Patterns of Non-Communicable Disease, Multimorbidity, and Population Awareness in Bahir Dar, Northwest Ethiopia: A Cross-Sectional Study

Figures & data

Figure 1 Study household sampling and recruitment flow chart.

Table 1 Independent Variables and Measurements

Categories	Variables
Demographic	Age, sex (male, female), and marital status (single, married, and others including living together but not married, separated/divorced, or widowed).
Socioeconomic status	Educational status: no formal education, primary school (grade 1 to 8), secondary school (grade 9 to 12), college (certificate or diploma), and tertiary (degree and above) Occupational status: house duties, government employee, private organization employee, merchant, manual workers (daily, factory, building, garment, garage), driver, agriculture, unemployed, and others to be mentioned. For interpretation and analysis, the occupational status of adults was classified into three groups: securely employed, insecure job, and unemployed. Income: The average monthly income of participants were collected and classified into three groups based on the country’s minimum salary rate: very low (less than 2250 Ethiopian birr), low to middle (2251 to 5000), and middle income (5001 and above) Health care affordability: The health care affordability of participants was assessed by participants’ “yes” or “no” response to the question, “Can you afford to see a health care provider?”
Family history	Family history of NCDs such as CVD, diabetes, cancer, chronic respiratory diseases, hypertension, and chronic kidney diseases was collected by a self-report question: “Does your family member have any of the above-mentioned chronic diseases”? A participant was recorded as having a family history of chronic diseases if they responded “yes” to at least one of the above-mentioned chronic diseases.
Dietary habits	Dietary habits of adults were assessed by collecting the daily intakes of: Fruit/vegetable: Adequate fruit/vegetable intake was assessed by the daily consumption of any fruit (like banana, mango, avocado, apple, orange, and pineapple) or vegetable (like green leafy vegetables, papaya, tomato, cauliflower, cabbage, and beans) for five or more servings per day.^Citation42 Salt intake: This was assessed by interviewing participants; how often did they add salt when cooking or eating meals or drinks? If they replied as always, it was classified as daily salt intake. Sweet and sugary foods (any sugar, honey, or jam) intake was assessed by interviewing participants about whether they consume these food groups daily.
Physical activity	Physical activity was measured based on the adult’s weekly physical activity status. Performing at least 75 minutes of vigorous physical activity or 150 minutes of moderate-intensity physical activity classified the participants as physically active.^Citation43
Alcohol consumption, tobacco use, and khat chewing	These risk behaviours were collected and categorised into three categories: former user (refers to participants who have used these products in the past but not currently), current use (refers to participants who have used these products within the past 30 days prior to the survey), and non-user (refers to participants who have never used these products).^Citation42,Citation44–46
Individual risk factor score	The presence of each tobacco use, alcohol consumption, diet (fruits/vegetable intake), physical inactivity, and khat chewing received a score of “1” and the absence a score “0”. The sum of each individual risk factor score was used to describe “low” to “high” individual risk factor score on a continuum scale of 0 to 5 to compare the prevalence of NCD between low and high individual risk factor scores.
Wellbeing	Adults’ level of wellbeing was assessed by using the WHO wellbeing scale. We assessed participants level of wellbeing in the past two weeks before the survey. The scale consists of five questions to be rated from 1 to 5. The total response scores were categorized into three groups (low, average, and high) to compare NCDs prevalence variations between adults with low and high wellbeing values.^Citation47
Anthropometricmeasurements	Adult’s weight, height, and hip/waist circumference were measured in this study: Weight: Participants’ weight was measured using standardised portable weight scales and collected in kilograms (kg) to the nearest decimal point (example 73.1 kg). Height: the height of participants was measured using fixed, non-bending wooden meters. Participants were instructed to take off their shoes and stand upright while the occiput, shoulder, buttock, and heels touching the wall. Height measures were recorded in centimeters (cm). Waist/hip circumference: These were measured using non-stretchable meters at the midpoint of the end of ribs and iliac crest for waist circumference and at the largest part of the buttock for hip circumference.^Citation48 Values were recorded in cm.
Overweight/obesity	Overweight/obesity: We computed the body mass index of adults by dividing weight (kg) by height square in meters (m^2), and values between 25–29.9 kg/m^2 classify an adult as overweight and ≥30 as obese.^Citation49 Abdominal obesity: This was assessed by calculating the ratio of waist circumference (cm) to hip circumference (cm), and values were categorized by using the WHO cut of points: ≥0.85 for females and ≥0.90 for males.^Citation50

