Effect Of A Training Programme On Knowledge And Practice Of Lifestyle Modification Among Hypertensive Patients Attending Out-Patient Clinics

Project and Seminar Material for Nursing (Science)

Project and Seminar Material for Nursing (Science)


Abstract


Hypertension is the most common non-communicable disease and the leading causeof cardiovascular disease in the world.Many people with hypertension are unaware of their condition making treatment infrequent and inadequate. According to Seven Joint National Committee Criteria (JNC7), the precise rule for the treatment of hypertension begins with lifestyle modifications and ends with medication. Unfortunately, many patients diagnosed to be hypertensive don’t usually have proper education about lifestyle modification. Lifestyle modification is advised for all patients with hypertension, in respective of pharmacological treatment, because it may reduce or even abolish the need for medications.

The objective of the study was to determine the effect of a training programme on knowledge about hypertension, lifestyle modification and practice .Quasi experimental method was used for this study to determine the effect of a training programme on knowledge and practice of lifestyle modification. Sample size of 60 participants diagnosed to be hypertensive and registered at the general out-patients and medical out-patients clinics were used. (Control group n=30, intervention group n=30). Two research settings were selected randomly from the three tertiary hospitals in Lagos state. One of the hospitals was randomly selected to be the control group and the other the experimental group.

Purposive sampling was used to select the participant from each setting. Data were collected through administered questionnaire using a modified structured questionnaire from World health organization for hypertensive patients and hypertension knowledge-level scale (HK-LS). Data obtained were coded and analysed using SPSS version 21.0 statistical software. Variables and research questions were analysed using descriptive analysis e.g. percentage, mean, and standard deviation and to show relationship between dependent and independent variables. Hypotheses were tested using inferential t-test at 0.05 level of significance.

Demographic data showed that female were more prevalent in the study, level of literacy was fair in both groups. Above ninety three percent were Yoruba in the control group and above 44% in the experimental group. This is because this study was carried out in South-west Nigeria which is mainly dominated by the Yoruba. Results suggested that pre-test general knowledge of hypertension was low in both groups (t=2.836, p=0.065). Knowledge about lifestyle modification was also low in both groups (t=0.256, p=0.7989). Practice of lifestyle modification as reported by the participant was also inadequate (t=1.390, 0.1705). Intervention was given and there was significant increase in the level of knowledge about hypertension and lifestyle modification (t=2.665, p=0.010) and (t=4.741, p=0.001) and improvement on their practice ((t=5.599, p=0.001)) after intervention.

The study concluded that, there is relationship between knowledge and practice, hence, it is pertinent that health care providers especially the nurses should help provide continuous and focused health education and training for the hypertensive in order to improve their knowledge and practice of lifestyle modification therefore controlling their blood pressure and reducing the risk for cardiovascular diseases. It is therefore recommended that health sector should intensify efforts on health educating the populace on the type of lifestyle that put them at risk of developing hypertension.

  • Keywords; Hypertension, Lifestyle modification, Effect, Knowledge, Practice
  • Word Count; 495

Table Of Contents


Content Page

  • Title Page
  • Certification
  • Dedication
  • Acknowledgements
  • Abstract
  • Table of Contents
  • List of Tables
  • List of Figures
  • List of appendices

Chapter One:

Introduction

  • 1.1 Background to the Study
  • 1.2 Statement of the Problem
  • 1.3 Objective of the Study
  • 1.4 Research Questions
  • 1.5 Hypotheses
  • 1.6 Scope of the Study
  • 1.7 Significance of the Study
  • 1.8 Justification for the Study
  • 1.9 Operational Definition of terms

Chapter Two:

Review Of Literature

  • 2.0 Introduction
  • 2.1 Definition, Types, Causes and Signs and Symptoms
  • 2.2 Prevalence of Hypertension
  • 2.3 Management of Hypertension
  • 2.4 Hypertension Morbidity and Mortality
  • 2.5 Existing Programs/Interventions for Controlling Hbp
  • 2.6 Empirical Review
  • 2.7 Theoretical Review
  • 2.8 Conceptual Model

Chapter Three:

