SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA CARDIOVASCULAR DISEASE RISK ASSESSMENT AMONG AUTOMOBILE TECHNICIANS AT THE INDUSTRIAL AREA IN THE TAMALE METROPOLIS, NORTHERN REGION, GHANA BY ERIC MISHIO BAWA (10805159) A THESIS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF PHILOSOPHY IN APPLIED EPIDEMIOLOGY AND DISEASE CONTROL DECEMBER, 2021. University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Eric Mishio Bawa, declare that except for duly acknowledged reference work, this thesis is my original work undertaken under the supervision of Dr. Samuel O. Sackey and Dr. Seth Kwaku Afagbedzi. I also declare that no part of this research work has been submitted elsewhere or within the university for the award of another degree. Signature: Date: 04/07/2022 Eric Mishio Bawa (Student) Signature: Date: 07/07/2022 Dr. Samuel O. Sackey (Supervisor) Signature: Date: 06/07/2022 Dr. Seth Kwaku Afagbedzi (Co-supervisor) University of Ghana http://ugspace.ug.edu.gh ii DEDICATION For their unwavering support, I dedicate this project to my family and friends. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGMENT I thank the almighty God for the miracles that came my way before and during this phase of my life and for the numerous blessings bestowed on me. My heartfelt gratitude goes to Dr. Samuel O. Sackey and Dr. Seth Kwaku Afagbedzi for the supervisory roles they played and for the numerous supports beyond the scope of this research work. May God richly bless you. To the Director and staff of the Ghana Field Epidemiology and Laboratory Training Program (GFELTP) and the West African Health Organisation (WAHO), I wish to express my sincerest appreciation for the training, guidance, and sponsorship provided. To my wife, Lieutenant Grace Awadari, and friend, Mr. Ayambire Felix Apelba for their encouragement and support through thick and thin, and to all and sundry who played either direct or indirect roles in making this study a reality. University of Ghana http://ugspace.ug.edu.gh iv ABSTRACT Background: There is a rapid increase in the burden of CVD in Low and Middle-Income Countries (LMIC). The prevalence of its risk factors and early outcomes are reaching epidemic proportions in Ghana. The global risk function presented by the Framingham investigators estimates the risk of developing CVD and can be used to quantify risk and guide preventive care. Automobile technicians are constantly in contact with harmful chemicals in their work environment that impact their health negatively. Regular exposure to automotive pollutants increases the risk of developing atherosclerosis leading to adverse cardiovascular events among automobile technicians. Though total risk assessment is recommended and the rise in morbidity and mortality associated with CVD is noticeable, individuals and societies, particularly automobile technicians, have no idea of their level of risk. This results in limited and untargeted preventive measures. This study, therefore, aimed at assessing the risk of developing CVD in 10-years among automobile technicians at the industrial area in the Tamale Metropolis, Northern Region Methods: A cross-sectional study involving automobile technicians aged 20 years or older in the industrial area of the Tamale metropolis was carried out. A multi-stage sampling technique was used to select participants. Data on individual factors, risk factors, knowledge, attitude, and practices were collected with the aid of a semi-structured questionnaire. Anthropometric measurements were taken and blood samples were also collected for biochemical analysis. Using the Framingham Risk Scoring algorithm, the 10-year CVD risk for each participant was estimated. Data collected was analyzed using STATA 15 and results were presented as frequencies, proportions, and odds ratios in tables and graphs. Results: All the study participants (210) were males, with 36 years being the median age. The most prevalent risk factor for CVD was hypertension with a prevalence of 32.86%. Hypertension University of Ghana http://ugspace.ug.edu.gh v was significantly associated with diabetes (p = 0.016) and other risk factors. The prevalence of low, moderate, and high 10-year CVD risk was 80.0%, 11.43%, and 8.57%, respectively. The 10- year CVD risk varied significantly with age (p <0.001), years of work experience (p < 0.001), and the job category/specialty (p = 0.004). The majority of the participants had adequate knowledge (74.29%) and attitude (57.14%) towards cardiovascular disease risk factors and prevention with a few (<5%) engaging in good practices. Those with an adequate attitude had 87% reduced odds of having a high 10-CVD risk score when compared to those with inadequate attitudes. Conclusion: There was a high prevalence of CVD risk factors among the automobile technicians, with a fifth of them having a moderate to high 10-year CVD risk score. Whiles the majority of the participants had adequate knowledge and attitude scores, only a few had adequate practices scores on CVD risk factors and prevention. Adequate attitude had a reduced the 10-year CVD risk score among the automobile technicians. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGMENT................................................................................................................ iii ABSTRACT ................................................................................................................................... iv TABLE OF CONTENTS ............................................................................................................... vi LIST OF TABLES ......................................................................................................................... ix LIST OF FIGURES ........................................................................................................................ x LIST OF ABBREVIATIONS ........................................................................................................ xi CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.1 Background ........................................................................................................................... 1 1.2 Problem statement ................................................................................................................. 5 1.3 Justification ........................................................................................................................... 7 1.4 Conceptual Framework ......................................................................................................... 9 1.5 Research Questions ............................................................................................................. 11 1.6 Objectives ............................................................................................................................ 11 1.6.1 General Objective ......................................................................................................... 11 1.6.2 Specific Objectives ....................................................................................................... 11 CHAPTER TWO .......................................................................................................................... 12 LITERATURE REVIEW ............................................................................................................. 12 2.1 Cardiovascular Diseases ...................................................................................................... 12 2.2 The Global Burden of CVD ................................................................................................ 12 2.3 The Burden of CVD in Sub-Saharan Africa ....................................................................... 12 2.4 The Burden of CVD in Ghana............................................................................................. 13 2.5 Risk Factors of CVD ........................................................................................................... 13 2.5.1 Age................................................................................................................................ 14 2.5.2 Sex ................................................................................................................................ 14 2.5.3 Obesity .......................................................................................................................... 15 2.5.4 Diabetes ........................................................................................................................ 15 2.5.5 Hypertension ................................................................................................................. 16 University of Ghana http://ugspace.ug.edu.gh vii 2.5.6 Smoking ........................................................................................................................ 17 2.5.7 Dyslipidaemia ............................................................................................................... 17 2.6 Pathophysiology of CVD .................................................................................................... 18 2.7 Cardiovascular Disease Risk Prediction ............................................................................. 19 2.8 Prevention of CVDs ............................................................................................................ 21 2.9 Conclusion of Literature Review ........................................................................................ 22 CHAPTER THREE ...................................................................................................................... 23 METHODS ................................................................................................................................... 23 3.1 Study Design ....................................................................................................................... 23 3.2 Study Area ........................................................................................................................... 23 3.3 Study Population ................................................................................................................. 23 3.4 Sample Size Determination ................................................................................................. 24 3.5 Sampling technique ............................................................................................................. 24 3.6 Inclusion Criteria ................................................................................................................. 25 3.7 Exclusion Criteria ................................................................................................................ 25 3.8 Study Variables ................................................................................................................... 25 3.8.1 Dependent Variable ...................................................................................................... 25 3.8.2 Independent Variables .................................................................................................. 26 3.9 Measurement of Weight and Height ................................................................................... 31 3.10 Measurement of Blood Pressure ....................................................................................... 32 3.11 Blood Sample Collection and Processing ......................................................................... 32 3.12 Biochemical Analysis ........................................................................................................ 