Table 2 Sociodemographic Characteristics of Participants, Individual Risk Factors, and Non-Communicable Disease

Variables	Variable Category	Total n (%)	Number of Non-Communicable Diseases^§			P-value
			0	1	2^+
Age	18–40	312 (74.8)	236 (84.6)	36 (11.5)	12 (3.8)	<0.01
	41–55	53 (12.7)	36 (67.9)	13 (24.5)	4 (7.5)
	56+	52 (12.5)	17 (32.7)	18 (34.6)	17 (32.7)
Gender	Male	189 (45.3)	136 (72.0)	36 (19.0)	17 (9.0)	0.20
	Female	228 (54.7)	181 (79.4)	31 (13.6)	16 (7.0)
Marital status	Married	235 (56.4)	175 (74.5)	42 (17.9)	18 (7.7)	<0.01
	Others	47 (11.3)	26 (55.3)	12 (25.5)	9 (19.1)
	Single	135 (32.4)	116 (85.9)	13 (9.6)	6 (4.4)
Education	Primary or lower	94 (22.5)	56 (59.6)	23 (24.5)	15 (16.0)	<0.01
	Secondary	96 (23.0)	79 (82.3)	15 (15.6)	2 (2.1)
	Post-secondary^╪	227 (54.5)	182 (80.2)	29 (12.8)	16 (7.1)
Occupation	Securely employed†	137 (32.9)	104 (75.9)	25 (18.2)	8 (5.8)	0.76
	Unemployed	121 (29.0)	93 (76.9)	17 (14.0)	11 (9.1)
	Insecure jobs^‡	159 (38.1)	120 (75.5)	25 (15.7)	14 (8.8)
Income (ETB)	Less than 2250	53 (13.7)	39 (73.6)	10 (18.9)	4 (7.5)	0.76
	2251–5000	126 (32.6)	99 (78.6)	16 (12.7)	11 (8.7)
	5001 and above	208 (53.9)	153 (73.6)	37 (17.8)	18 (8.7)
Health care affordability^₴	Yes	266 (63.8)	212 (79.7)	39 (14.7)	15 (5.6)	0.03
	No	151 (36.2)	105 (69.5)	28 (18.5)	18 (11.9)
Family history	Yes	166 (39.8)	91 (54.8)	45 (27.1)	30 (18.1)	<0.01
	No	251 (60.2)	226 (90.0)	22 (8.8)	3 (1.2)
Fruits/vegetables intake	Adequate	18 (4.3)	14 (77.8)	3 (16.7)	1 (5.6)	-
	Inadequate	399 (95.7)	303 (75.9)	64 (16.0)	32 (8.0)
Salt intake (daily)	Yes	366 (87.8)	283 (77.3)	60 (16.4)	23 (6.3)	<0.01
	No	51 (12.2)	34 (66.7)	7 (13.7)	10 (19.6)
Sweet foods intake (daily)	Yes	136 (32.6)	114 (83.8)	14 (10.3)	8 (5.9)	0.03
	No	281 (67.4)	203 (72.2)	53 (18.9)	25 (8.9)
Physical activity level	Active	259 (62.1)	196 (75.7)	43 (16.6)	20 (7.7)	0.92
	Inactive	158 (37.9)	121 (76.6)	24 (15.2)	13 (8.2)
Alcohol consumption	Yes	221 (53.0)	177 (80.1)	34 (15.4)	10 (4.5)	0.02
	No	196 (47.0)	140 (71.4)	33 (16.8)	23 (11.7)
Current tobacco use	Yes	8 (1.9)	6 (75.0)	2 (25.0)	0 (0.0)	-
	No	409 (98.1)	311 (76.0)	65 (15.9)	33 (8.1)
Current khat chewing	Yes	21 (5.0)	15 (71.4)	3 (14.3)	3 (14.3)	-
	No	396 (95.0)	302 (76.3)	64 (16.2)	30 (7.6)
Individual risk factor score (risk behaviours)	0–1	107 (25.7)	76 (71.0)	20 (18.7)	11 (10.3)	0.49
	2	223 (53.5)	173 (77.6)	32 (14.3)	18 (8.1)
	3–4	87 (20.9)	68 (78.2)	15 (17.2)	4 (4.6)
Wellbeing	Low	146 (35.1)	112 (76.7)	22 (15.1)	12 (8.2)	0.96
	Average	125 (30.0)	92 (73.6)	23 (18.4)	10 (8.0)
	High	145 (34.9)	112 (77.2)	22 (15.2)	12 (7.6)
Overweight/obesity	Normal	290 (70.4)	229 (79.0)	42 (14.5)	19 (6.6)	<0.01
	Overweight	87 (21.1)	66 (75.9)	13 (14.9)	8 (9.2)
	Obese	35 (8.5)	17 (48.6)	12 (34.3)	6 (17.1)
Central obesity	Yes	274 (65.7)	198 (72.3)	49 (17.9)	27 (9.9)	0.06
	Low risk	143 (34.3)	119 (83.2)	18 (12.6)	6 (4.2)