Methodology

  • 3.0 Introduction
  • 3.1 Research Design
  • 3.2 Population
  • 3.3 Sample size and sampling Technique
  • 3.4Instrumentation
  • 3.5 Validity of Instrument
  • 3.6 Reliability of Instrument
  • 3.7 Method of data Collection
  • 3.8 Method of Data Analysis
  • 3.9 Ethical Consideration

Chapter Four:

Data Analysis, Results And Discussion Of Findings

  • 4.0 Introduction
  • 4.1 Socio-demographic data of the participants
  • 4.2 Pre-intervention
  • 4.3 Post intervention
  • 4.4Hypotheses Testing
  • 4.5 Discussion of Findings
  • 4.6 Application of the conceptual model (precede procede theory)

Chapter Five:

Summary, Conclusion And Recommendations

  • 5.1Summary
  • 5.2 Conclusion
  • 5.3 Recommendations
  • 5.4 Limitation of the Study
  • 5.5 Suggestion for Further Studies
  • References
  • Appendices

List Of Tables


Table Page

  • 4.1 Socio-demographic data of the participants
  • 4.2.1 Pre intervention knowledge about hypertension
  • 4.2.2 Summary of responses on knowledge about hypertension
  • 4.2.3 Significance of knowledge about hypertension pre intervention
  • 4.2.4 Pre intervention knowledge about lifestyle modification
  • 4.2.5 Summary of responses on knowledge about hypertension pre intervention
  • 4.2.6 Significance of knowledge about lifestyle modification pre intervention
  • 4.2.7 Practice of lifestyle modification pre intervention; Diet section
  • 4.2.8 Summary of responses to practice of lifestyle modification pre intervention
  • 4.2.9 Significance of practice of lifestyle modification pre intervention
  • 4.3.1 Knowledge about hypertension post intervention
  • 4.3.2 Summary of responses on knowledge about hypertension post intervention
  • 4.3.3 Significance of knowledge about hypertension post intervention
  • 4.3.4 Knowledge about lifestyle modification post intervention
  • 4.3.5 Summary of responses on knowledge about lifestyle modification post intervention
  • 4.5.6 Significance of knowledge about lifestyle modification post intervention
  • 4.5.7 Practice of lifestyle modification post intervention: Diet section
  • 4.5.8 Summary of responses on practice of lifestyle modification post intervention
  • 4.5.9 Significance of practice lifestyle modification post intervention
  • 4.5.10 Effect of the training programme on control group
  • 4.5.11 Table Effect of the training programme on Experimental group
  • 4.6.1 Effect of the training programme on knowledge about hypertension and lifestyle modification in both control and experimental groups. (Post intervention).
  • 4.6.2 Effect of the training programme on practice post intervention in both groups

List Of Figures


Figure page

  • 2.7 Application of Procede-Preced theory
  • 2.8 Conceptual Model

Appendices


  • Inform consent
  • Questionnaire
  • Teaching plan
  • Notification for ethical clearance
  • Ethical approval
  • i. LASUTH
  • ii. LUTH
  • iii. BUHREC

List Of Abbreviations


  • LASUTH – Lagos State University Teaching Hospital
  • LUTH – Lagos University Teaching Hospital
  • HIN – Hypertension
  • BP – Blood Pressure
  • SBP – Systolic blood pressure
  • DBP – Diastolic Blood Pressure
  • DASH – Dietary Approaches to Stop Hypertension
  • DALYS – Disability adjusted life years
  • US – United State
  • UK – United Kingdom
  • AHA – American Heart Association
  • JNC7– Joint National Committee on detection, Evaluation and Treatment of High Blood Pressure (JNC7)
  • ADA – American Diabetics Association

Chapter One


Introduction

1.1 Background to the Study

Hypertension is the most common non-communicable disease and the leading cause of cardiovascular disease in the world. Many people with hypertension are unaware of their condition making treatment infrequent and inadequate, which is responsible for it poor control and not always taken seriously (Neutel & Campbell, 2008). Majority who are suffering from hypertension have a type of hypertension called essential hypertension or type one hypertension. Heredity and unhealthy lifestyle have been widely acceptable has being responsible for this type of hypertension. This has become a menace especially in Africa because of the adoption of western lifestyle, coupled with its challenges of unhealthy environment, poverty, lack of health seeking behaviour, lack of health insurance and sedentary life lived by many.

