Perception and Screening Practices for Non-Communicable Diseases among Pentecostals in a Semi-Urban Community: A Divergence from Paradigm

Background: Anecdotal evidence suggests a rising incidence of noncommunicable diseases (NCDs) and a common attitude of “spiritualizing” diseases among Pentecostals. Some risk factors are modifiable and/or preventable thus understanding the level awareness of risk factors, causes, features of and screening practices for common NCDs among Pentecostals in Sapele, Delta state has become imperative so as to provide a premise for instituting interventions that will tackle NCDs in our locality.


Background
Non-communicable diseases (NCDs) are usually long-standing non-infectious medical conditions and health states or events, with slow, often unnoticeable progression though some NCDs occur suddenly and rapidly e.g., road traffic accidents, rapes, burn etc. Underlying most NCDs are bio-psychosocial factors which are generally known as modifiable and non-modifiable risk factors [1]. Extraneous factors such as sedentary living, unsafe reproductive and/or sexual behaviour, tobacco exposure, harmful alcohol ingestion etc., all constitute changeable (adjustable or modifiable) risk factors. Exposure to these factors interact with unchangeable (fixed) factors such as genetics, age, ethnicity or race, gender and family history and induces changes in the homeostasis of the body to amplify the risk for initiating and developing NCDs [2].
Globally, non-communicable diseases are becoming an epidemic accounting for most deaths annually. Developing countries like Nigeria with very poor socio-economic and infrastructural development are among the worst hit due to inadequate and unequal access to facilities and services for prevention, early diagnosis and treatment of non-communicable diseases [3,4]. The burdens of NCDs borne by the population are enormous and more profound among low and middle-income countries in which majority of mortalities are recorded [4].
NCDs are the most important cause of death, representing over 60% of deaths and killing over 36 million people globally each year. In 2015, WHO estimated 15.0 million deaths from noncommunicable diseases among people aged 30 to 69 years; over 80% of these untimely deaths, were due to cardiovascular disease, cancer, diabetes and chronic respiratory disease [5].
Tobacco smoking was estimated to account for over 70% of lungs cancer, over three-fifth of chronic respiratory disorders and nearly one-tenth of cardiovascular disease [6]. The probability of dying prematurely is higher among people who do not engage in regular physical exercise by 20-30%; and over 3 million people die each year due to insufficient physical exercise. Alcohol intake contributed about 3.8% of the yearly deaths [7]. Similarly, poor dietary habit/obesity contributes over 4% of these deaths, with the risk of heart diseases, strokes and diabetes soaring progressively with expanding body mass index (BMI) [7].
Nigeria contributes one-fifth of the overall deaths from NCDs with major inputs from cardiovascular, endocrine, respiratory and renal diseases. It is forecasted that by 2020, 70% of the global burden of disease from NCDs will occur in developing countries thus economically productive young people that incidentally are less able to afford early detection and treatment would not be spared. Diabetes mellitus and hypertension ranked topmost in the causes of kidney failure. Diabetes mellitus is one of leading causes of mortality globally; and within the next two decades there will be a projected rise of 64% if the present trend continues [4].
Anecdotal evidence suggests a surge in the incidence of noncommunicable diseases (NCDs) in the general population and a common attitude of "spiritualizing" causes of diseases among Pentecostals which often undesirably influence their health seeking behavior [8,9]. However, there is a probability that the level of awareness of non-communicable diseases such as diabetes mellitus, hypertension, and chronic kidney disease is low, and a strong indication that hypertension and diabetes mellitus will invariably lead to chronic kidney disease if not adequately managed. The likelihood that the burden of NCDs will increase is high and World Health Organization predicted in 2009 that by 2020, there will be a 17% surge in the burden of NCDs with low-and middle-income countries having more than a quarter of the rise (27% upsurge) [4]. Considering this extrapolation, and the fact that most of the risk factors such as tobacco intake, sedentary lifestyle, westernization of diet and others are modifiable and/or preventable it has become progressively vital to understand the level of awareness of the risk factors, causes, features of and screening practices for common non-communicable diseases among Pentecostals in Sapele, Delta state so as to provide a premise for instituting interventions that will tackle NCDs in our locality.

Study location
The study was conducted in Sapele, Delta state. The major tribe in Sapele is Okpe (a part of the Urhobos) and the foremost occupations of the people of Sapele include trading, sustenance farming and civil service. There are different religious groups in Sapele; Christians, Muslims, traditional worshippers, atheists etc.