Notes: n: number; ^§the sum of the number of chronic diseases that participants reported which includes cardiovascular diseases, diabetes mellitus, cancer, hypertension, chronic respiratory diseases, chronic kidney diseases); ^╪college (certificate or diploma) and tertiary (degree and above); ^†securely employed (government or private organization employee), ^‡insecure jobs (daily, factory, building, garment, garage driver, agriculture, and house duties); ^₴The health care affordability of participants was assessed by participants’ “yes” or “no” response to the question, “Can you afford to see a health care provider?”; ETB: Ethiopian birr; and p-values are from chi-square tests.

Figure 2 Prevalence of non-communicable diseases and multimorbidity.

Table 3 Knowledge and Attitudes of Participants About Selected Non-Communicable Diseases

General NCD Awareness and Attitude	Responses	Total n (%)	Non-Communicable Disease		p-value
			Yes	No
A non-communicable disease is one that cannot be spread between people?	Yes	362 (86.8)	82 (82.0)	280 (88.3)	0.10
Chronic non-communicable diseases are more dangerous than communicable diseases?	In favour of the statement	316 (75.8)	66 (66.0)	250 (78.9)	0.01
Hypertension knowledge and attitude
How much do you know about hypertension?	Know about it*	290 (69.5)	70 (70.0)	220 (69.4)	0.91
Do you think high blood pressure cause health problems?	Yes	391 (93.8)	94 (94.0)	297 (93.7)	0.91
How regularly do you think people should check their blood pressure?	Frequently	222 (53.2)	58 (58.0)	164 (51.7)	0.27
Which of the following is/are effective to prevent hypertension?	Reduce salt intake	387 (92.8)	92 (92.0)	295 (93.1)	0.72
	Avoiding alcohol	347 (83.2)	80 (80.0)	267 (84.2)	0.32
	Quitting tobacco	305 (73.1)	77 (77.0)	228 (71.9)	0.31
	Physical exercise	333 (79.9)	80 (80.0)	253 (79.8)	0.96
	Weight loss	324 (77.7)	76 (76.0)	248 (78.2)	0.64
Cardiovascular knowledge and attitude
How much do you know about cardiovascular diseases?	Know about it	223 (53.5)	49 (49.0)	174 (54.9)	0.30
Have you ever concerned about developing cardiovascular diseases?	Yes	157 (37.6)	47 (47.0)	110 (34.7)	0.02
Do you think cardiovascular diseases are preventable?	Yes	276 (66.2)	70 (70.0)	206 (65.0)	0.36
Which of the following do you think would increases someone chance of getting cardiovascular diseases	Smoking	315 (75.5)	71 (71.0)	244 (77.0)	0.22
	Alcohol intake	305 (73.1)	71 (71.0)	234 (73.8)	0.57
	Physical inactivity	296 (71.0)	72 (72.0)	224 (70.7)	0.79
	Overweight	326 (78.2)	79 (79.0)	247 (77.9)	0.82
	Salty food	315 (75.5)	71 (71.0)	244 (77.0)	0.22
	Hypertension	224 (53.7)	56 (56.0)	168 (53.0)	0.59
	Stress	322 (77.2)	77 (77.0)	245 (77.3)	0.95
Cancer knowledge and attitude
How much do you know about cancer?	Know about it	231 (55.4)	47 (47.0)	184 (58.0)	0.05
Do you worry about cancer affect you or your family?	Yes	135 (32.3)	32 (32.0)	103 (32.5)	0.92
Diabetes knowledge and attitude
How much do you know about diabetes?	Know about it	300 (72.5)	73 (73.7)	227 (72.1)	0.88
Do you think diabetes is preventable?	Yes	314 (75.3)	80 (80.0)	234 (73.8)	0.21
Which of these things can a person do to reduce their chances of getting diabetes?	Changing dietary habit	386 (92.6)	93 (93.0)	293 (92.4)	0.84
	Physical activity	349 (83.7)	78 (78.0)	271 (85.5)	0.07
	Losing weight	357 (85.6)	84 (84.0)	273 (86.1)	0.59
	Quitting smoking	286 (68.6)	70 (70.0)	216 (68.1)	0.72
	Avoiding alcohol use	299 (71.7)	74 (74.0)	225 (71.0)	0.55
Diabetes knowledge (using diabetes knowledge scale)	Adequate	371 (89.2)	90 (90.0)	281 (88.9)	0.76
Overall, awareness about non-communicable diseases	Know some about NCDs	144 (34.5)	25 (25.0)	119 (37.5)	0.02

