
status Middle 5.45 1.05 28.32 0.04 5.44 0.82 35.94 0.08
Poorer 3.59 0.61 20.88 0.15 3.73 0.48 28.81 0.21
Poorest 12.55 2.38 66.01 0.00 10.36 1.40 76.74 0.02
Mental Low Ref
emotional High 0.58 0.23 1.42 0.23
status
Family Yes Ref Ref
history No 2.05 0.92 4.57 0.08 2.33 0.91 5.98 0.08
Family No Ref
members Yes 0.90 0.42 1.92 0.78
smoking
status
Smoking No Ref
status Yes 0.68 0.23 2.02 0.48
Location Kampung Mandar Ref Ref
Ketapang 0.67 0.20 2.26 0.52 1.17 0.28 4.94 0.83
Bangsring 0.09 0.02 0.47 0.00 0.24 0.03 1.62 0.14
Grajagan 0.64 0.20 2.07 0.46 1.01 0.23 4.47 1.00
Buluagung 0.63 0.18 2.22 0.48 1.56 0.31 7.73 0.59
Ethnic group Javanese Ref
Madura 0.41 0.16 1.05 0.06
Others 0.84 0.20 3.64 0.82
a
Odds Ratio, bAdjusted Odds Ratio

DISCUSSION
Our study found that the prevalence of systolic
and diastolic hypertension among coastal
communities in Banyuwangi District was high at
33.33% and 31.71%, respectively. The final
model of multiple logistic regression showed

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 Prevalence and Risk Factors of High Blood Pressure… E. Astutik, et al. 947

that older age and lower socioeconomic status The strength of this study was that we
were the determinants of higher systolic and assessed various determinants, including
diastolic blood pressure levels after controlling demographic factors, socioeconomic factors,
for other variables. Older people had greater individual lifestyles, smoking factors in the
odds of having higher systolic and diastolic family, ethnicity and family health history.
hypertension compared to younger ones. Those Studies regarding systolic and diastolic
of the lower socioeconomic status had greater hypertension specifically those focusing on
odds of having higher systolic and diastolic coastal areas are limited. Hence, this study will
hypertension compared to those of the highest add to the current limited pool of data on the
socioeconomic status. topic. Together with the results for increased
Our results on coastal communities reflect blood glucose level (34), this study can provide
similar findings from another study conducted in information on metabolic syndrome in coastal
rural community in Indonesia that showed communities. The coastal communities in our
people of older age had greater risk of study locations comprised mostly people of
hypertension compared to younger ones (13). Javanese and Maduranese ethnic groups. Our
This study found that people aged 40 years or results may be generalized for other coastal
older had greater risk of developing communities in Indonesia with similar ethnic
hypertension compared to those aged 17-39 profile. However, further studies are needed to
years, and the risk was most prominent among cover other coastal communities with other
the age group of 55-59 years (13). Other studies ethnic profiles.
also reported an increase in prevalence of The limitation of this study is its cross-
hypertension as age increased (4, 28-30). Due to sectional design which does not permit
structural changes that comes with aging, arterial assumption for causality of risk factors with
wall loses its flexibility and becomes stiffer. outcome (temporal ambiguity). Another
Consequently, systolic and diastolic blood limitation perhaps is the small sample size,
pressure increases due to reduce pulsatility of although only 81.46% observation ready for
the arterial wall (31). analysis is considered good. In addition, waist
A research conducted in low- and middle- circumference was measured at respondents’
income countries found that higher incomes, navel which might have underestimated the true
household assets or social class were positively waist circumference in this population (35).
associated with hypertension in South Asia, but The prevalence of hypertension among
in East Asia and Africa, no associations were coastal communities in Banyuwangi was high.
detected (20). Our results are also in line with Factors related to systolic and diastolic
other studies showing that lower socioeconomic hypertension in these coastal communities were
status was associated with high blood pressure older age and lower socioeconomic status. Our
(15,32). Modifiable socio-economic factors, finding implies the need for promotion of
such as education and employment, were also healthy lifestyle that would reduce the risk of
associated with hypertension. This is in line hypertension, such as healthy diet and improved
with the fact that the final stages of the physical activities among coastal communities.
epidemiological transition, the burden of chronic There is currently a national program in
diseases including hypertension shifts from the Indonesia for the management of chronic disease
higher socioeconomic groups to the lower called Prolanis, which help monitor and ensure
socioeconomic groups (15,33). This may be continuous treatment for chronic disease at the
because awareness of prevention and disease community health centres. The government of
control was better in groups with higher socio- Indonesia can optimize the program by
economic status. In addition, people from the integrating it with hamlet level health posts
higher socioeconomic status had better access to available widely in Indonesia for maternal and
healthcare. child health services. Hamlet level service will
improve health care and health information

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 948 Ethiop J Health Sci. Vol. 30, No. 6 November 2020

access of the elderly, especially those from low Cross-Sectional Survey. Jurnal Ners . 2017;
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