According to Seven Joint National Committee Criteria (JNC7), the precise rule for the treatment of hypertension begins with lifestyle modifications and ends with medication. Unfortunately, many patients diagnosed to be hypertensive don’t usually have proper knowledge about lifestyle modification. Studies on lifestyle modifications have revealed that modifications such as weight loss, taking Dietary Approaches to Stop Hypertension (DASH) diet, exercising and reducing salt consumption would be effective in lowering blood pressure and reducing its complications especially the rate of morbidity and mortality of cardiovascular diseases (Jafari, Shahriari, Sabouhi, Farsani & Babadi, 2016).

Lifestyle modification is advised for all hypertensive, in respective of pharmacological treatment, because it may abolish or even reduce the need for medications. The goal of prescribed lifestyle changes is to lower blood pressure. This lifestyle changes also offers a lot of health benefits and better outcomes for common chronic diseases (Huang, Duggan & Harman, 2008). Yet studies have showed that ignorance and lack of knowledge and awareness are some of the barriers to having a healthy lifestyle and not controlling and preventing high blood pressure. It is assumed that increased knowledge about the role of lifestyle in the occurrence of high blood pressure would cause people to start modifying their lifestyles and enhance their preventive behaviours as supported by the results of a study which says `when the score of knowledge in high blood pressure patients increases by one, their score of practice would increase by 0.12. (Jafari, Shahriari, Sabouhi, Farsani & Babadi, 2016).

However, studies have shown that improving knowledge and awareness alone could not be enough to control the effects of diseases by itself but by increasing the score of attitude toward high blood pressure through reinforcement, systolic and diastolic blood pressures would decrease significantly. There are a lot of other barriers that can prevent individual to modifying their lifestyle but studies have showed that increased knowledge, attitudinal and change of perceptions will all lead to practice of lifestyle modification (Jafari, Shahriari, Sabouhi, Farsani & Babadi, 2016).

The recommended lifestyle modification such as, moderate alcohol intake, weight loss of 3% to 9% of body weight, the DASH diet, regular aerobic exercise, and reduced dietary salt are lifestyle modification that controls blood pressure. Depending on the type of intervention, blood pressure reduction of 3 to 11 mm Hg systolic and 2.5 to 5.5 mm Hg diastolic, are believed to have great influence on blood pressure reduction and ability to potentiate antihypertensive drugs. The recommended diet called DASH diet is low in total and saturated fat, sugar, sugary drinks, refined carbohydrates, and red meat but high in vegetables, fruits, whole grains, poultry, fish and low-fat dairy products. This DASH diet has long been documented to lower weight, risk of type 2 diabetes, heart rate, apolipoprotein B, homocysteine, C-reactive protein, and is accompanying by a lower incidence of stroke, heart failure, and all-cause mortality (Lochner, Rugge & Judkins, 2006).

In a premier trial, it was also documented that a reduction of 14.2/7.4 mmHg in blood pressure is attained when DASH diet is accompany by salt reduction and alcohol, aerobic exercise and weight loss, which also reduces the prevalence of hypertension from 38% to 12% over the period of six months. Reduce salt consumption by hypertensive patents, possibly the single most important hypotensive measure, entails regularly checking food labels for salt content, staying away from processed foods, and using spices and herbs for flavour. It is generally acceptable that personal efforts from the patients and reinforcing and enabling environment from health personnel will lead to a great success in diet and behavioural modification (Nicoll & Henein 2010).

Knowledge and practice of lifestyle modification among patients with high blood pressure has however been showed to be inadequate in some studies. In UK, Nicoll and Henein (2010) in their study revealed that many hypertensive patients are unwilling to accept that their lifestyle practices or choices have made a worthwhile contributed to their condition and may refuse advice to change, this may be true of other hypertensive patients. Therefore, health education about hypertension, its consequences and lifestyle modification is been advocated to begin as early as possible in population identified to be at risk (American Heart Association, 2010).