32 3.13 Measurement of Knowledge, Attitude and Practices Score .............................................. 33 3.14 Ten-year (10-year) CVD Risk Scoring ............................................................................. 33 3.15 Data Collection techniques................................................................................................ 33 3.16 Data collection tools .......................................................................................................... 34 3.17 Quality control................................................................................................................... 34 3.18 Data Storage and Processing ............................................................................................. 34 3.19 Data Analysis .................................................................................................................... 35 3.20 Ethical Considerations....................................................................................................... 36 The completed questionnaires will be stored for no more than one year before being destroyed by burning. ................................................................................................................................ 37 3.21 Sponsorship ....................................................................................................................... 37 University of Ghana http://ugspace.ug.edu.gh viii CHAPTER FOUR ......................................................................................................................... 38 RESULTS ..................................................................................................................................... 38 4.1 Characteristics of the Study Population .............................................................................. 38 4.1.1 Anthropometric, Hemodynamic, and Biomechanical parameters of study participants .. 40 4.2 Prevalence of CVD risk factors ........................................................................................... 41 4.2.1 Distribution of CVD Risk Factors .................................................................................... 42 4.2.3 Prevalence of Hypertension Co-morbidities .................................................................... 43 4.3 Ten-year (10-year) CVD risk .............................................................................................. 44 4.3.1 Distribution of 10-year CVD Risk Score ......................................................................... 45 4.3.2 Knowledge, Attitude, and Practices Score of Study Participants .................................... 47 4.3.3 Knowledge of CVD and its risk factors ........................................................................... 48 4.3.4 Distribution of the Knowledge Scores ............................................................................. 49 4.3.5 Attitude towards the Prevention of CVD ......................................................................... 51 4.3.6 Distribution of Attitude Scores ........................................................................................ 52 4.3.7 Practices towards the prevention of CVD ........................................................................ 54 4.3.8 Distribution of Practices Score ......................................................................................... 55 4.4 Factors Associated the 10-year CVD Risk Score................................................................ 57 CHAPTER FIVE .......................................................................................................................... 59 DISCUSSION ............................................................................................................................... 59 5.1 Prevalence of CVD Risk Factors ........................................................................................ 59 5.2 The 10- year CVD Risk Score and its Distribution ............................................................. 62 5.3 Knowledge, Attitude and Practices regarding CVD Risk Factors and Prevention ............. 64 5.4 Factors Associated with the 10-year CVD Risk Score ....................................................... 66 5.5 Strengths of the Study ......................................................................................................... 66 5.6 Limitation of the Study ....................................................................................................... 67 CHAPTER SIX ............................................................................................................................. 68 CONCLUSIONS AND RECOMMENDATIONS ....................................................................... 68 6.1 Conclusion ........................................................................................................................... 68 6.2 Recommendations ............................................................................................................... 69 REFERENCES ............................................................................................................................. 70 APPENDIX 1: PARTICIPANT INFORMATION SHEET ......................................................... 82 APPENDIX 2: CONSENT FORM ............................................................................................... 86 University of Ghana http://ugspace.ug.edu.gh ix APPENDIX 3: QUESTIONNAIRE ............................................................................................. 89 APPENDIX 4: ETHICAL CLEARANCE.................................................................................... 94 APPENDIX 5: FRAMINGHAM RISK SCORING GUIDE ........................................................ 95 LIST OF TABLES Table 1 Operational definition of the dependent variable ............................................................ 26 Table 2 Operation definition of independent variables................................................................. 27 Table 3 Data analysis per specific objective ................................................................................. 36 Table 4 Characteristics of Study Participants ............................................................................... 39 Table 5 Anthropometric, Hemodynamic, and Biomechanical parameters of study participants . 40 Table 6 Prevalence of CVD risk factors among Automobile Technicians ................................... 41 Table 7 Distribution of CVD risk Factors by Job Category ......................................................... 42 Table 8 Hypertension co-morbidities among participants ............................................................ 43 Table 9 Ten-year CVD risk score of participants ......................................................................... 44 Table 10 Distribution of the 10-year CVD risk score ................................................................... 46 Table 11 Knowledge regarding CVD and its risk factors ............................................................. 48 Table 12 Distribution of the Knowledge scores of study participants .......................................... 50 Table 13 Attitude towards the prevention of CVD among participants ....................................... 51 Table 14 Distribution of the attitude scores of study participants ................................................ 53 Table 15 Practices towards the prevention of CVD among participants ...................................... 54 Table 16 Distribution of practices score of the participants ......................................................... 56 Table 17 Multivariable ordinal logistic regression model of factors associated with higher 10- year cardiovascular disease risk scores ......................................................................................... 58 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES Figure 1 Conceptual Framework .................................................................................................... 9 Figure 2 Knowledge, attitude, and practices of automobile technicians on CVD, risk factors, and prevention ..................................................................................................................................... 47 University of Ghana http://ugspace.ug.edu.gh file:///D:/thesis%20and%20prof%20fobil/thesis%20on%20cvd/Main%20work/turn%20it%20in/quil%204/Final%20thesis_Eric%20Mishio%20Bawa%20(10805159).docx%23_Toc90475141 xi LIST OF ABBREVIATIONS BMI - Body Mass Index BP - Blood Pressure CVD - Cardiovascular Disease CVDs - Cardiovascular Diseases DBP - Diastolic Blood Pressure ERC - Ethics Review Committee FRS - Framingham Risk Score GFELTP - Ghana Field Epidemiology and Laboratory Training Program GHS - Ghana Health Service GHS-ERC - Ghana Health Service Ethics Review Committee HDL - High-Density Lipoprotein LDL - Low-Density Lipoprotein LMIC - Low and middle-Income Countries NCD - Non-Communicable Disease NCDs - Non-Communicable Diseases NGO - Non-Governmental Organisation PROCAM - Prospective Cardiovascular Munster University of Ghana http://ugspace.ug.edu.gh xii SCORE - Systematic Coronary Risk Evaluation TC - Total Cholesterol TG - Triglycerides TMA - Tamale Metropolitan Assembly SBP - Systolic Blood Pressure WAHO - West Africa Health Organisation WHO - World Health Organisation University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background Cardiovascular diseases (CVD) are a group of heart and blood vessels disorders (Wang et al., 2015). They include coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis, and pulmonary embolism (Wang et al., 2015; World Health Organization, 2017). Tobacco use, together with physical inactivity, inappropriate diet, obesity, elevated blood pressure, and a poor lipid profile, accounts for about 75% of new cases of CVD (Beaglehole et al., 2001). Contributing to the rise of non- communicable diseases particularly CVDs, are non-modifiable and modifiable risk factors. Non- modifiable risk factors include age, sex, and race, whereas modifiable risk factors include diabetes, alcoholism, elevated blood pressure, overweight, smoking, abnormal blood lipids, and unhealthy diet (Mohammadnezhad et al., 2016). Globally, CVD is one of the leading causes of death. In 2016, an estimated 17.9 million people representing 31% of deaths in the world, died from CVD (World Health Organization, 2017). In 2016, ischemic heart disease (IHD) was the leading cause of the worldwide burden of CVD, followed by stroke, which accounted for 33% of all CVD cases. Hypertensive heart disease, cardiomyopathy, atrial fibrillation, endocarditis, and other cardiovascular diseases account for relatively small proportions of the total CVD burden (Thomas et al., 2018). There is a great concern that the morbidity and mortality burden associated with CVD is increasing rapidly in Low and Middle-Income Countries (LMICs), within which sub-Saharan Africa countries can be classified (Mensah et al., 2015). The surge in the incidence of Non-Communicable University of Ghana http://ugspace.ug.edu.gh 2 Diseases (NCDs), particularly CVDs within sub-Saharan Africa can be accounted for by countries currently experiencing an epidemiological transition characterized by increased urbanization and changing lifestyle factors (BeLue et al., 2009). Death associated with CVD in sub-Saharan Africa constitutes 8.8% of all deaths. However, these deaths occur on average at younger ages than it is for the rest of the world (Moran et al., 2013). In 2013, nearly one million deaths were caused by CVD in sub-Saharan Africa. This constituted 38.3% of NCD deaths and 11.3% of deaths from all causes (Mensah et al., 2015). In Ghana, the burden of CVD is on the rise and this is driven by a significant behavioral change in the country as a result of globalization (Ofori-Asenso & Garcia, 2016). In Ghana, CVD has been identified as one of the leading causes of mortality (World Health Organization, 2010). The country is experiencing epidemic proportions of the prevalence of its risk factors and early outcomes (Li et al., 2020). In 2008, CVD was the leading cause of institutional deaths accounting for 14.5% of total deaths compared to 13.4% from malaria in the country (Bosu, 2013). According to the WHO, the likelihood of dying from cancer, chronic respiratory illness, CVD, or diabetes between age 30 and 70 years in Ghana was 20.8% for both sexes, 18.2% for males, and 23.2% for females in 2016 (WHO, n.d.). Between 2004 and 2014, there was a 78% increase in CVD admissions with heart failure, dysrhythmias, and ischemic heart disease being the top 3 causes of CVD admissions in a tertiary medical center in Ghana (Appiah et al., 2017). In a study on the prevalence and determinants of obesity, Lartey et al. (2019) revealed that there is an increase in the prevalence of overweight and a decrease in the prevalence of underweight among Ghanaian adults. Cardiovascular Diseases are also on the rise in the Northern part of Ghana. Within the Tamale metropolis, uncontrolled hypertension is at appreciable levels (Isaac, 2015). A study conducted University of Ghana http://ugspace.ug.edu.gh 3 among type 2 diabetics receiving primary care at the Tamale Teaching Hospital by Brobbey et al., (2020) revealed that 65% of the patients had hypertension, 89% had elevated glycated hemoglobin levels and 49% received statin for primary prevention of CVD. Ayijunu, (2015) also found that the majority of school teachers in the Tamale metropolis were at risk of developing cardiovascular diseases. Even among school children aged 5 to 14 years, the prevalence of overweight/obesity, which is a risk factor for CVD was found to be high (Mogre et al., 2013). Opare-Asamoah et al., (2017) highlighted the surge in the prevalence of hypertension (55.7%), general obesity (19.7%), and abdominal obesity (49.2%) among type 2 diabetics in the Tamale metropolis. There is an agreement by member states of the United Nations to reduce premature cardiovascular disease deaths by 25% by the year 2025, but this can only be achieved by a reduction in risk factors associated with CVD (Roth et al., 2015). With a continuous increase in CVD risk factors, a corresponding increase in associated mortalities will be experienced in both developing and developed countries (Deaton et al., 2011). A major advancement in the systematic approach to preventing CVDs in both research and clinical practice is the identification of factors in determining the risk of developing CVD (Teramukai et al., 2016). Because CVD risk factors are multifactorial and interact over time to produce an effect, the Framingham investigators developed the Framingham risk functions or scores to evaluate the likelihood of developing CVD in individuals (D’Agostino et al., 2013). The CVD risk score ranks individuals and groups to target therapy to those at greatest risk and also provides prognostic information on the likely benefit from therapeutic interventions (Chamnan et al., 2009). These functions combine information on CVD risk factors such as age, sex, diabetes status, systolic blood pressure, smoking, total cholesterol, and high-density lipoprotein to produce an estimate that reflects the risk of developing CVD over a fixed time (D’Agostino et al., 2013). University of Ghana http://ugspace.ug.edu.gh 4 The global risk function presented by the Framingham investigators in 2008 estimates the risk of developing CVD and can be used to quantify risk and guide preventive care (D’agostino et al., 2008). Though for clinical guidelines, the Framingham risk functions are commonly used, other important risk functions are also available. These include but are not limited to the European Systematic Coronary Risk Evaluation (SCORE) function, and the Prospective Cardiovascular Munster (PROCAM) model (Lloyd-Jones, 2010). The risk of developing CVD in 10 years has been reported to be higher in urban areas. In Indonesia, the proportion of individuals with high CVD risk was found to be 29.2%, with the proportion of individuals with high CVD risk being greater in urban (31.6%) than in semi-urban(28.7%) and rural areas (26.2%) (Maharani et al., 2019). The proportion of men with an increased risk of developing cardiovascular disease was also found to be greater among those in urban Ghana (45.5%) than in rural Ghana (34.7%) (Boateng et al., 2017). In Nigeria, Oguoma et al., (2016) revealed that the prevalence of high, moderate, and low risk of developing CVD in 10 years was 1.9%, 11.8%, and 86.3% respectively among apparently healthy individuals. The proportion of patients with high, low, and medium risk of developing cardiovascular disease in 10 years have also been found to be 30.4%, 41.5%, and 28.1% respectively among patients attending two cardiac clinics in the Ashanti Region of Ghana, with men being at a higher risk than women (Nyiambam et al., 2020). With notable risk factors being hypertension along with diabetes mellitus, a moderate to high risk of a fatal or non-fatal event of CVD was found in 10.4% of adults in Northern Ghana (Skerratt & Wilson, 2021). Automobile technicians are constantly in contact with harmful chemicals in both soil and air that impact their health negatively (Obianime et al., 2017). Particulate matter exposure due to air pollution has become a recognizable risk factor for adverse cardiovascular events with smaller- University of Ghana http://ugspace.ug.edu.gh 5 sized particles produced mainly from combustion sources shown to be very toxic (Fang et al., 2010). The quality of air around the workshops where automobile technicians repair vehicles is very poor and puts them at risk of CVD morbidity and mortality over time (Akintunde et al., 2019). Regular exposure to automotive pollutants increases the risk of developing atherosclerosis leading to adverse cardiovascular events among automobile technicians (Sharman et al., 2002). Despite the high level of physical activity and exertion, the prevalence of metabolic syndrome was found to be higher among automobile technicians when compared to teachers in Southwest Nigeria (Akintunde & Oloyede, 2017). Metabolic syndrome, characterized by mild hypertension, overweight, dyslipidemia, and impaired glucose and insulin metabolism increases the occurrence of CVDs in men (Lakka et al., 2002). Even in the absence of obesity, metabolic syndrome, closely associated with CVDs is on the rise among manually active populations such as automobile technicians (Amidu et al., 2012) Though there is a noticeable rise in morbidity and mortalities associated with CVD globally, individuals and societies particularly automobile technicians, have no idea of their risk of developing CVD. This study, therefore, aimed at assessing the risk of developing CVD in 10 years among automobile technicians in the industrial area in the Tamale metropolis. 1.2 Problem statement Globally, CVD is one of the leading causes of death. In 2016, it was estimated that 17.9 million individuals died from CVD globally, and this represents 31% of all deaths (World Health Organization, 2017). In low and middle-income countries, CVDs and other NCDs are responsible for the increase in the proportions of preventable deaths (Moran et al., 2014). Out of a total of 17 University of Ghana http://ugspace.ug.edu.gh 6 million premature deaths attributed to NCDs, 37% are caused by CVDs and 82% are in LMIC (World Health Organization, 2017). Because NCDs still pose a global threat, the Sustainable Development Goal (SDG) 3.4 is targeted at reducing by one-third, premature mortality from NCDs through prevention and treatment by the year 2030 (CEPAL, 2019) Cardiovascular diseases have been implicated to be one of the most common causes of death and morbidity in Ghana. CVD constituted 22.2% of all causes of deaths from autopsy cases at the Korle-Bu Teaching Hospital within 5 years (Sanuade et al., 2014). In Ghana, the proportion of men with a higher likelihood of developing cardiovascular disease was also found to be 45.5% among men in urban areas and 34.7% among men in rural areas (Boateng et al., 2017). Particulate matter exposure due to air pollution has become a recognizable risk factor for adverse cardiovascular events (Fang et al., 2010). Exposure to particulate matter from multiple combustion sources contributes to CVD (Lee et al., 2019; Pope et al., 2018). Automobile technicians are constantly exposed to harmful chemicals and particulate matter in the work environment that impacts their health negatively (Obianime et al., 2017). Regular exposure to automotive pollutants increases the risk of developing atherosclerosis leading to adverse cardiovascular events among automobile technicians (Akintunde et al., 2019; Sharman et al., 2002). Though total risk assessment is recommended and the rise in morbidity and mortality associated with CVD is noticeable, individuals and societies, particularly automobile technicians, are unaware of their level of risk. This results in limited and untargeted preventive measures. Also, little is known about the CVD risk among populations whose occupational activity is mainly manual and energy-based resulting in limited literature in the area of CVD risk assessment, particularly among automobile technicians. University of Ghana http://ugspace.ug.edu.gh 7 This study, therefore, aimed at assessing the risk of developing cardiovascular disease in 10-years among automobile technicians at the industrial area in the Tamale Metropolis. Since CVD and other NCDs are major causes of preventable deaths, it is important that risk assessments are carried out to support decisions and policies that seek to reduce the burden of such conditions. Earlier knowledge of the risk of developing CVD will result in individuals and institutions engaging in practices that will lower the risk. In addition, Studies of this will contribute towards achieving the target of SDG 3.4, which is to reduce premature mortality from NCDs (CEPAL, 2019) 1.3 Justification Most cardiovascular diseases can be prevented. Cardiovascular disease risk assessment can help identify individuals or groups that may benefit from interventions targeted at reducing risk. Early detection and management are therefore important for individuals at high risk. Premature deaths can be prevented by identifying individuals and groups at the highest risk of CVD and making sure they receive the appropriate treatment. The development of CVD is gradual. There is a need for a preventive approach to the management of CVDs because once CVD manifests, it is mostly immediately lethal and survivors can seldom be restored to full function (Kannel, 2005). Assessing the risk of developing CVD over time can help with CVD management, especially in people who are not yet symptomatic and may most likely benefit (Francula-Zaninovic & Nola, 2018). Total risk assessment and management have been recommended by cardiovascular prevention guidelines. Assessment of Cardiovascular Disease Risk among automobile technicians in the industrial area of the Tamale metropolis will contribute to the efficient use of limited resources by targeting individuals and groups that will benefit more. In relation to current health expenditures, the University of Ghana http://ugspace.ug.edu.gh 8 economic impact of CVD is substantial (Gheorghe et al., 2018). This approach of risk assessment will limit unnecessary treatment and reduce the cost of drugs by about 50% (Mendis et al., 