Notes: *These options are based participant response that they know some or well about the diseases; and p-values are from chi-square tests; n (%): number and percent.

Table 4 Adjusted Odds Ratio (AOR) and 95% Confidence Intervals for Multivariable Logistic Regression for NCD Prevalence and Multimorbidity

Variables	Variable Category	Non-Communicable Diseases		Non-Communicable Disease (1 NCD)				Multimorbidity (≥2 NCD)
		Yes n (%)	No n (%)	AOR	95% CI		p-value	AOR	95% CI		p-value
Age (in years)	18–40	48 (15.4)	264 (84.6)	0.17	0.07	0.39	<0.01	0.08	0.03	0.26	0.00
	41–55	17 (32.1)	36 (67.9)	0.27	0.10	0.71	<0.01	0.18	0.05	0.61	0.06
	56+	35 (67.3)	17 (32.7)	Ref				Ref
Marital status	Married	60 (25.5)	175 (74.5)	1.78	0.86	3.70	0.12	0.91	0.27	3.05	0.88
	Others	21 (44.7)	26 (55.3)	1.70	0.53	5.49	0.37	0.56	0.11	2.94	0.49
	Single	19 (14.1)	116 (85.9)	Ref				Ref
Educational status	Primary/lower	38 (40.4)	56 (59.6)	0.94	0.43	2.06	0.87	0.79	0.28	2.24	0.66
	Secondary	17 (17.7)	79 (82.3)	0.75	0.36	1.58	0.44	0.23	0.05	1.09	0.06
	Post-secondary	45 (19.8)	182 (80.2)	Ref				Ref
Health care affordability	Yes	54 (20.3)	212 (79.7)	0.72	0.39	1.32	0.28	0.50	0.21	1.23	0.13
Family history	Yes	75 (45.2)	91 (54.8)	7.71	4.23	14.06	<0.01	-	-	-	-
Salt use	Yes	35 (18.5)	154 (81.5)	0.83	0.46	1.48	0.52	0.82	0.34	2.00	0.67
Sweet diet intake	Yes	22 (16.2)	114 (83.8)	1.36	0.71	2.60	0.36	0.87	0.33	2.30	0.78
Alcohol use	Yes	44 (19.9)	177 (80.1)	1.17	0.60	2.07	0.60	0.42	0.18	1.03	0.06
Weight status	Normal	61 (21.0)	229 (79.0)	0.27	0.10	0.77	0.01	0.95	0.26	3.49	0.93
	Overweight	21 (24.1)	66 (75.9)	0.32	0.10	0.97	0.04	1.23	0.30	5.11	0.77
	Obese	18 (51.4)	17 (48.6)	Ref				Ref
NCD attitude	More dangerous	66 (20.9)	250 (79.1)	0.84	0.44	1.58	0.58	0.65	0.26	1.59	0.34
NCDs knowledge	Good	119 (82.6)	25 (17.4)	1.65	0.87	3.16	0.13	1.98	0.73	5.35	0.18

Notes: NB: Family history of NCD is not adjusted for multimorbidity due to small observation in a cell (<5).

Abbreviations: Ref, reference; NCD, non-communicable disease; Model I, adjusted model for NCD; Model II, adjusted model for multimorbidity; AOR, adjusted odds ratio; CI, confidence interval.