Study population
Christian Worshippers in Pentecostal churches in Sapele, Delta state who willingly give their consent.

Sampling technique
From a list of all Pentecostal churches (obtained from the leader of Sapele branch of Pentecostal Fellowship of Nigeria) eleven churches were selected with a simple random technique by balloting. Then, with stratified sampling method with proportionate allocation a minimum of 30 members were selected from each of the chosen churches.

Data collection
The study instrument was a pre-tested, semi-structured, selfadministered questionnaire. Participants' information was not recorded on the questionnaire to ensure strict confidentiality of their responses.

Data analysis
Data generated was entered into spreadsheet of SPSS software version 22 for analysis. Descriptive data was displayed in frequency tables.

Ethical Clearance
Ethical clearance was obtained from Health Research Ethics Committee in Delta State University Teaching Hospital. Written informed consent was sought and obtained from the participants salt or toxic substances from the body (96.9%). While 65.6% were ignorant of predisposing factors to kidney disease, 34.4% identified nutritional habit, and only 3.1% thought family history was a risk factor (Table 4).
A significant proportion (68.8%) of the respondents opined that diabetes can be prevented and agreed that a healthy lifestyle was important for preventing DM but, less than two-fifth (37.5%) disagreed with eating processed sugar as a preventive measure. Majority (71.9%) identified dietary control as a means of cure but more than three-fifth did not know drugs or herbal concoction could be applied in treating diabetes (Table 5).
Almost all respondents (93.8%) reported that hypertension can be prevented and agreed that a healthy lifestyle was important for preventing hypertension, while the same proportion disagreed that eating processed sugar can cause hypertension. About the same proportions (68.8% and 65.6%) of respondents identified dietary control and drug therapy respectively as treatment options for hypertension (Table 6).
before recruiting them for this study. Permission was sought from the head of each church be commencement of the survey.

Results
Males were marginally more than females (53.1% vs. 46.9%). The 40-49 years age-group was most frequent (40.6%) with a mean age of 38.15 years for all participants. Most participants were married (75.0%) and had tertiary education (96.9%), however, their job types varied among them with only two-fifth (40.6%) being teachers ( Table 1).
All participants were aware of diabetes mellitus, most having heard through electronic and print media (68.7%), perceived genetics and risky lifestyle (82.8%) as possible causes and identified excess sugar intake (92.9%) as a predisposing factor. Nonetheless, about three-fifth (59.3%) identified family history as a risk factor (Table 2).
All participants were aware of hypertension, more than half having heard from relatives, friends and colleagues (54.2%), and all thought hypertension referred to high blood pressure. While slightly less than a third (31.2%) identified excess salt intake as a predisposing factor, family history and sedentary living were both identified by almost three-fifth (59.4%) of the respondents as risk factors (Table 3).
No participant was unaware of kidney disease. The majority of respondents thought kidney disease meant inability to excrete   Only 3.1% felt kidney disease cannot be prevented, 62.5% disagreed that kidney disease can be prevented by exercise, vegetable intake, dietary control but, over three-fifth (65.6%) were undecided about intake of excess protein, canned food or concoction causing or worsening kidney failure. Only a little over one-third (34.4%) knew dialysis to be a treatment modality for kidney failure. Whereas over three-fifth did not know if dialysis can treat the condition; almost a majority (62.5%) identified renal transplant a cure for kidney failure (Table 7).
A sizeable proportion of all participants had never checked their weight, blood pressure, fasting blood sugar, lipid profile, HIV and HBV status; while a minute fraction (3.1%) did check in the year preceding the study. More than a quarter checked their weight within 6 months prior to the study, while less one-tenth (6.3%) did so within the previous year (Table 8).