2011). Estimation of CVD risk can be used to raise the awareness of the population on CVD and to motivate adherence to recommended therapies and lifestyle changes. Knowledge of an individual or a group of their risk of developing CVD over a period will go a long way to support policy formation on the prevention and management of CVDs in the country. This study will also serve as baseline data with which other studies can be compared or the basis on which decisions on CVD management can be taken. University of Ghana http://ugspace.ug.edu.gh 9 1.4 Conceptual Framework Figure 1 Conceptual Framework Individual factors • Age • Sex • Ethnicity Life style factors • Smoking • Alcohol intake • Exercise • Diet • Knowledge, attitude and practices Biochemical and Physical Measurements • Total Cholesterol • HDL-Cholesterol • LDL- Cholesterol • Triglyceride • Blood sugar level • Body mass index • Blood pressure • Socio-economic factors • Occupation • Level of Education • Religion • Marital status Outcome 10-year Cardiovascular Diseases Risk Score University of Ghana http://ugspace.ug.edu.gh 10 The risk of developing cardiovascular disease is generally influenced by several factors. It is influenced indirectly by non-modifiable risk factors through its effect on the modifiable risk factors and also directly by the non-modifiable risk factors themselves. These modifiable and non- modifiable factors interrelate to cause CVD and can also be regrouped into individual, lifestyle, socioeconomic and biochemical factors. Individual factors directly influence the outcome, which is the 10-year cardiovascular disease risk score. They are also able to indirectly influence the 10-year CVD risk by influencing or playing a role in the socioeconomic factors and biochemical factors. For instance, the risk of developing CVD increases with age. The older you get, the higher the chances of developing CVD, hence an increasing CVD risk score. Lifestyle factors such as smoking, alcohol intake, and exercise have a direct effect on the risk of developing CVD in 10 years and an indirect effect on the outcome through its influence on biochemical factors. Tobacco use for instance could result in oxidative stress and endothelial dysfunction leading to CVD. Salt intake, which falls under diet results in or worsens one's hypertensive state which could further result in CVD, and lack of physical exercise will result in dyslipidemia leading to CVD. Biochemical and physical measurements also do influence the outcome variable. These biochemical factors include the lipid profile and the blood sugar level. Alterations or deviations in the lipid profile result in dyslipidemia. Conditions such as atherosclerosis and ischaemic heart disease could be the consequence of poor lipid and sugar metabolism. University of Ghana http://ugspace.ug.edu.gh 11 1.5 Research Questions 1. What is the prevalence of cardiovascular disease risk factors among automobile technicians at the industrial area in the Tamale metropolis? 2. What is the distribution of the 10-year cardiovascular disease risk score among automobile technicians at the industrial area in the Tamale metropolis? 3. What are the levels of knowledge, attitude, and practices regarding cardiovascular diseases and cardiovascular disease risk factors among automobile technicians at the industrial area in the Tamale metropolis? 4. What are the factors associated with the 10-year CVD risk among automobile technicians at the industrial area in the Tamale Metropolis? 1.6 Objectives 1.6.1 General Objective To assess the risk of developing cardiovascular disease in 10 years among automobile technicians at the industrial area of the Tamale metropolis using the Framingham risk score algorithm 1.6.2 Specific Objectives 1. To determine the prevalence of cardiovascular disease risk factors among automobile technicians at the industrial area of Tamale metropolis 2. To determine the distribution of the 10-year cardiovascular disease risk score among automobile technicians at the industrial area of Tamale metropolis 3. To assess the knowledge, attitude, and practices regarding CVD, its risk factors, and prevention among automobile technicians at the industrial area in the Tamale metropolis 4. To determine the factors associated with the 10-year CVD risk score among automobile technicians at the industrial area in the Tamale metropolis University of Ghana http://ugspace.ug.edu.gh 12 CHAPTER TWO LITERATURE REVIEW 2.1 Cardiovascular Diseases Cardiovascular Diseases (CVDs) are diseases of the heart muscle and of the vascular system that supply the brain, heart, and other vital organs (Gaziano et al., 2006). These conditions affect the functions and structures of the heart. They include rheumatic heart disease, coronary heart disease, cerebrovascular disease, peripheral arterial disease, deep vein thrombosis, and congenital heart disease, (WHO, 2017). Symptoms associated with CVDs vary based on the specific conditions. However, pain in the chest, shortness of breath, fatigue, nausea, dizziness, cold sweats, lightheadedness, and pain in the left shoulders are typical of an underlying cardiovascular issue. 2.2 The Global Burden of CVD Globally, CVD is one of the leading causes of death. In 2016, it was estimated that 17.9 million individuals died from CVD globally, and this represents 31% of all deaths (Tulu et al., 2021; World Health Organization, 2017). In 2016, ischemic heart disease (IHD) was the leading cause of the worldwide burden of CVD, followed by stroke, which accounted for 33% of all CVD cases. Hypertensive heart disease, cardiomyopathy, atrial fibrillation, endocarditis, and other cardiovascular diseases account for relatively small proportions of the total CVD burden (Thomas et al., 2018). Even in some regions where other causes of mortality such as injuries, nutritional deficiencies, respiratory infections, and HIV/AIDS play the main role, CVD is now an important cause of mortality (Gaziano et al., 2006). 2.3 The Burden of CVD in Sub-Saharan Africa There is a great concern that the morbidity and mortality burden of CVD is increasing rapidly in Low and Middle-Income Countries (LMIC) within which countries in sub-Saharan Africa can be University of Ghana http://ugspace.ug.edu.gh 13 classified (Mensah et al., 2015). LMICs account for about 80 percent of global CVD mortalities (Gaziano et al., 2006). In sub-Saharan Africa, the rise in the incidence of Non-Communicable Diseases (NCDs), particularly CVDs can be accounted for by countries currently experiencing an epidemiological transition characterized by changing lifestyle factors and increased urbanization (BeLue et al., 2009). Death associated with CVD in sub-Saharan Africa constitutes 8.8% of all deaths. However, these deaths occur on average at younger ages than it is for the rest of the world (Moran et al., 2013). In 2013, nearly one million deaths were caused by CVD in sub-Saharan Africa. This constituted 38.3% of NCD deaths and 11.3% of deaths from all causes (Mensah et al., 2015). 2.4 The Burden of CVD in Ghana In Ghana, the burden of CVD is on the rise and this is driven by the significant behavioral changes in the country as a result of globalization (Ofori-Asenso & Garcia, 2016). CVD has been identified as one of the common causes of mortality in Ghana (World Health Organization, 2010). In 2008, CVD was the leading cause of institutional deaths. It accounted for 14.5% of total mortalities compared to 13.4% from malaria in the country (Bosu, 2013). According to the WHO, the likelihood of dying from cancer, chronic respiratory illness, CVD, or diabetes between age 30 and 70 years in Ghana was 20.8% for both sexes, 18.2% for males, and 23.2% for females in 2016 (WHO, n.d.). Between 2004 and 2014, there was a 78% increase in CVD admissions with heart failure, ischaemic heart disease and dysrhythmias being the top 3 causes of CVD admissions in a tertiary medical center in Ghana (Appiah et al., 2017). 2.5 Risk Factors of CVD There are several risk factors associated with the development of CVDs. These risk factors can be classified as either non-modifiable or modifiable. Below are the risk factors of CVD; University of Ghana http://ugspace.ug.edu.gh 14 2.5.1 Age Age, a known risk factor of CVD is generally considered non-modifiable for obvious reasons (Dhingra & Vasan, 2012). Aging is inevitable. The process of aging is associated with a gradual deterioration in the heart’s structure and function, contributing to the development of CVD (Costa et al., 2015). The most important determinant of cardiovascular health is age (North & Sinclair, 2012). It is included as a predictor in all risk prediction models used in assessing an individual’s CVD risk (Dhingra & Vasan, 2012). Though an independent risk factor, the lifetime risk for people whose lifestyle risk factors remain unchanged is lower at age 70 than 50 (Dhingra & Vasan, 2012). In the same vein, the lifetime risk of CVD does not continue to increase with age for hypertension (Vasan et al., 2002), heart failure (Lloyd-Jones et al., 2002), and stroke (Seshadri et al., 2006). The burden of age-associated CVD risk can be reduced in part by the modification of other coexisting risk factors (Dhingra & Vasan, 2012). 2.5.2 Sex Diseases are expressed differently in men and women due to sex-related physiological differences (Mikkola et al., 2013). Though seen as men’s disease, CVD is less common in men than in women but generally assumed in medicine that the effects of major risk factors on CVD outcomes are the same for both sexes (Appelman et al., 2015). Sex is also a non-modifiable risk factor for CVD. The manifestation of CVD is different in men and women (Maric-Bilkan et al., 2016). This difference in sex manifestation suggests that the biomedical principles in the male may not apply equally to the female (P. et al., 2017). Except for prolonged smoking that was found to be significantly hazardous for women than for men, the effects of risk factors such as obesity, elevated University of Ghana http://ugspace.ug.edu.gh 15 blood pressure, elevated cholesterol, obesity, and overweight on CVD outcomes was found to be largely similar between men and women (Appelman et al., 2015). 2.5.3 Obesity Obesity has been on the rise across every age, race, and sex. with most individuals in the highest weight groups (BMI > 40 Kg/m2) than in the lower BMI categories (BMI<35 Kg/m2) (Wright & Aronne, 2012). The global prevalence has doubled since 1980, with close to a third of the population in the world being classified now as either obese or overweight (Chooi et al., 2019). Obesity is associated with an increased likelihood of developing metabolic syndrome, type 2 diabetes, and cardiovascular disease (Phillips, 2013). Localization of excess fat in the muscles, liver, and visceral adipose tissue has been associated with a greater cardiometabolic risk (Chooi et al., 2019). In epidemiological studies, body mass index (BMI) is typically used to determine obesity, however, it is low in sensitivity due to the variability in body fat partly due to age, ethnicity, and sex (Chooi et al., 2019). In dealing with obesity, most practitioners will need to measure only height, weight, and sometimes waist circumference to enable them to estimate a patient's risk for related co-morbidities such as CVD and diabetes mellitus, and appropriate treatment measures established (Purnell, 2018). The manifestation of obesity in men and women is different. Women have more generalized but less central obesity than men, whereas men have more central but less generalized obesity than women (Purnell, 2018) 2.5.4 Diabetes Diabetes is a chronic illness characterized by high blood glucose levels and disruption in fat and protein metabolism (Roglic, 2016). It is a common endocrine disorder and affects about 6% of the world’s population (Adeghate et al., 2006). Diabetes has become an important public health University of Ghana http://ugspace.ug.edu.gh 16 condition mainly due to the increase in its prevalence fueled by obesity over the last decade, the mortality, morbidity, reduced life expectancy, and cost of management (Forouhi & Wareham, 2010). The two main reasons for the increasing prevalence are an aging population and obesity (Kaul et al., 2013). Diabetes can be caused by genetic and environmental factors. For diabetes to become overt, there may have to be an interplay between environmental and genetic factors. Environmental factors that may result in diabetes include viral infection, drugs, and toxic agents, physical inactivity, and obesity (Adeghate et al., 2006). Diabetes has an economic impact on healthcare systems, national economies, and individuals. It is estimated that a total of 1.7 trillion US dollars losses in gross domestic product with 800 billion US dollars for low and middle-income countries is a result of the direct and indirect costs of diabetes (Roglic, 2016). In 2012 and 2013, 1.5 to 5.1 million people per year died as a result of diabetes, making it the 8th leading cause of death globally with a prediction that about 592 million people will die by the year 2035 (Tao et al., 2015). 