Effect of Healthy Lifestyle Education on Modifiable Risk Factors of Metabolic Syndrome and Health Related Quality Of Life among Middle-Aged Adults in Nekemte Town, Western Ethiopia

Background: Metabolic syndrome (MetS) and associated chronic non-communicable diseases (NCDs) are likely a noticeable public health threats in the world. There is a disparity in the distribution of MetS and its health outcomes by geography, time, age, sex, physiology, and economic status of the population. Latterly, the encumbrance of MetS and NCDs is emerging in developing countries at an alarming rate. Likewise, the burden of diseases and mortality related to NCDs is believed to have been confronting Ethiopia in the last three decades. Nowadays, a lot of work is being done on MetS, but there is a lack of concrete data on the effect of a community-based healthy lifestyle education intervention on MetS and health-related quality of life (HRQoL). Up until now, the majority of research particularly in developing nations like Ethiopia has concentrated more on control than prevention. MetS and associated lifestyle diseases are accelerating internationally. Like in other countries, non-communicable diseases are currently the main cause of death in Ethiopia. Multimorbidity, the presence of two or more chronic non communicable diseases in a given person affects all aspects of people‘s lives. Still, many people perceive it as a disease of developed countries. Especially, the perception of obesity is misapprehension in West Ethiopia. Metabolic Syndrome and obesity are increasing in Ethiopia due to several lifestyle-related factors including urbanization, increasing lifestyle changes, and the backlog of organ stunting due to malnutrition during the early life span. Obesity and MetS prevention necessitate appropriate screening followed by education. What is healthy lifestyle education in the local language? It is termed ―Barnoota Akkaataa Soona Jireenyaa Fayyaa‖ in Afan Oromo and ―ጤናማ የአኗኗር ዘይቤ ትምህርት‖ in Amharic language. In Ethiopia, advanced laboratory methods of screening obesity and MetS are not accessible for routine service purposes. Early detection is the most strategic method for the identification of asymptomatic MetS risks as a major health concern of the 21st century. However, it has not yet been practiced potentially leading to a poor quality of life in Nekemte and other towns of Western Ethiopia. Poor quality of life (QoL) is one of the major consequences of living with multimorbidity. The distributions of metabolic syndrome and its outcomes were wavered by several factors xii nationwide. In recent years, a lot of work has been done on metabolic syndrome, but there is a lack of concrete data on the effect of a community-based healthy lifestyle education intervention on metabolic syndrome and health-related quality of life, as most studies hitherto focused on control rather than prevention, and remains a matter of concern, especially in the least developed countries like Ethiopia. As a result, the quality of life deteriorated at early productive age. Poor quality of life decreases the performance of work. Currently, subjective well-being has become a part of health outcome evaluation in studies and clinical practices. Quality of life is one of the important health outcome concepts that are expressed subjectively by patients. It considers all health dimensions, physical, mental, and socioeconomically. Metabolic syndrome is a multi-factorial disorder that deteriorates human life. One or more modifiable risk factors: unhealthy diet, physical inactivity, smoking, and other unhealthy lifestyles lead to morbidity and/or mortality. Behavioural risk factors are also interrelated with physiological risk factors; because they are associated with many adverse health outcomes. Doing healthy behaviors and having a healthy lifestyle in middle adulthood is important for later life. Early detection and prevention are the most strategic methods for the identification of asymptomatic and undiagnosed NCDs; metabolic syndrome risks are one of the health concerns today; yet not practiced in western Ethiopia Towns. Though community-based healthy lifestyle education was not practiced; it intended to meet emerging needs, save lives of reproductive age, reduce the costs of hospital-based ambulatory care, and it also an input for community health workers. Studies suggest that lifestyle interventions can reduce overweight/obesity, high blood pressure and glucose levels, and lipid profiles; but there is little information regarding the feasibility of the interventions in community settings mostly in Ethiopia. Prevention of metabolic syndrome, obesity, and quality of life improvement requires lifestyle education interventions. In Ethiopia, although there is an increase in the prevalence of metabolic Syndrome due to epidemiologic transition, there is no study that evaluated the effect of community-based healthy lifestyle education intervention. Objective: To evaluate the effect of theory-based healthy lifestyle education on modifiable risk factors of metabolic syndrome, its distributions, and health-related quality of life among middle aged adults in Nekemte Town. xiii Methods: This dissertation used a pre and post-test nonequivalent control quasi-experimental intervention study, a community-based cross-sectional study triangulated with descriptive and phenomenological qualitative studies to generate context-specific evidence. A community-based cross-sectional study was triangulated with a qualitative study at baseline. The research project spanned eight months, starting from the beginning of 2019. We recruited the participants and collected their baseline data in the first quarter of the year. During this time, we also provided intensive lifestyle education to the intervention group through regular sessions. During the last quarter of the project, we conducted several activities to evaluate the impact of our intervention. We met with researchers. We also visited the field sites to observe the changes in the behavior and attitudes of the participants. We collected data from surveys, interviews, and focus groups in August 2019, after the intervention was completed. Two hundred sixty-six apparently healthy middle-aged adults were recruited and sampled. An individual quasi-experimental