Discussion
The mean age and predominant age group identified in this study seemingly represents the middle-age group among whom a surge in the incidence of non-communicable diseases has been reported [10]. Thus, they require regular health promotional activities to make them mindful of this fact, since diseases which used to be prevalent only among the frail and old have become popular amongst younger ages [11]. In addition, contrary to common belief that females tend to be more religious than males [12] this study showed a higher male to female ratio, probably because, men were more willingly to participate in this study.
While most participants had heard of diabetes, hypertension, and kidney disease and understand what they connoted, some still lacked knowledge of the causes and risk factors of these diseases. For instance, some participants considered food poisoning a predisposing factor for diabetes and kidney disease, while over a quarter identified low carbohydrate diet and twofifth were oblivious of predisposing factor for hypertension. On the other hand, it is commendable that most participants       correctly identified risk factors of non-communicable diseases; though surmising that they therefore will avoid these risk factors may be preposterous since the bulk of them have neither checked their weight nor blood pressures in their entire life.
Nonetheless, addressing these misconceptions through timely and properly organized health campaigns could equip them with the appropriate information regarding their health [13].
Most respondents had good perception about prevention, cause and treatment of diabetes and hypertension. This finding is remarkably positive for promoting activities to ensure they safeguard their health and could stimulate policy drive for sustaining health-related SDGs in the general population [14]. Perception about causes of kidney failure appeared adequate but, their perception about likely preventive measures was poor as over three-fifth disagreed that exercise, vegetable intake, dietary control were important aspects of prevention. Knowledge of a cure for kidney failure seemed high but, over three-fifth did not know dialysis was a renal replacement therapy. People need the right information to seek healthcare when they are ill. Thus, this level of ignorance about dialysis as a viable option for renal therapy exemplified in this study may be a reflection of discriminatory access to accurate health-related information rather than a religious inclination [15]. Moreover, even among patients with chronic kidney disease perception about treatment modalities was poor due to a failure on the part of their attending physicians to educate them appropriately [16].
Screening practices among these religious worshippers appeared low, especially as at least three-fifth of the study participants had never checked their weight. It is not impossible that some of the participants may have undetected diseases such as diabetes, hypertension and dyslipidemia, as a greater proportion of them have not been screened for these conditions. The negative impact for not screening at all or regularly may have long-term implications for these participants, particularly because, NCDs have likely complications affecting vital organs in the body which often remain asymptomatic until irreversible damage becomes inevitable [17]. This observation not only highlights a disparity from what is expected but also indicates a significant gap in the application of simple and useful measures for looking after one's own health and wellbeing. A possible reason that may be adduced for this finding may well be related to their belief in divine healing and health often demonstrated with a regular confession of "I cannot be sick", commonly observed among various religious sects in Nigeria [18]. Nevertheless, this abysmal void in screening practice among these participants likely reflects their knowledge of non-communicable disease. Thus, the inevitability for planning educational and preventive interventional programs for this group of participants has become obviously apparent if they are to lead and maintain a healthy lifestyle.
One may want to excuse them for not screening for noncommunicable diseases on the ground that, they have poor knowledge of these diseases. Nevertheless, it is noteworthy that most of them had never screened for HIV, an infection for which there is intensified awareness, free counseling, testing and treatment. Their spiritual belief in divine immunity against all forms of diseases may also have influenced this poor practice, especially because some Pentecostals maintain that prayers from their spiritual leaders are often sufficient to keep HIV at bay [19]. Their poor screening practice might have been ingrained in their attitude such that without a change in behavior no meaningful progress can be made with only public enlightenment. Even HIV/ AIDS prevention messages have been contradicted by Pentecostal groups in Mozambique [20]. Consequently, they may benefit from the application of health belief model of health promotion, because their poor practice may not be independent of their belief. Moreover, religion can be an avenue for stimulating social change, [21] thus, awareness campaigns and health promotion activities can be targeted towards this Pentecostal group using their well-respected leaders as arrow heads. The screening for hepatitis B as observed for HIV was poor; almost all respondents have never screened for this infection. While religious persons may have low sexual risky behavior, [22] other means of transmitting the diseases such as sharing of sharp objects and blood transfusion cannot be completely excluded among Pentecostals. Thus, their risk of contracting hepatitis B is not absolutely insignificant and they may need proper education in this regard.
As alarming as the foregoing seems it might not be out of place to explore deeply the socio-behavioral components underlying the low screening uptake which is a clear divergence from an exemplar. Therefore, it can be posited that future studies among these participants should include qualitative investigation, simply because religious, socio-cultural as well as personal factors crisscross in an individual's daily life [23].

Conclusion
All participants were aware of diabetes; hypertension and kidney disease and all knew what hypertension represented; though gaps in their knowledge and misconceptions about predisposing factors also existed. Most participants correctly identified risk factors of non-communicable diseases; nevertheless, it is uncertain if they would avoid such risks given their poor practice of simple screening tests (weight and blood pressure check). The significant disparity in their screening practices requires health promotion approaches based on health belief model because their poor practice may not be independent of their belief.