2.5.5 Hypertension Hypertension is the leading cause of CVD. It's a risk factor with a rising prevalence all over the world, particularly in LMIC (Mills et al., 2020). In order to lower the risk of renal disease, cerebrovascular disease, and cardiovascular disease, adherence to prescribed medication is required (Hamilton, 2003). Even though women have lower blood pressure in the reproductive years when compared to men, women account for half of all CVD-related deaths, resulting in a higher CVD incidence in older women than in men of the same age (Colafella & Denton, 2018). Hypertension is a common University of Ghana http://ugspace.ug.edu.gh 17 comorbidity with type 2 diabetes, and it is two times more frequent in patients with diabetes compared to those without (Petrie et al., 2018). Risk factors of hypertension include alcohol consumption, high sodium intake, physical inactivity, low potassium intake, unhealthy diet, and obesity. Reduction in these risk factors are recommended for the control and prevention of hypertension (Mills et al., 2020). 2.5.6 Smoking Tobacco use, including smoking, are modifiable risk factors for CVD and preventable causes of death (Erhardt, 2009). Smoking is associated with an increased risk of CVD because smokers experience side effects such as insulin resistance and increased catecholamines that contribute to increased blood pressure and heart rate, and hypercholesterolemia (Campbell et al., 2008). Similar to smoking 20 cigarettes per day, there is a 40 to 50% increased risk of CVD linked with smoking one cigarette per day (Le Bras, 2018). Cigarette smoking increases triglycerides, total cholesterol, and low-density lipoprotein whiles acting to decrease cardioprotective high-density lipoprotein (Campbell et al., 2008). Though maximum implementation of smoking cessation therapies is lacking, smoking cessation is a cost-effective way to reduce the risk of CVD and improve cardiovascular health among smokers (Erhardt, 2009). The significance of quitting smoking in the prevention of CVD is highlighted in the adverse effects of all forms of smoking (Katsiki et al., 2013). 2.5.7 Dyslipidaemia Dyslipidemia is an established risk factor for CVD. It is defined as increased serum concentrations of total cholesterol, increased serum concentration of low-density lipoproteins, increased serum concentrations of triglycerides, or a decreased serum concentration of high-density lipoprotein University of Ghana http://ugspace.ug.edu.gh 18 (Hedayatnia et al., 2020). Globally, hypercholesterolemia has been estimated to cause 18% of strokes and 56% of ischemic heart disease, resulting in 4.4 million deaths every year (Chandra et al., 2014). The progressive decline in dyslipidemia in developed countries is not the same for LMIC (Agongo et al., 2018). Persons with a favorable lipid profile have a reduced incidence of CVD (Kopin & Lowenstein, 2017). Dyslipidemia causes an increase in blood pressure by causing endothelial damage that results in loss of physiological vasomotor activity (Halperin. et al., 2006). The risk of a stroke or a myocardial infarction can be increased by an imbalance between LDL-C and HDL-C (Gebreegziabiher et al., 2021), and the development of atherosclerosis is aggravated by the presence of dyslipidemia in general (Cziraky, 2004). 2.6 Pathophysiology of CVD The high incidence of CVD cannot be explained adequately by classic risk factors such as diabetes mellitus, gender, smoking, age, dyslipidemia, obesity, family history, and hypertension (Marinou et al., 2010). There is, therefore, a tendency for CVD risk factors to cluster and interact to promote CVD risk because the pathophysiology of most of the CVD risk factors is similar (Waindim, 2015). Treatment targeted at risk factors such as lowering blood pressure, controlling plasma lipid levels, and controlling diabetes does not eliminate the risk of CVD (Yusuf et al., 2004). Though the relationship between hypertension and obesity has been well established, the mechanism through which hypertension is caused by obesity is not well established (Kotsis et al., 2010). Excess calories as a result of the imbalance between energy expenditure and intake results in varying disorders which are all major CVD risk factors (Kang, 2013). Studies have revealed that extracellular fluid expansion due to sodium retention, inflammation, high plasma renin University of Ghana http://ugspace.ug.edu.gh 19 activity, increased aldosterone levels, activation of the renin-angiotensin-aldosterone system, endothelial dysfunction, and insulin resistance are some possible mechanisms of hypertension induced by obesity (Kang, 2013; Kotsis et al., 2010; Yusuf et al., 2004). The pathophysiology of the link between diabetes and CVD is that of a multifactorial and complex one (Dokken, 2008). Diabetes is linked with increased levels of serum total cholesterol, reduced levels of serum high-density lipoprotein, increased serum levels of low-density lipoprotein, and increased serum levels of triglycerides, (Dokken, 2008; Smith & Lall, 2008). Diabetes and hypertension occur together frequently. With inflammation, insulin resistance, obesity, and oxidative stress thought to be the common pathways, there is a substantial overlap in the aetiology and mechanism of hypertension and diabetes (Cheung & Li, 2012). Dyslipidemia is one of the main driving forces behind the progression of cardiometabolic disorders and is an important link between obesity and diabetes, hypertension, and CVD (Su et al., 2021). Though it predisposes individuals to CVDs, the mechanism is not well understood (Liu & Li, 2015). Serum lipids can lead to cardiac dysfunction by accumulating in circulation, inducing inflammation and oxidative stress, interfering with the mitochondrial function of cells in the heart, and decreasing microvascular density and autophagy (Yao et al., 2020). Dyslipidemia causes loss of physiological vasomotor activity and endothelial dysfunction, leading to systemic hypertension and increasing the chance of CVD (Dalal et al., 2012). 2.7 Cardiovascular Disease Risk Prediction Cardiovascular disease risk prediction is essential in the prevention of CVDs. The purpose of CVD risk predictions is to triage decisions on starting, discontinuing, or intensifying preventive medication, and to support informed treatment (Rossello et al., 2019). The use of CVD risk prediction tools is recommended by guidelines on the prevention of CVD (Cooney et al., 2016). University of Ghana http://ugspace.ug.edu.gh 20 In the past decades, several models for predicting the risk of cardiovascular disease have been developed (Hajifathalian et al., 2015). These models combine predictors mathematically to estimate the CVD risk (Damen et al., 2016). CVD risk prediction models include the Systematic Coronary Risk Evaluation (SCORE), the QRISK mainly used in the United Kingdom, and the Framingham Risk Score (FRS) (Hasabullah et al., 2020). The Framingham Risk Score algorithm is the first to be conceptualized in respect of CVD assessment and it has been validated in several populations across the world (Bitton & Gaziano, 2010). It makes use of sex, age, smoking status, diabetes, cholesterol profile, treatment of hypertension, and blood pressure to estimate the likelihood of getting a cardiovascular event in 10 years (Bitton & Gaziano, 2010; Devine & Taylor, 2009). The Systematic Coronary Risk Evaluation (SCORE) is the most preferred by the European Society of Cardiology. It was developed from 12 European cohort studies and (Bitton & Gaziano, 2010; Piepoli et al., 2016). The CVD risk is calculated by a mathematical combination of age, sex, smoking status, systolic blood pressure, and cholesterol level (Piepoli et al., 2016). The QRISK is used mainly in the UK (Hasabullah et al., 2020). It is recommended updated annually and recommended for use by the National Institute for Health and Care Excellence in the UK and updated annually (Bitton & Gaziano, 2010; Collins & Altman, 2010). The SCORE algorithm incorporates sex, age, ethnicity, smoking status, systolic blood pressure, antihypertensive medication, cholesterol/HDL ratio, weight, height, rheumatoid arthritis, stage of chronic kidney disease, diabetes, atrial fibrillation, and angina (Collins & Altman, 2010). University of Ghana http://ugspace.ug.edu.gh 21 2.8 Prevention of CVDs The majority of the global CVD burden can be accounted for by modifiable risk factors. The burden of CVD can therefore be reduced by controlling these risk factors (Feigin et al., 2015, 2016). A population health approach –‘prevention is better than cure’ is, therefore, the most suitable approach in dealing with CVDs (Buttar et al., 2005). Maintenance of normal blood pressure, being physically active, eating a healthy diet, lowering serum cholesterol and glucose levels, smoking cessation and reduced alcohol consumption are some important interventions that can contribute to reducing the risk of CVD (Hobbs, 2004). Preventive measures in dealing with CVDs include primordial, primary, secondary, and tertiary prevention. Primordial prevention of CVDs focuses on avoiding the development of risk factors of CVD in the first place and maintaining cardiovascular health (Patel & Daniels, 2020; Siddiqui, 2021). These activities prevent the development of risk factors through the establishment of sociobehavioural, environmental, cultural, and economic patterns that influence lifestyle (Pandian et al., 2018). Primary prevention refers to the treatment of risk factors once they develop (Patel & Daniels, 2020; Siddiqui, 2021). In primary prevention, steps are taken by individuals to prevent disease onset (Karunathilake & Ganegoda, 2018). These steps may be lifestyle modifications such as exercising, smoking cessation, eating a healthy diet, reducing alcohol consumption, and maintaining a healthy weight. They may also be the use of lipid-lowering therapy to improve the lipid levels (Stewart et al., 2017). Through early diagnosis, secondary prevention focuses on minimizing the impact of the disease thereby limiting life-threatening situations and permanent damage. Secondary prevention involves the identification of risk factors and determining how the variation in these risk factors affects University of Ghana http://ugspace.ug.edu.gh 22 CVD (Karunathilake & Ganegoda, 2018). Tertiary prevention comes to play when a long-term event set in. It focuses on managing pain, increasing the quality of life, and increasing the life expectancy of patients (Karunathilake & Ganegoda, 2018). 