study was conducted among 266 middle-aged adults of Nekemte Town who were randomly allocated into the intervention (n=133) and control (n=133) groups. The intervention group received a community leaders-led lifestyle education-based behavioral change approach on the Pender Health Promotion Model and routine follow-ups of the control group continued. The WHO stepwise approach was used to gather datas. A multivariable logistic and linear regression model run on the testing metabolic syndrome of populations, independent variables were significant predictors of metabolic syndrome, HRQoL and there was a significant increase in each of the theory of planned behavior(TPB) contracts. Correlation analysis was conducted to examine the relationship between the independent variable and the dependent variables. The collected data was checked, entered into Epi-info Version 3.5.3, and then transferred to SPSS version 24, and associated variables were considered at P-value<0.05. Results: The prevalence of undiagnosed metabolic syndrome, undiagnosed diabetes, and unhealthy lifestyle among middle-aged adults in the study area was revealed by this study. Metabolic syndrome was linked to poor health-related quality of life. The baseline characteristics of the two groups were similar. The results indicated significant differences between the baseline and end line. Lifestyle diseases can create a vicious cycle without intervention. The main document contains the papers and articles from the structured dissertation phase by phase, which provide the data of the results. The dissertation was divided into phases. The first part included: xiv Chapter One which encompasses the introduction, hypothesis, objectives, dissertation sketch, methods and materials, and healthy lifestyles educational intervention strategies. The second phase covers the findings of the baseline of the study (Chapters 3 and 4). The third phase of the dissertation came with the main part of the study which encompasses the end-line findings of the dissertation (Chapter 5). The final phase of the dissertation was chapter six which illustrates the overall discussion, conclusions, recommendations, and future research perspectives. Mixed-model regression approach was applied to properly deal with within- and between subjects variance during baseline and end-line tests. Chapter 3 offers the magnitude of MetS, an association of MetS and HRQoL, healthy dietary practices, and barriers to adopting healthy lifestyle among middle-aged adults in west Ethiopia. Findings of multivariate logistic regression analyses showed that having poor HRQoL (AOR: 3.15; [95% CI: (1.81, 4.96), P=0.009]), and mobility problems (AOR: 7.53; [95%CI :( 2.057, 3.747], P=0.003) were significantly associated with MetS. Likewise, being high BMI ≥ 25Kg/m2 (AOR: 9.30, [95%CI (1.12, 77.37], p<0.0001) and SBP>130 mmHg (AOR: 5.67; [95%CI: (3.42, 9.09] p=0.039) more likely associated to MetS. Adults being in low-income households, unable to read and write, and having meal frequency less than three times per day were significantly associated with unhealthy diet practices (AOR: 1.59, 95% CI: [1.37, 3.21], AOR: 3.20, 95% CI: [2.04, 5.98], AOR: 1.91, 95% CI: [1.04, 2.71], respectively) (Chapter 3). Chapter 4 presents the magnitude of newly diagnosed raised fasting blood sugar among urban residents in west Ethiopia and identifies the age group that is more likely at risk for the onset of diabetes. The mean and SD of fasting blood glucose level was 99.7(29.60 mg/dl) with (95%CL: 96.12, 103.27; p<0.0001). Age specification was associated as risk factors for diabetes among middle-aged adults in Nekemte Town. Chapter 5 describes the effect of healthy lifestyle education on metabolic syndrome, its distributions of biomarkers, and health-related quality of life. The difference in differences in metabolic syndrome and its components between baseline and end line were compared by the intervention status. Multivariable logistic and linear regression models were used to identify the effect of the intervention neat of other predictors of metabolic syndrome and its components, respectively. Also, health-related quality of life and its domains are analyzed by Generalized estimating equations analysis. There was a significant difference (P<0.001) in the prevalence of xv metabolic syndrome between an intervention (17.19%) and control groups (24.8%) on the end line assessment. In Nekemte, HDDS was stratified using a wealth index. Accordingly, baseline HDDS and end-line HDDS (48.3%) had big differences among the intervention group. The generalized estimating equation analyses were used to determine the effectiveness of lifestyle education on HRQoL and its domains. The mean difference in differences in waist circumference was 1 ± 1.1 (P<0.001), while that of blood pressure (BP) was 0.46 ± 3.06mmHg (P< 0.001. The findings revealed that middle-aged adults in the intervention groups had a greater HRQoL than did those in the control group at six months (ß=9.7, P<0.001) and ß=2.6, P=0.003, respectively) (Chapter 5:3). After the intervention, the mean score of knowledge, attitude, subjective norms, and perceived behavioral control in the intervention group was significantly higher than the control group and the difference was significant (p<0.001). After theory-based lifestyle education through the intensive participation of community leaders, there was a statistically significant difference in the mean BMI among the two groups (F=14.17, P<0.001) (Chapter 5:1). Conclusions and Recommendations: Community leaders-led healthy lifestyle education through theory-based targeting of middle-aged brought acceptable adopting healthy lifestyle behaviors, reduced the prevalence of MetS, and improved physiological factors, and health related quality of life on a community basis. This dissertation implies that educational interventions targeting age specification need intensive community leaders‘ engagement in designing healthy lifestyle education programs. Therefore, we recommend that policy makers, initiators, and health care workers lead and network the communities through community leaders which are used as a prominent tool to implement effectively the program, tackle lifestyle diseases, and contribute a crucial role in the achievement of sustainable development goals.