INTRODUCTION:

Background of the study:

Health is the soul that animates all the enjoyments of life. It is viewed differently by different people all over the world(Goel SL, 2007).¹ Disease or illness is the alteration in the state of the body or some of it organs, interrupting or disturbing the performance of vital functions, causing or threatening pain and weakness. It can be classified into infectious disease, contagious disease, communicable disease and non communicable disease. Non-communicable diseases are emerging as a major cause of morbidity and mortality worldwide. It causes 38 million deaths annually. WHO forecasts that globally, deaths from non communicable diseases are likely to increase by 17% over next 10 years. Seventy-five percent of this death will occur in developing countries. High blood pressure or hypertension is also a non communicable disease.²

The 5^th report of joint national committee in 1997 said that, there is a steady increase in the rate of hypertension over the last 50 years in India, more in urban areas than in rural areas. Across WHO regions research indicates that about 62% of strokes and 49% of heart attacks are caused by hypertension.³

blood pressure. These include weight loss in the overweight, physical activity, a diet with increased fresh fruits and vegetables and reduced saturated fat content, and reduction of dietary sodium intake. Lifestyle interventions also have the potential to reduce the need for or the amount of medications in hypertensives and prevent high BP from developing in non hypertensives.⁴

In this context, hypertension presents a major area of intervention because it is a frequent condition and is amenable to control through both non pharmacological lifestyle factors and pharmacological treatment. Prevention of hypertension by lifestyle modification may be one of the ways to decrease the CVD population risk attributed to hypertension. A variety of lifestyle modifications have been shown in clinical trials to lower blood pressure. These include weight loss in the overweight , physical activity, a diet with increased fresh fruits and vegetables and reduced saturated fat content, and reduction of dietary sodium intake. Lifestyle interventions also have the potential to reduce the need for or the amount of medications in hypertensives and prevent high BP from developing in non hypertensives.⁴

A cross-sectional study was done to determine the prevalence of hypertension in the age group of 30 years and above, in a rural community, Maharashtra. A random sample of 406 people of 30 years and above was selected from a rural area. The pre-tested proforma was used to collect the data by trained doctors. Study results revealed that the prevalence of smoking and tobacco use was 16%, alcohol intake 9.4%, daily salt intake (≥ 5 gram) 34.2%, daily saturated fat intake (≥ 10% of daily energy intake) 47 .0% and physical inactivity (work and leisure) as 18.5%. Body Mass Index (BMI) was ≥ 25 in 18% and ≥ 30 in 3.2% men and women. Differences in prevalence of risk factors between men and women were statistically significant in case of smoking, alcohol consumption and abdominal obesity. Prevalence of risk factors for hypertension was significantly more among subjects suffering from systolic and diastolic hypertension than normotensive subjects. Hence the study concluded that the prevalence of systolic hypertension in rural community was 18.5% and of diastolic hypertension 15% with higher prevalence in the age group of 60 years and above, in case of men and women. There was a significant linear trend in prevalence of systolic hypertension with respect to age group in men whereas it was not significant in case of women.⁵

The Nurse plays an important role in teaching patient with hypertension especially in the community set up, since without any lifestyle changes hypertension cannot be treated.The investigator was motivated to carry out this study to bring awareness among hypertensive patients on lifestyle modification, in the control of hypertension due to changes in people’s lifestyle, work related stress and altered food habits which is found more among urban community. After an extensive review of literature, the researcher has taken up this study to educate the hypertensive subjects on lifestyle modification. ⁶

MATERIALS AND METHODS:

Operational definitions:

Effectiveness:

In this study effectiveness refers to the extent to which the individual teaching programme will improve the knowledge and practice on lifestyle modification among patients with hypertension as evidenced by difference in post-test scores between Group 1 and Group II.

Knowledge:

Knowledge refers to the right response given by the patients with hypertension to the questionnaire related to lifestyle modification in hypertension.

Practice:

In this study practice refers to the score obtained from self practicing rating scale rated by patients with hypertension on the following aspects: regular exercise, weight reduction, diet modification, habits, and intake of antihypertensive medication.