1.2 Statement of the problem

Despite the treatment guideline and numerous drugs available for the treatment of hypertension, having patients bringing their blood pressure under control has always been a mirage. Part of the guidelines for the treatment of hypertension is lifestyle modification. In terms of economic burden, morbidity, mortality, poorly controlled blood pressure is a considerable important public health concern among older adult in the world. High blood pressure is the leading and most significant modifiable risk factor for, stroke, heart diseases, renal diseases and retinopathy. Recent recommendations for the prevention and treatment of hypertension has placed importance on modifying lifestyle. It has been proven that lifestyle modifications that is capable of lowering hypertension include increased physical activity, weight loss, reduced sodium intake. This include, a diet rich in fruit, vegetables, and low-fat dairy products reduced in total and saturated fat (Al-wehedy, Abd Elhameed, & Abd El-Hammed, 2015).

Despite the above fact, it’s been documented in several studies that most hypertensive patients don’t have enough knowledge about lifestyle modification. In a study carried out among 101 participants on perception and practice of lifestyle modification in South-East Nigeria, it was revealed that about 87.1% of the participant were not aware that exercising regularly is part of lifestyle modification while 60% were not aware that alcohol intake should be of moderate consumption. The roles of unsaturated oil and reduction in diary food intake, vegetables, and fruits in the control of blood pressure were not aware by 80% and above. A little above 60% practiced salt restriction among 88% that has some knowledge of salt restriction. This is also applicable to the few with knowledge of weight reduction, regular exercise, fruit intake, cigarette smoking and alcohol moderation, respectively. The study shows there was a negative relationship between diastolic and systolic blood pressures and the level of practice. This typifies that knowledge level and practice of lifestyle modifications were poor among the studied participants. (Okwuonu, Emmanuel & Ojimadu, 2014).

This is in congruence with the researchers experience with patients, colleagues and family members who are diagnosed to be hypertensive, and are far away from modifying their lifestyle. This may be due to lack of adequate knowledge, belief and lack of reinforcement and enabling environment motivating them to modifying their lifestyle as documented. Jafari, Shahriari, Sabouhi, Farsani & Babadi, (2016), postulated that having knowledge or a partial knowledge and awareness alone will not lead to a change in health behaviours and practical application of knowledge but enhancement of awareness through appropriate educational programs. Therefore, this study is aimed at bridging the gap in knowledge and practice of lifestyle modification through a training programme.


1.3 Objective of the Study

The main objective of this study, is to determine the effect of a training programme on the knowledge and practice of lifestyle modification programme among hypertensive patients attending out-patient clinics in Lagos.

The specific objectives are to:

  1. Determine the existing knowledge level of high blood pressure and lifestyle modification among hypertensive patients in both groups;
  2. determine the level of reported practice of lifestyle modification among hypertensive patients in both groups;
  3. Implement a lifestyle modification programme among hypertensive patients and
  4. Determine the effect of a training programme on knowledge and reported practice of lifestyle modification among hypertensive patients in experimental group.

1.4 Research Questions

  1. What is the existing knowledge level about hypertension and lifestyle modification among hypertensive patients in control and experimental group?
  2. What are the reported lifestyle modification practices among hypertensive patients in both groups?
  3. What is the effect of a training programme on post intervention knowledge of hypertension, lifestyle modification and self-reported practice among hypertensive patients in experimental group?

1.5 Hypotheses

The hypotheses were tested at 0.05 level of significance

  • H1: Patients who attend the training programme will demonstrate high knowledge of hypertension and lifestyle modification than those who did not
  • H1: Patients who attend the training programme will report improved practice of lifestyle modification

1.6 Scope of the Study

This study was carried out on hypertensive patients attending general and medical outpatient clinic in Lagos University Teaching Hospital and Lagos State University Teaching Hospital. The pre-test reliability of instrument was carried out on patients with the same inclusion characteristics attending hypertension clinic in Crystal Specialist Hospital Akowonjo, Lagos.