2.9 Conclusion of Literature Review The literature review section summarized literature on CVD, its burden, risk factors, prevention and the 10-year CVD risk score. There was a a noticeable gap in respect of the prevalence and distribution of CVD risk factors among special subgroup populations, particularly automobile technicians. As deaths from CVDs are preventable, studies aimed at answering questions in relation to CVD among subgroup populations such as automobile technicians will be useful is developing targeted interventions. University of Ghana http://ugspace.ug.edu.gh 23 CHAPTER THREE METHODS 3.1 Study Design The study was a cross-sectional study carried out from June to July 2021 among automobile technicians in the industrial area of the Tamale metropolis. Data on modifiable and non-modifiable risk factors of CVD were collected for each participant with the aid of a semi-structured questionnaire, knowledge, attitude, and practices assessed, blood samples collected for laboratory analysis, and the risk of developing CVD in 10 years was estimated. 3.2 Study Area The study was carried out at the industrial area in the Tamale metropolis. It is the hub of automobile technicians in the metropolis. In addition to these technicians, several other business entities that deal in the sale of vehicle spare parts, food, and general merchandise can be found there. Tamale is the regional capital of Ghana's Northern Region and is home to the Mole-Dagomba ethnic group, with other ethnic groups such as Akans, Gas, and Ewes making up the minority. According to the 2010 census, it has a population of 371,351, making it Ghana's third-largest settlement and West Africa's fastest-growing city. The majority of residents (90.5%) are Muslims, with a small minority belonging to other religious sects. Most of the indigenous people are traders, with many others practicing other informal jobs. 3.3 Study Population The population for the study was made up of automobile technicians at the industrial area of the Tamale metropolis who aged 20 years or older and willing to partake in the study. University of Ghana http://ugspace.ug.edu.gh 24 3.4 Sample Size Determination Using Cochran’s (1977) sample size formula, below is the calculation of the minimum sample size that was required for this study: n = z2 x p(1 − p) d2 where n represents the minimum sample size, z represents confidence level 95% (standard value of 1.96), d represents acceptable error margin (5%), and p the estimated prevalence of CVD among automobile technicians. A prevalence of 13.8% as estimated by Pyakurel et al., (2016) among industrial workers in Nepal was used for the sample size calculation. The minimum sample size for this study was then calculated as follows n = 1.962 x 0.138(1 − 0.138) 0.052 n = 3.8416 x 0.138(0.862) 0.0025 n = 182.79 ≈ 183 Therefore, the minimum sample size for this study was 183 automobile technicians. A total of 210 was however collected because of the availability of extra resources 3.5 Sampling technique A multi-stage sampling approach was employed in this study. The sampling frame of automobile technician shops in the industrial area was retrieved from the Business Advisory Center (BAC) of the Tamale metropolis. Each shop was treated as a cluster. With a cluster size of 3, the minimum number of shops that were selected based on the estimated sample size for this study was 61. The shops were selected University of Ghana http://ugspace.ug.edu.gh 25 using a simple random selection approach by assigning numbers to the shops in the sampling frame and drawing at random the shops to be included. Three automobile technicians in each of the selected shops were then recruited for the study. Where the technicians who qualified for selection in a shop were more than 3, the 3 participants required were selected by balloting. However, if the qualified technicians in a shop were less than or equal to 3, they were all recruited. 3.6 Inclusion Criteria All automobile technicians at the industrial area in the Tamale metropolis who were at least 20 years old were included in the study. This is because the Framingham risk assessment tool used was meant for individuals who were greater than or equal to 20 years. 3.7 Exclusion Criteria The study excluded automobile technicians who were absent from work, or ill at the time of the study. 3.8 Study Variables 3.8.1 Dependent Variable In this study, was the 10-year cardiovascular disease risk score was the dependent variable. It was estimated by using the Framingham risk assessment tool and guidelines. Based on categorical values of systolic blood pressure, age, treatment of hypertension, smoking, high-density lipoprotein, and total cholesterol, participants received a point score. These point scores were then added to get the total risk points and the total risk points used to obtain the corresponding 10-year CVD risk score with the aid of the Framingham chart. The risk scores were then categorized as low risk for less than 10%, moderate risk for 10% to 20%, and high risk for greater than 20%. University of Ghana http://ugspace.ug.edu.gh 26 Table 1 Operational definition of the dependent variable Variable Operational definition Scale of measurement Source of data 10-year CVD risk score The risk of developing cardiovascular disease in 10 years Ordinal - Low risk (a 10-year CVD risk score of < 10%) - Moderate risk (a 10-year CVD risk of 10% - 20%) - High risk (a 10-year CVD risk of > 20%) Interview Laboratory analysis Anthropometric measurements 3.8.2 Independent Variables The independent variables were classified into individual factors, socioeconomic factors, lifestyle factors, and biochemical factors. Individual factors that were measured included age, sex, blood pressure, and body mass index, knowledge, attitude, and practices of participants. Socioeconomic factors that were measured included occupation, level of education, marital status, and religion. Lifestyle factors that were assessed included exercise, smoking, and alcohol intake. Biochemical factors that were measured included the blood glucose level, total cholesterol, low-density lipoprotein, triglycerides, and high-density lipoprotein. Table 2 below shows the operational definitions of the independent variables University of Ghana http://ugspace.ug.edu.gh 27 Table 2 Operation definition of independent variables Variable Operational Definition Scale of measurement Source of data Sex Being a female or a male Nominal - Male - Female Observation Age Age (in years) of the participant at the last birthday Ratio Interview Marital status Relationship status with a partner as per law Nominal - Never married - Currently married - Divorced - Widowed Interview Highest level of education Highest level of formal education attained Ordinal - No formal education - Primary school - Junior High School - Senior High School - Tertiary Interview Religion Religious denomination Nominal - African Traditional Religion - Christian - Islam Interview University of Ghana http://ugspace.ug.edu.gh 28 Variable Operational Definition Scale of measurement Source of data Body Mass Index (BMI) The body mass index, calculated by dividing the weight by the square of the height Ratio Measurement of weight and height BMI category Grouping BMI into categorical variables Ordinal - Underweight (a BMI of less than 18.5 Kg/m2) - Healthy weight/ normal weight (a BMI 18.5 to 24.9 Kg/m2) - Overweight (a BMI 25.0 to 29.9 Kg/m2) - Obese (a BMI of 30.0 Kg/m2 and above) Measurement of weight and height Work experience Number of completed years of work as an automobile technician Ordinal - Less than 10 years - 10 to 19 years - 20 to 29 years - 30 to 39 years - Greater than 40 years Interview University of Ghana http://ugspace.ug.edu.gh 29 Variable Operational Definition Scale of measurement Source of data Job category Specialty of work as an automobile technician Nominal - Auto electrician - Auto mechanic - Pump technician - Welding and fabrication technician Interview Ownership of workshop Whether the workshop is the property of the participant Nominal - Yes - No Interview Stage of work Whether the participant is under training or not Nominal - Master - Apprentice Interview Use of personal protective equipment Using safety equipment such as gloves, goggles, and booths during work Nominal - Yes - No Interview Observation Hypertension Having ever been diagnosed of hypertension, or use of antihypertensives, or an elevated BP measurement (≥140/90 mmHg) Nominal - Yes - No Interview Measurement of blood pressure with a sphygmomanometer University of Ghana http://ugspace.ug.edu.gh 30 Variable Operational Definition Scale of measurement Source of data Diabetes Random blood glucose level greater than or equal to 11.1 mmol/L or use of any hypoglycemic agent Nominal - Yes - No Interview Measurement of blood glucose Smoking Currently smoking or having ever smoked Nominal - Yes - No Interview Alcohol consumption Having ever taken alcohol or currently taking alcohol Nominal - Yes - No Interview Knowledge score The aggregate of scores from knowledge assessment questions. Ordinal - Poor (a total score of less than 50%) - Moderate (a total score of 50% to 79%) - Adequate (a total score of 80% to 100%) Interview University of Ghana http://ugspace.ug.edu.gh 31 Variable Operational Definition Scale of measurement Source of data Attitude score The aggregate of scores from attitude assessment questions. Ordinal - Poor (a total score of less than 50%) - Moderate (a total score of 50% to 79%) - Adequate (a total score of 80% to 100%) Interview Practices score The aggregate of scores from practices assessment questions. Ordinal - Poor (a total score of less than 50%) - Moderate (a total score of 50% to 79%) - Adequate (a total score of 80% to 100%) Interview 3.9 Measurement of Weight and Height Weight was measured in light clothing to the nearest 0.1kg with the aid of a weighing scale manufactured by SECA (Hamburg, Germany). Using a portable microtoise tape measure manufactured by SECA (Hamburg, Germany), height was also measured to the nearest 1cm then converted to meters. University of Ghana http://ugspace.ug.edu.gh 32 3.10 Measurement of Blood Pressure Blood pressure was measured with the aid of an automated blood pressure apparatus (Omron M3, HEM-7155-e, Omron Corporation, Japan) in a sitting position after subjects were made to sit for at least five (5) minutes per the recommendation of the American Heart Association (Muntner et al., 2019). Triplicate measurements were taken with a five (5) minute rest interval between measurements and the mean value recorded to the nearest 2.0 mmHg. 3.11 Blood Sample Collection and Processing With the aid of a vacutainer set, 5 mL of blood was collected into a serum separator gel tube and Fluoride oxalate-containing tube under aseptic conditions. The samples were well labeled and transported immediately on ice to the laboratory where they were centrifuged for 5 minutes at a speed of 3000 rpm. Serum from the gel tubes and plasma from the fluoride samples were then aliquoted into cryotubes, labeled, and stored at -70oC until the time for biochemical assay. COVID 19 safety protocols were strictly adhered to. Appropriate precautionary measures to fight COVD 19 were ensured. These measures included the wearing of a face mask, social distancing, hand washing, and the use of hand sanitizers. Participants were provided with a face mask and given education on COVID 19 safety protocols. Study participants were not put together in a group, but they were attended to on a one-on-one basis. 