Table 5 Adjusted Odds Ratio (AOR) and 95% Confidence Intervals for Multivariable Logistic Regression for NCD Knowledge, Diabetes Knowledge, and Attitude

Variables	Variables Category	Total n (%)	NCD Knowledge		Diabetes Knowledge		NCD Attitude
			AOR (95% CI)	P-value	AOR (95% CI)	P-value	AOR (95% CI)	P-value
Age	18–40	312 (74.8)	0.93 (0.39, 2.17)	0.87	0.39 (0.09, 1.67)	0.21	1.07 (0.46, 2.48)	0.87
	41–55	53 (12.7)	1.131 (0.41, 3.15)	0.81	0.84 (0.17, 4.05)	0.83	0.91 (0.35, 2.34)	0.84
	56+	52 (12.5)	Ref		Ref		Ref
Gender	Male	189 (45.3)	1.76 (1.06, 2.93)	0.03	1.82 (0.79, 4.16)	0.16	0.70 (0.39,1.24)	0.23
	Female	228 (54.7)	Ref		Ref		Ref
Marital status	Married	235 (56.4)	1.34 (0.73, 2.47)	0.34	2.14 (0.80, 5.73)	0.13	0.90 (0.44, 1.82)	0.77
	Others	47 (11.3)	0.34 (0.09, 1.23)	0.10	1.22 (0.29, 5.13)	0.79	0.49 (0.17, 1.39)	0.18
	Single	135 (32.4)	Ref		Ref		Ref
Education	Primary or lower	94 (22.5)	0.56 (0.25, 1.22)	0.14	0.80 (0.27, 2.43)	0.70	0.61 (0.28, 1.34)	0.23
	Some/secondary	96 (23.0)	0.703 (0.38, 1.28)	0.25	0.78 (0.32,1.92)	0.59	0.76 (0.39, 1.50)	0.44
	Post-secondary	227 (54.4)	Ref		Ref		Ref
Occupation	Securely employed	137 (32.9)	2.91 (1.52, 5.57)	0.01	3.41 (1.07,10.82)	0.04	0.77 (0.38,1.58)	0.49
	Unemployed	121 (29.0)	2.55 (1.27, 5.11)	0.01	1.07 (0.43, 2.65)	0.89	0.56 (0.27, 1.16)	0.12
	Insecure jobs	159 (38.1)	Ref		Ref		Ref
Income (ETB)	≤2250	53 (13.7)	0.79 (0.36,1.73)	0.56	0.72 (0.25, 2.10)	0.55	0.89 (0.41,1.95)	0.78
	2251–5000	126 (32.6)	0.82 (0.48,1.39)	0.45	0.58 (0.27, 1.28)	0.18	1.38 (0.76, 2.48)	0.28
	≥5001	208 (53.9)	Ref		Ref		Ref
Fruit/vegetable intake	Adequate	18 (4.3)	0.97 (0.29, 3.18)	0.96	2.67 (0.31, 23.10)	0.37	2.42 (0.52, 11.40)	0.45
	Inadequate	399 (95.7)	Ref		Ref		Ref
Salt intake	Yes	366 (87.8)	1.90 (0.87, 4.16)	0.11	2.37 (0.92, 6.18)	0.08	0.91 (0.42, 1.98)	0.81
	No	51 (12.2)	Ref		Ref		Ref
Physical activity	Active	259 (62.1)	0.72 (0.44, 1.21)	0.22	1.85 (0.87, 3.93)	0.11	1.07 (0.62,1.85)	0.81
	Inactive	158 (37.9)	Ref		Ref		Ref
Alcohol use	Yes	221 (53.0)	1.05 (0.65, 1.71)	0.84	1.04 (0.49, 2.20)	0.92	1.85 (1.08,3.14)	0.02
	No	196 (47.0)	Ref		Ref		Ref
Khat chewing	Yes	21 (5.0)	0.62 (0.21, 1.78)	0.37	1.73 (0.45, 6.59)	0.42	0.94 (0.32, 2.78)	0.92
	No	396 (95.0)	Ref		Ref		Ref
Overweight/obesity	Normal	290 (70.4)	1.32 (0.51,3.44)	0.57	1.71 (0.46,6.29)	0.42	3.23 (1.42, 7.39)	0.01
	Overweight	87 (21.1)	1.01 (0.35, 2.89)	0.99	0.51 (0.14,1.91)	0.32	2.00 (0.80, 4.97)	0.14
	Obese	35 (8.5)	Ref			Ref		Ref

Abbreviations: Ref, reference; AOR, adjusted odds ratio; CI, confidence interval; ETB, Ethiopian birr.

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