1.7 Significance of the Study

Having established a correlativity between knowledge of hypertension, knowledge of lifestyle modification and its practice, this study therefore has helped to support this claim and its effectiveness, by increasing participants’ knowledge, thereby preventing the eminent complications of unhealthy lifestyle and increase the number of patients practising positive lifestyle modification. Hence, this study gave a focus training on lifestyle modifications, having acquired knowledge on hypertension and its treatment as a registered nurse with many years of experience and a master’s student undergoing a training as an advanced nurse practitioner in adult health.

This study is also appropriate and significant because it has added to the body of knowledge in healthcare system by emphasising to the physicians and nurse clinicians the need to focus more on lifestyle modification than sole dependence on antihypertensive. This study is also beneficial to patients by bringing to their awareness the magical role lifestyle modification can play in the management of their blood pressure thereby preventing life threatening complications. In precise terms, this study is without doubt, a useful tool in projecting the contributions of nurses to the body of knowledge on non-pharmacological treatment of hypertension through their skill of health education.


1.8 Justification for the Study

Nigeria is gradually shifting from treating communicable diseases to non-communicable diseases. High blood pressure is one of the non-infectious diseases whose prevalence and complication has become an increasing problem, with a lot of Nigerians suffering from strokes and other coronary artery disease. Globally, hypertension is implicated to be responsible for 45% deaths from heart disease and 51% of deaths due to strokes (WHO, 2013).
African region out of the six other regions also has the highest occurrence of high blood pressure estimated at 46% of adult from age 25 and above of which Nigeria contributes significantly to the increase, this is according to WHOs Global status report on non- communicable diseases in 2012, (JCN, 2013). This is so in spite of the accessibility to safe and potent drugs for hypertension and the availability of treatment guidelines, hypertension is still grossly not controlled in a large proportion of patients worldwide. Lack of awareness of lifestyle modifications, and inability to practice these were one of the identified patient- related barriers to hypertension control (Shibiru, Bayeta, Selamu, & Eliyas, 2016).

This study might help the non-hypertensive to avoid hypertension through lifestyle modification, as the number of people diagnosed with hypertension is on the increase on a daily basis, thereby reducing its level of prevalence. Therefore this study is needed in order to increase the number of hypertensive patients who will meet the target goal blood pressure of less than 140/80mmHg according to Joint national committee on the prevention of hypertension (JNC, 2013).


1.9 Operational Definition of Terms

Effect:

These are the outcome of the training programme on lifestyle modification.

Hypertension:

hypertension is defined as a systolic blood pressure (sbp) of 140 mmHg or more, or a diastolic blood pressure (dbp) of 90 mmHg or more, or taking antihypertensive medication.

Adult Patient:

Anyone aged 21 and above diagnosed with high blood pressure of above 140/90mmhg who is on antihypertensive medication or not, attending the out-patient clinics.

Lifestyle Modification:

Are the health promoting lifestyle such as physical activity, nutrition, quitting smoking, reduced alcohol reduction which when practiced bring about reduction in blood pressure.

Programme:

Are strategies or interventions put in place to help client have a better understanding of lifestyle modification and management of hypertension.

Knowledge:

This is the understanding of what lifestyle modification is before and after the intervention programme.

Practice:

These are the lifestyles behaviour of the participants reported before and after the lifestyle modification programme as assessed by their responses in pre and post-test results using questionnaire.


Chapter Five


Summary, Conclusion And Recommendations

5.1 Summary

This study investigated the effect of a training programme on knowledge and practice of lifestyle modification among hypertensive patients. The purpose of the study was to determine the effect of a training programme on knowledge about hypertension and it treatment, knowledge of lifestyle modification and practice of lifestyle modification. To answer this, three research questions were raised and two hypotheses formulated. A quasi experimental design was adopted for the study. The population of the study consist of 60 participants, 30 from Lagos university teaching hospital used for the experimental group and 30 from Lagos state teaching hospital for the control group.