3.12 Biochemical Analysis Lipid profile (total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides) and blood glucose were measured using an automated Mindray BS-240 (Mindray, China) and Medsource Diagnostic reagents according to the manufacturer’s instruction. In brief, serum from the samples was brought out of the freezer and allowed to thaw at room temperature. These samples were then aliquoted and fed to the machine which operates using the University of Ghana http://ugspace.ug.edu.gh 33 principle of spectrophotometry. The reagents were added to the serum in predetermined proportions by the machine, incubated and change in absorbance read at a wavelength of 454nm. The concentration of the analyte is directly proportional to the change in absorbance. 3.13 Measurement of Knowledge, Attitude and Practices Score Knowledge, attitude and practices was measured through an interview with the aid of a questionnaire. Knowlegde, attitude, and practices were treated as separate arms and a set of 10 questions were used to determine the score of each arm. A correct answer to each question was worth 1 point and the score was determnined by adding the number of points made under each arm. Final scores were converted into percentages by diving the number of points made by 10 and multiplying by 100. The maximum point for each arm was 100% and the minimum was 0%. The cutoff point for poor was total scores less than 50%, moderate was a total of 50% to 79% and adequate was a total of 80% to 100% 3.14 Ten-year (10-year) CVD Risk Scoring For each participant, the 10-year CVD risk score was estimated with the aid of the Framingham risk scoring algorithm as described by Schisterman & Whitcomb, (2004). For each category, participants were assigned a score based on conditions such as sex and age. The various risk scores were then added to get the total risk points and the total risk points used to obtain the corresponding 10-year CVD risk score with the aid of the Framingham chart. 3.15 Data Collection techniques Data was collected through a face-to-face administration of a questionnaire to respondents. A semi-structured questionnaire was used to extract information on age, sex, weight, blood pressure, diabetes status, smoking, alcohol consumption, hypertension, height, knowledge, attitude, and practices of each participant. Data on laboratory measures of blood glucose and lipid profile were University of Ghana http://ugspace.ug.edu.gh 34 also recorded after testing and matched to the appropriate semi-structured questionnaire for each participant. 3.16 Data collection tools The data collection tool for this study was a semi-structured questionnaire. This was designed to collect data on personal information, modifiable, and non-modifiable risk factors of CVD for each participant. It was also used to collect data on the knowledge, attitude, and practices of the participants. 3.17 Quality control Healthcare workers with skills in blood sample collection and transport were recruited and trained as research assistants. Training on data collection methods and research ethics was carried out for the research assistants to harmonize understanding and ensure similar ways of data collection to minimize errors during data collection. Data collectors were closely supervised during data collection and collected data checked for completeness and accuracy. The questionnaire for data collection was pretested among randomly selected automobile technicians within the Tamale metropolis to enable the identification of errors, correction of errors, and streamlining the questionnaire before the study. 3.18 Data Storage and Processing Data collected password protected on a computer. Codes were used to identify participants. The data collected on the sheets were checked for errors and missing values. After that, the data was entered into Microsoft Excel, double-checked for errors again, and then exported to STATA I/C 15 (Stata Corp LLC, Texas, USA) for analysis. University of Ghana http://ugspace.ug.edu.gh 35 3.19 Data Analysis Data was analyzed using STATA I/C 15 (Stata Corp LLC, Texas, USA). Categorical variables were described using percentages and proportions whiles mean ± SD was used for continuous variables. Chi-square test was used to compare categorical variables. Univariate and multivariate ordinal logistic regression was conducted to determine factors associated with the 10-year CVD risk score among participants. Independent variables with a p-value of 0.1 at the univariate level were used in a multivariate analysis. The model with the best Bayesian’s Information Criterion (BIC) and Akaike’s Information Criterion (AIC) was selected. The significance level was set at 5% for all associations. Regression diagnostic was performed to assess to assess for collinearity. Variables with a Variance inflation factor (VIF) of greater than 5 was taken out of the model. Below is a table of how data were analyzed per objective. University of Ghana http://ugspace.ug.edu.gh 36 Table 3 Data analysis per specific objective Specific objective Statistical analysis To determine the prevalence of CVD risk factors among the automobile technicians at the industrial area in the Tamale Metropolis - Frequencies and proportions To determine the distribution of the 10-year CVD risk among the automobile technicians at the industrial area in the Tamale Metropolis - Frequencies and Proportions - Chi-square/ Fisher exact test To assess the knowledge, attitude, and practices regarding CVD and its risk factors among the automobile technicians at the industrial area in the Tamale Metropolis - Frequencies and Proportions - Chi-square/ Fisher exact test To determine the factors associated with the 10-year CVD risk among the automobile technicians at the industrial area in the Tamale Metropolis - Univariate ordinal logistic regression - Multivariate ordinal logistic regression 3.20 Ethical Considerations Ethical approval was sought from the Ghana Health Service Ethical Review Committee (GHS- ERC). Approval was granted on the 3rd June 2021 with GHS-ERC 051/04/21 as the GHS-ERC number. Approval was also sought and granted by the Tamale Metropolitan Assembly before the commencement of the study. Informed consent was obtained from each participant to ensure voluntary participation in the study. They were informed of their right to withdraw from the study at any time during the study. University of Ghana http://ugspace.ug.edu.gh 37 Participants who agreed to partake in the research were made to endorse the informed consent form. The endorsement of the form was either with a signature or a thumbprint. Participants' names were not taken in order to maintain anonymity. The completed questionnaires were kept under lock and key, and no third parties were allowed to handle them. The completed questionnaires will be stored for no more than one year before being destroyed by burning. 3.21 Sponsorship The Ghana Field Epidemiology Laboratory Training Program (GFELTP) in collaboration with the West African Health Organization (WAHO) supported this study. University of Ghana http://ugspace.ug.edu.gh 38 CHAPTER FOUR RESULTS 4.1 Characteristics of the Study Population Table 4 shows the characteristics of the study participants. They were all (210) males with the majority (32.38%) being within the 20 to 29 years age group. The median age was 36years (IQR: 27,49) and 134/210 (63.81%) were under training (apprentice). Most of the participants were Muslims (91.60%), currently married (76.67%), and had no formal education (37.60%). Of the total, the majority (71.90%) were auto mechanics and 61 (29.05) were the owners of the workshops visited. University of Ghana http://ugspace.ug.edu.gh 39 Table 4 Characteristics of Study Participants Variable Frequency (N=210) Percentage Age group (years) 20 – 29 68 32.38 30 – 39 48 22.86 40 – 49 43 20.48 50 – 59 30 14.29 >60 21 10.00 Highest Level of education No formal education 79 37.60 Primary School 21 10.00 Junior High School 49 23.33 Senior High School 45 21.43 Tertiary 16 7.62 Marital Status Never married 46 21.90 Currently married 161 76.67 Widowed 1 0.48 Divorced 2 0.95 Religion African Traditional Religion 4 1.90 Christianity 13 6.19 Islam 193 91.90 Work experience (years) Less than 10 81 38.57 10 – 19 60 28.57 20 – 29 32 15.24 30 – 39 16 7.62 Greater than 40 21 10.00 BMI classification Underweight 9 4.29 Normal weight 115 54.76 Overweight 60 28.57 Obese 26 12.38 Job category Auto electrician 8 3.81 Auto mechanic 151 71.90 Pump technician 4 1.90 Welding and fabrication 47 22.38 Own the workshop No 149 70.95 Yes 61 29.05 Stage of work Apprentice 134 63.81 Master 76 36.19 Use of personal protective equipment No 98 46.67 Yes 112 53.33 University of Ghana http://ugspace.ug.edu.gh 40 4.1.1 Anthropometric, Hemodynamic, and Biomechanical parameters of study participants The mean weight and height of study participants were 72 ± 17.5 Kg (95% CI: 70.30, 74.94) and 17.6 ± 0.73 m (95% CI: 16.96, 17.12) respectively. The mean BMI of the participants was 24.98 ± 5.92 Kg/m2 and within the healthy weight range but very close to being overweight. The mean total cholesterol, triglycerides, and LDL cholesterol were 156.33 ± 45.80 mg/dL, 127 ± 75.56 mg/dL, and 74.79 ± 26.40 mg/dL respectively and within the desirable range whiles the mean HDL cholesterol (56.11 ±18.63 mg/dL) was below the desirable levels (Table 5). Table 5 Anthropometric, Hemodynamic, and Biomechanical parameters of study participants Variable Mean ± SD 95% Confidence Interval Weight (Kg) 72 ± 17.05 70.30 - 74.94 Height (m) 17.06 ± 0.73 16.96 – 17.12 Body mass (Kg/m2) 24.98 ± 5.92 24.18 – 25.79 Systolic Blood Pressure (mmHg) 131.71 ± 20.38 128.94 – 134.49 Diastolic Blood Pressure (mmHg) 83.38 ± 14.38 81.42 – 85.33 Total Cholesterol (mg/dL) 156.33 ± 45.80 150.10 – 162.56 Triglycerides (mg/dL) 127.11 ± 75.56 116.83 – 137.39 HDL Cholesterol (mg/dL) 56.11 ±18.63 53.58 – 58.65 LDL Cholesterol (mg/dL) 74.79 ± 26.40 71.20 – 78.38 Random Blood Glucose (mmol/L) 6.49 ± 2.12 6.20 – 6.78 University of Ghana http://ugspace.ug.edu.gh 41 4.2 Prevalence of CVD risk factors The most prevalent CVD risk factor was hypertension and the least prevalent risk factor was alcohol intake. The prevalence of alcohol intake and hypertension among the study participants was 2.38% (95% CI: 0.78, 5.47) and 32.86% (95% CI: 26.55, 39.66), respectively. The prevalence of obesity was 12.38% (95% CI: 8.25, 17.61) among the study participants (Table 6). Table 6 Prevalence of CVD risk factors among Automobile Technicians Risk factor Frequency (N=210) Percentage 95% confidence interval Hypertension 69 32.86 (26.55 - 39.66) Diabetes 10 4.76 (2.31 - 8.58) Obesity 26 12.38 (8.25 - 17.61) Smoking 24 11.43 (7.46 - 16.53) Alcohol 5 2.38 (0.78 - 5.47) High Cholesterol 39 18.57 (13.55 - 24.50) High Triglycerides 65 30.95 (24.77 - 37.68) High LDL 39 18.57 (13.55 - 24.50) Low HDL 49 23.33 (17.79 - 29.65) University of Ghana http://ugspace.ug.edu.gh 42 4.2.1 Distribution of CVD Risk Factors Prevalence of hypertension was significantly low (p=0.029) among auto mechanics (27.2%) compared to the prevalence of hypertension among auto electricians (50.0%), pump mechanics (46.8%), and welding and fabrication technicians (46.8%). The proportion of pump mechanics with high total cholesterol (75.0%) was higher (p=0.001) than the proportions of participants with high total cholesterol among auto electricians (12.50%), auto mechanics (13.91%), and welding and fabrication technicians (29.79%). Similarly, high LDL was significantly higher (p= 0.022) among pump technicians when compared to auto electricians, auto mechanics, and welding and fabrication technicians. However, high triglycerides were significantly lower (p=0.013) among pump mechanics as compared to the other groups (Table 7). Table 7 Distribution