Individual teaching programme:

In this study individual teaching refers to systematically developed instructional and teaching aids designed and given for individual patients with hypertension, on information regarding lifestyle modification to be followed by patients to prevent complications associated with hypertension.

Lifestyle modification:

In this study lifestyle modification refers to the measures that the patients with hypertension adopts to control their high blood pressure within the normal limits. It includes diet modification, regular exercise, weight reduction, cessation of smoking and alcohol consumption and regular intake of antihypertensive medications.

Hypertension:

In this study patients with hypertension are within the age group of 35- 55 yrs, those who are diagnosed to have essential hypertension( a rise in BP of unknown cause) and on treatment for more than 1 year.

Assumptions:

1. Patients with hypertension have limited knowledge on lifestyle modification in hypertension

2. Individual teaching program have some effect on the knowledge and practice of lifestyle modification among patients with hypertension.

Delimitations:

The study is delimited to

· Patients with hypertension only.

· Patient with hypertension who are available during the study.

Research Approach:

Quantitative evaluative research approach was adopted for this study in order to accomplish the envisaged objectives.

The research design selected for this study was Quasi experimental non equivalent pre-test post-test design.

The design can be represented as follows:

E O₁X O₂

C O₁O₂

E: Experimental group (hypertensive patients in urban community of Mangalore).

C: Control group (Hypertensive patients in urban community of Mangalore).

O₁: Pre-test on knowledge and practice score of hypertensive patients on lifestyle modification by using knowledge questionnaire and practice rating scale.

X: Individual teaching programme on lifestyle modification in hypertension.

O₂: Post-test on knowledge and practice score of hypertensive patients on lifestyle modification using knowledge questionnaire and practice rating scale.

The study was conducted in a selected community at Mangalore.

Population:

The population in the study comprised of all hypertensive patients in a selected community at Mangalore.

Sampling:

· Sample: The sample for the study comprised of hypertensive patients who resides in a selected community at Mangalore, and those who fulfil the inclusion criteria.

· Sample Size: The sample size for this study was 60 hypertensive patients. Among them, 30 hypertensive patients were selected to the experimental group and other 30 hypertensive patients were selected to the control group.

Sampling technique:

In this study purposive sampling is used to select the sample because of economy of time, money, access and feasibility.

All hypertensive patients of the selected communities who fulfilled the inclusion criteria and those who are available during the data collection are selected for the study.

Sample selection criteria:

Inclusion criteria:

· both male and female patients with hypertension are included in the study.

· adults in the age group of 35 to 55 yrs are included in the study.

· adults who are suffering with hypertension since 1 year.

Exclusion criteria:

· patients with hypertension who are not willing to participate

· those who are unavailable during the time of study

· who are above 55 years of age.

· patients suffering from other medical disorders.

Variables:

Independent variable: Individual teaching programme

Dependent variable: knowledge and lifestyle practice.

Extraneous Variable: Age, gender, education, occupation, habits, monthly income, height, marital status, duration of hypertension.

Data collection instruments:

Structured knowledge questionnaire is used to collect the baseline data and the knowledge on lifestyle modifications among hypertensive patients. Lifestyle practice is assessed using practice rating scale.

Description of the tool:

To conduct the study two tools were prepared.

Part I: Baseline proforma with 9 items like age, gender, religion, marital status, education, habits, previous information, and duration of hypertension. (Annexure 13)

Part II - Tool I: Structured knowledge questionnaire to assess the knowledge level of patients with hypertension on lifestyle modification.

Part III - Tool II: Practice rating scale to assess the lifestyle practise of hypertensive patients.

Content validity:

To ensure content validity the tool and the individual teaching lesson plan along with the criteria checklist is submitted to nine experts in the

Pre-testing of the tool:

The pre-testing is conducted from 15^th September 2013 to 18^th September 2013 at one of the communities in Mangalore.

Reliability of the tool:

The reliability coefficient for the questionnaire was computed using Karl Pearson’s correlation co efficient and Spereman rank correlation for the practice rating scale. The reliability coefficient of knowledge questionnaire and practice rating scale was 0.74 and 0.83.

