Individual and Community-Level Determinants of Hypertension among Overweight and Obese Adults in Ethiopia: A Multilevel Analysis of Demographic and Health Survey Data

Abstract Background: Sub Saharan Africa is experiencing an accelerating epidemiological transition characterized by a growing burden of non-communicable diseases. Although excess body weight is an established risk factor for cardiovascular disease significant variations in hypertension status exist among overweight and obese adults due to individual traits and community environments. This study aimed to identify individual and community level determinants of hypertension among overweight and obese adults in Ethiopia using nationally representative Demographic and Health Survey data. Methods: We analyzed nationally representative data from non pregnant adults aged eighteen years and older with a Body Mass Index of 25 kilograms per meter squared or higher from the two stage cluster sampled 2024-25 Ethiopia Demographic and Health Survey across 797 enumeration areas. The primary outcome was hypertension, defined by elevated blood pressure or current antihypertensive medication use. Two level multivariable logistic regression evaluated fixed effect Adjusted Odds Ratios with 95% Confidence Intervals, alongside cluster random effects and model performance using Intra Class Correlation, Median Odds Ratio, Proportional Change in Variance and the Akaike Information Criterion. Results: Among a total weighted sample of three thousand eight hundred forty-two overweight and obese adults across six hundred twelve clusters, the weighted national prevalence of hypertension was 24.8%. In the final multivariable multilevel model, advancing age, male sex, higher educational status and upper wealth index categories were significant individual level risk factors. At the community level, residing in urban clusters and high community level wealth concentration significantly elevated hypertension odds. The null model revealed substantial clustering, which dropped substantially in the final model, demonstrating that contextual factors account for much of the cluster variations. Conclusions: Both individual metabolic and demographic drivers alongside community level economic and urban environments influence hypertension risk among overweight and obese Ethiopian adults. Cardiovascular health strategies should combine clinical targeted screening with urban structural modifications that facilitate active living environments.