of CVD risk Factors by Job Category Variable Auto electrician (N=8) Auto mechanic (N=151) Pump mechanic (N=4) Welding and Fabrication (N=47) Fisher’s exact n (%) n (%) n (%) n (%) Hypertension 4 (50.00) 41 (27.15) 2 (46.81) 22 (46.81) 0.029 Diabetes 1 (12.50) 5 (3.31) 0 (0.00) 4 (8.51) 0.188 Obesity 0 (0.00) 16 (10.60) 0 (0.00) 10 (21.28) 0.226 Smoking 3 (37.50) 16 (10.60) 1 (25.00) 4 (8.51) 0.073 Alcohol 0 (0.00) 2 (1.32) 0 (0.00) 3 (6.38) 0.257 High Cholesterol 1 (12.50) 21 (13.91) 3 (75.00) 14 (29.79) 0.001 High Triglycerides 4 (50.00) 39 (25.83) 0 (0.00) 22 (46.81) 0.013 High LDL 3 (37.50) 25 (16.56) 3 (75.00) 8 (17.02) 0.022 Low HDL 0 (0.00) 4 (26.49) 0 (0.00) 9 (19.15) 0.235 University of Ghana http://ugspace.ug.edu.gh 43 4.2.3 Prevalence of Hypertension Co-morbidities Table 8 shows the prevalence of hypertension co-morbidities among the study participants. Some study participants had hypertension in addition to other risk factors. Hypertension was significantly associated with alcohol intake (p = 0.003), obesity (p < 0.001), diabetes (p = 0.016), high cholesterol (p < 0.001), high triglycerides (p = 0.006) and low HDL (p = 0.034). Table 8 Hypertension co-morbidities among participants Hypertension status P-value Factor No (N=141) Yes (N=69) Chi-square value N n (%) n (%) Diabetes 3 (2.13) 7 (10.14) Ω 0.016 Obesity 10 (7.09) 16 (23.19) 11.06 <0.001 Smoking 16 (11.35) 8 (11.59) 0.00 0.96 Alcohol 0 (0.00) 5 (7.25) Ω 0.003 High Cholesterol 17 (12.06) 22 (31.88) 12.04 <0.001 High Triglycerides 35 (24.82) 30 (43.48) 7.54 0.006 High LDL 21 (14.89) 18 (26.09) 3.84 0.05 Low HDL 39 (27.66) 10 (14.49) 4.49 0.034 Ω: Fischer’s exact chi-square test University of Ghana http://ugspace.ug.edu.gh 44 4.3 Ten-year (10-year) CVD risk The majority (80.0%) of the study participants had a low 10-year CVD risk score. Less than 10% of the participants had a high-risk score with 20% of participants in the moderate to high-risk score category (Table 9) Table 9 Ten-year CVD risk score of participants 10-year CVD risk Frequency Percentage 95% CI Low risk (<10%) 168 80.00 (73.99 – 84.91) Moderate risk (10 – 20%) 24 11.43 (7.75 – 16.53) High risk (>20%) 18 8.57 (5.45 – 13.24) University of Ghana http://ugspace.ug.edu.gh 45 4.3.1 Distribution of 10-year CVD Risk Score Table 10 shows the distribution of the 10-year CVD risk score of the participants. The risk scores varied significantly (p < 0.001) with age. Participants who were 20 to 29 years old were the majority (40.48%) among those with low CVD risk scores whiles participants who were greater than 60 years old were the majority among those with high CVD risk scores. None (0.0%) of the participants who reported to have never married had a high CVD risk score. The risk score also increased with an increasing number of years of work experience (p <0.001). The majority (38.89) of the participants with a high CVD risk score worked for greater than 40 years while the majority of participants who had low CVD risk scores worked for less than 10 years. Compared to the other job categories welding and fabrication technicians were the majority (44.44%) among participants with a high 10-year CVD risk score whereas, among those with a low CVD risk score, the majority (77.98%) were auto mechanics (p = 0.004). University of Ghana http://ugspace.ug.edu.gh 46 Table 10 Distribution of the 10-year CVD risk score Factor Total Low risk Moderate risk High risk P-value N N n (%) n (%) n (%) 210 168 (80.00) 24 (11.43) 18 (8.57) Age group (years) <0.001 20 – 29 68 68 (40.48) 0 (0.00) 0 (0.00) 30 – 39 48 47 (27.98) 1 (4.17) 0 (0.00) 40 – 49 43 36 (21.43) 6 (25.00) 1 (5.56) 50 – 59 30 15 (8.93) 13 (54.17) 2 (11.11) >60 21 2 (1.19) 4 (16.67) 15 (83.33) Highest Level of education 0.39 No formal education 79 63 (37.50) 7 (29.17) 9 (50.00) Primary School 21 15 (8.93) 4 (16.67) 2 (11.11) Junior High School 49 40 (23.81) 7 (29.17) 2 (11.11) Senior High School 45 34 (20.24) 6 (25.00) 5 (27.78) Tertiary 16 16 (9.52) 0 (0.00) 0 (0.00) Marital Status 0.012 Never married 46 44 (26.19) 2 (8.33) 0 (0.00) Currently married 161 122 (72.62) 22 (91.67) 17 (94.44) Widowed 1 1 (0.60) 0 (0.00) 0 (0.00) Divorced 2 1 (0.60) 0 (0.00) 1 (5.56) Religion 0.18 African Traditional Religion 4 3 (1.79) 1 (4.17) 0 (0.00) Christianity 13 10 (5.95) 0 (0.00) 3 (16.67) Islam 193 155 (92.26) 23 (95.83) 15 (83.33) Work experience (years) <0.001 Less than 10 81 74 (44.05) 4 (16.67) 3 (16.67) 10 – 19 60 54 (32.14) 3 (12.50) 3 (16.67) 20 – 29 32 24 (14.29) 8 (33.33) 0 (0.00) 30 – 39 16 8 (4.76) 3 (12.50) 5 (27.78) Greater than 40 21 8 (4.76) 6 (25.00) 7 (38.89) BMI classification 0.028 Underweight 9 9 (5.36) 0 (0.00) 0 (0.00) Normal weight 115 100 (59.52) 8 (33.33) 7 (38.89) Overweight 60 43 (25.60) 10 (41.67) 7 (38.89) Obese 26 16 (9.52) 6 (25.00) 4 (22.22) Job category 0.004 Auto electrician 8 5 (2.98) 2 (8.33) 1 (5.56) Auto mechanic 151 131 (77.98) 11 (45.83) 9 (50.00) Pump technician 4 3 (1.79) 1 (4.17) 0 (0.00) Welding and fabrication 47 29 (17.26) 10 (41.67) 8 (44.44) Owner of the workshop <0.001 No 149 131 (77.98) 11 (45.83) 7 (38.89) Yes 61 37 (22.02) 13 (54.17) 11 (61.11) Stage of work <0.001 Apprentice 134 122 (72.62) 9 (37.50) 3 (16.67) Master 76 46 (27.38) 15 (62.50) 15 (83.33) Use of personal protective equipment 0.017 No 98 75 (44.64) 9 (37.50) 14 (77.78) Yes 112 93 (55.36) 15 (62.50) 4 (22.22) University of Ghana http://ugspace.ug.edu.gh 47 4.3.2 Knowledge, Attitude, and Practices Score of Study Participants Figure 2 Knowledge, attitude, and practices of automobile technicians on CVD, risk factors, and prevention The trend of knowledge and attitude scores were similar. The majority of the participants had adequate knowledge (74.29%) and attitude (57.14%). About 3 times the proportion who had poor knowledge (6.67%) also had a poor attitude (18.57%). Less than 5% of the study participants had adequate practices towards the prevention of CVD with the majority (69.05) having poor practices towards the prevention of CVD (Figure 2). 6.67 18.57 69.05 19.05 24.29 28.57 74.29 57.14 2.38 0 20 40 60 80 100 Knowledge Attittude Practices Poor Moderate Adequate University of Ghana http://ugspace.ug.edu.gh 48 4.3.3 Knowledge of CVD and its risk factors The mean knowledge score obtained was 82.86 ± 19.62 with 0.0% and 100.0% being the minimum and maximum scores respectively. Table 11 summarizes the responses participants gave to questions that were meant to assess their knowledge on, CVD, risk factors, and prevention. More than 60% of the participants answered correctly for each question. Almost 30% of the participants answered that prayer prevents the occurrence of CVD and a little over 10% of the participants did not know whether tobacco smoking can result in CVD or not. Table 11 Knowledge regarding CVD and its risk factors Item Answer choices True False I don’t know CVD is heart related 178 (84.76) * 13 (6.19) 19 (9.05) Most CVD cases are hereditary 19 (9.05) 172 (81.90) * 19 (9.05) CVD is a disease for only women 9 (4.29) 189 (90.00) * 15 (5.71) CVD can occur in young people 162 (77.14) * 30 (14.29) 18 (8.57) CVD is a disease for only the rich 15 (7.14) 190 (90.48) * 5 (2.38) Controlling high-fat food is essential 189 (90.00) * 5 (2.38) 16 (7.62) Prayer prevents the occurrence of CVD 60 (29.05) 139 (66.19) * 10 (4.76) Slender people do not need to exercise 21 (10.00) 181 (86.19) * 8 (3.81) Tobacco smoking can result in CVD 171 (81.43) * 71 (8.10) 22 (10.48) Adequate exercise prevents CVD 169 (80.48) * 25 (11.90) 16 (7.62) * Correct answers University of Ghana http://ugspace.ug.edu.gh 49 4.3.4 Distribution of the Knowledge Scores Table 12 shows the distribution of the knowledge scores of participants. Apart from age group and the use of personal protective equipment, there was no significant difference in the distribution of the knowledge scores of the study participants. Among participants with adequate knowledge, the majority (35.90%) were within the 20 to 29 years age bracket whiles the majority of participants with poor knowledge (42.86%) were within the 40 to 49 year age group. The majority of the participants with poor knowledge (71.43%) did not use personal protective equipment whereas most of those with adequate knowledge (58.97%) used personal protective equipment. University of Ghana http://ugspace.ug.edu.gh 50 Table 12 Distribution of the knowledge scores of study participants Knowledge Score Factor Total Poor Moderate Adequate P-value N N n (%) n (%) n (%) 210 14 (6.67) 40 (19.05) 156 (74.29) Age group (years) 0.028 20 – 29 68 2 (14.29) 10 (25.00) 56 (35.90) 30 – 39 48 2 (14.29) 9 (22.50) 37 (23.72) 40 – 49 43 6 (42.86) 4 (10.00) 33 (21.15) 50 – 59 30 2 (14.29) 9 (22.50) 19 (12.18) >60 21 2 (14.29) 8 (20.00) 11 (7.05) Highest Level of education 0.091 No formal education 79 8 (57.14) 21 (52.50) 50 (32.05) Primary School 21 1 (7.14) 3 (7.50) 17 (10.90) Junior High School 49 1 (7.14) 8 (20.00) 40 (25.64) Senior High School 45 4 (28.57) 8 (20.00) 33 (21.15) Tertiary 16 0 (0.00) 0 (0.00) 16 (10.26) Marital Status 0.520 Never married 46 2 (14.29) 8 (20.00) 36 (23.08) Currently married 161 12 (85.71) 31 (77.50) 118 (75.64) Widowed 1 0 (0.00) 1 (2.50) 0 (0.00) Divorced 2 0 (0.00) 0 (0.00) 2 (1.28) Religion 0.350 African Traditional Religion 4 0 (0.00) 2 (5.00) 2 (1.28) Christianity 13 0 (0.00) 1 (2.50) 12 (7.69) Islam 193 14 (100.0) 37 (92.50) 142 (91.03) Work experience (years) 0.130 Less than 10 81 5 (35.71) 14 (35.00) 62 (39.74) 10 – 19 60 1 (7.14) 9 (22.50) 50 (32.05) 20 – 29 32 4 (28.57) 6 (15.00) 22 (14.10) 30 – 39 16 1 (7.14) 6 (15.00) 9 (5.77) Greater than 40 21 3 (21.43) 5 (12.50) 13 (8.33) BMI classification 0.300 Underweight 9 1 (7.14) 0 (0.00) 8 (5.13) Normal weight 115 6 (42.86) 19 (47.50) 90 (57.69) Overweight 60 6 (42.86) 15 (37.50) 39 (25.00) Obese 26 1 (7.14) 6 (15.00) 19 (12.18) Job category 0.340 Auto electrician 8 1 (7.14) 2 (5.00) 5 (3.21) Auto mechanic 151 7 (50.00) 30 (75.00) 114 (73.08) Pump technician 4 0 (0.00) 1 (2.50) 3 (1.92) Welding and fabrication 47 6 (42.86) 7 (17.50) 34 (21.79) Owner of the workshop 0.270 No 149 8 (57.14) 26 (65.00) 115 (73.72) Yes 61 6 (42.86) 14 (35.00) 41 (26.28) Stage of work 0.310 Apprentice 134 7 (50.00) 23 (57.50) 104 (66.67) Master 76 7 (50.00) 17 (42.50) 52 (33.33) Use of personal protective equipment 0.015 No 98 10 (71.43) 24 (60.00) 64 (41.03) Yes 112 4 (28.57) 16 (40.00) 92 (58.97) University of Ghana http://ugspace.ug.edu.gh 51 4.3.5 Attitude towards the Prevention of CVD The mean score obtained for attitude was 67.62 ± 29.99 with, 0.0% and 100.0% being the minimum and maximum scores respectively. Table 13 summarizes the responses of participants to questions that were used to assess their attitude towards the prevention of CVD. The majority of the participants answered ‘agree’ to stop smoking (70.0%), reduce salt intake (78.57%), take less oily food (76.19%), and prefer walking to somewhere near (77.62%). Only 17.62% of the participants answered ‘disagree’ to snacking and 10.0% of the participants answered ‘disagree’ to stop smoking. Table 13 Attitude towards the prevention of CVD among participants Item Answer choices Agree Neutral Disagree Stop smoking 147 (70.00) * 42 (20.00) 21 (10.00) Regular medical check up 172 (81.90) * 31 (14.76) 7 (3.33) Fruits and/or vegetables intake 168 (80.00) * 37 (17.62) 5 (2.38) Prefer fast food 14 (6.67) 57 (27.14) 139 (66.19) * Prefer not to exercise 15 (7.14) 47 (22.38) 148 (70.48) * Prefer walking to go somewhere near 163 (77.62) * 34 (16.19) 13 (6.19) Avoid carbonated drinks 121 (57.62) * 47 (22.38) 42 (20.00) Take less oily food 160 (76.19) * 36 (17.14) 14 (6.67) Reduce salt intake 165 (78.57) * 41 (19.52) 4 (1.90) Snacking 88 (41.90) 85 (40.48) 37 (17.62) * * Expected answers University of Ghana http://ugspac