Two instruments, a modified structured questionnaire from World health organization for hypertensive patients, hypertension knowledge-level scale (HK-LS) and institute de recherches cliniques de montreal were used to measure knowledge of hypertension, lifestyle and reported practice. The instrument for data collection were modified hypertension knowledge-scale (HK-LS). The reliability test was carried out at Crystal Specialist hospital Akowonjo, Lagos, using 11 questionnaires and the Alpha Chronbach score of 0.793 was obtained. The final instrument were personally administered through interview and collected. The data were analyzed and interpreted using percentages, and frequency distribution tables, and Chi-square was used to determine the level of knowledge and practice pre and post in the control and study groups. The findings showed there was fair knowledge about hypertension in both groups but low knowledge about lifestyle modification and inadequate practice of lifestyle modification. The findings also showed an increased in knowledge and practice after intervention.


5.2 Conclusion

This study was carried out to determine the effect of lifestyle modification programme on knowledge and practice of lifestyle modification among adult hypertensive patients. This was related to the fact that despite the availability of different drugs option for the control of hypertension and advice to modify lifestyle, millions of people are living with the disease and new diagnosis are made every day. It was showed that training was associated with improved knowledge and practice of lifestyle modification. Hence, this study has helped to validate that training on lifestyle modification is effective in increasing level of knowledge and improving practice as reported by the participants.

This is clearly showed in Table 10 and 11.

It is therefore pertinent that health care providers especially the nurses must help provide continuous and focused health education and training for the hypertensive in order to empower them to practicing positive health behaviours that will in a long run help them control their blood pressure. This is also important because a reduction in blood pressure as low as 2mmHg is capable to reduce the risk of cardiovascular diseases by 15% ( Oza & Garcellano, 2015).


5.3 Recommendations

Based on the findings of this study, the following recommendations are made which call for the health sector to intensify effort on health educating the populace on the type of lifestyle that put them at risk of developing hypertension. Other recommendations are:

  1. There should be an advancement of the usual health talk at the medical out-patient clinics for the hypertensive to make it more focused and intentional towards promoting lifestyle modification. Also more time should be giving to health talk than the usual 10 to 15 minutes during the clinic2
  2. Increase awareness of hypertensive patients about risk factors of hypertension is important to motivate them to adopt healthy lifestyle to control the disease
  3. There should be regular jingle on the importance of lifestyle modification via mass media.
  4. Periodic training on lifestyle modification should be part of the treatment guideline for hypertensive patients.
  5. The relationship between health personnel and the patients should be based on trust which is important in motivating the patients to change their lifestyle behaviours.
  6. Encouraging hypertensive patients to sustain the practice of lifestyle modification such as regular exercise, maintaining healthy weight, consumption of DASH diet, quitting smoking and reduced alcohol consumption, salt restrictions and reducing stress.
  7. The findings of this study can help in developing health planning programmes to control hypertension, prevent complications in hypertensive and prevention for non-hypertensive individual.

5.4 Limitation of the study

Some limitations were encountered in the course of the study despite the research objectives were met. First, it was difficult randomizing the participants because the number of patients seen at the general out-patients clinic per day who met the inclusion criteria were few. Hence, purposive sampling method was use, which could limit the generalization of this study. Secondly, having all the patients in one session for the training progamme and for posttest was difficult, hence, the participants were taking in sessions. 25 participants in the experimental group and 20 in the control group were present for posttest as against 30 for the pretest.

Although lifestyle modifications focusing on knowledge and practice were the independent variables intended to be studied, there was an indication that other variables not included in this study could be effective in the control of blood pressure. Measurement of blood profile such as cholesterol level and triglycerides were not included because of financial constraints. In the same vein, limited time and financial resources made the study to take place only in LUTH and LASUTH. This challenges the generalizability of the study.


5.5 Suggestion for further studies

  1. This study was carried out within a short period of time, future researchers should consider giving more time for same study in order to follow up participant practice of lifestyle modification.
  2. For a wider generalization of the findings, future researchers in this area of study should enlarge the study setting in order to have a broader national outlook.
  3. This study is based on effect of a training programme on knowledge and practice of lifestyle modification, further studies should include the measurement of clinical parameters indicating effect of practice of lifestyle modification on blood pressure control. E.g. measurement of cholesterol level, triglycerin, body mass index etc.
  4. Further studies should also consider factors that may influence the practice of lifestyle modification among hypertensive patients.

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