Pilot study:

Pilot study was conducted in selected community (Athavar) at Mangalore from 2^nd October 2013 to 30^th October 2013. Pre-testing done for both the groups and individual teaching on lifestyle modification in hypertension given only for the experimental group. Knowledge was re assessed after 7 days and the practice was checked on the 28^th day. The data was analyzed using descriptive and inferential statistics.

Method of Data Collection:

Ethical consideration:

Formal permission was obtained from concerned authority before conducting the study. The purpose of the study was explained to the subject prior to the study to get their co-operation and the written consent was taken.

Data Collection Period:

The data was collected from 01-11-13 to 30-11-13.

Data Collection Procedure:

The patients who fulfilled the inclusion criteria were selected from the community by non probability purposive sampling technique. Out of 60 hypertensive patients, 30 hypertensive patients were selected to experimental group and 30 patients were selected to control group. In first week the researcher assessed the knowledge and lifestyle practice of both experimental and control group using structured knowledge questionnaire and practice rating scale. Individual teaching on lifestyle modification in hypertension implemented for experimental group and instructed to practice daily. Follow up was done through phone calls. The post-test was conducted for assessing the knowledge after 7 days and for the practice after 28 days for both experimental and control group.

RESULTS:

Hypotheses:

The following hypothesis will be tested at a .05 level of significance:

H₁: The mean post test knowledge score on lifestyle modification in hypertension is significantly higher than the mean pre test knowledge score among the hypertensive patients (Group I and Group II)

H₂: The mean post test practice score on lifestyle modification in hypertension is significantly higher than the mean pre test practice score among the hypertensive patients (Group I and Group II)

H₃: There is significant difference in the effect of individual teaching between Group I and Group II with respect to knowledge

H₄: There is significant difference in the effect of individual teaching between Group I and Group II with respect to practice

H₅: There is a significant association between pre-test level of practice on lifestyle modification in Group I and Group II with selected demographic variables among patients with hypertension.

Section I: Demographic characteristics:

This section describes the sample characteristics in terms of frequency and percentage and is depicted in Table 1.

Frequency and percentage distribution of sample according to demographic variable n=30+30

Sl. No. Demographic variable	Experimental group		Control group
Sl. No. Demographic variable	Frequency	Percentage	Frequency	Percentage
1. Age
a. 35-39 years	2	6.7	4	13.3
b. 40-44 years	8	26.7	9	30.0
c. 45-49 years	10	33.3	10	33.3
d. 50-55 years	10	33.3	7	23.3
2. Gender
a. Male	19	63.3	19	63.3
b. Female	11	36.7	11	36.7
3. Religion
a. Muslim	6	20.0	5	16.7
b. Hindu	12	40.0	13	43.7
c. Christian	12	40.0	12	40.0
4. Marital status
a. Single	1	3.3	1	3.3
b. Married	27	90.0	26	86.7
c. Widow/widower	2	6.7	1	3.3
d. Divorced/separated	0	0.0	2	6.7
5. Educational status
a. No formal education	5	16.7	6	20.0
b. Primary	8	26.7	8	26.7
c. Secondary	6	20.0	4	13.3
d. High school	4	13.3	2	6.7
e. Higher secondary	4	13.3	5	16.7
f. Graduation and above	3	10.0	5	16.7
6. From how many years you are suffering from hypertension?
a. 1-2 years	6	20.5	10	33.3
b. 3-4 years	15	50.5	14	46.7
c. 5-6 years	6	20.5	4	13.3
d. More than 6 years	3	10.0	2	6.7
7. Do you have the habits of smoking?
a. Yes	15	50.0	11	36.7
b. No	15	50.0	19	63.3
8. Do you have the habits of taking alcohol?
a. Yes	18	60.0	18	60.0
b. No	12	40.0	12	40.0
9. Do you have any previous information on lifestyle modification in hypertension?
a. Yes	6	20.0	4	13.3
b. No	24	80.0	26	86.7

Effectiveness of individual teaching programme on knowledge and practice regarding lifestyle modification in hypertension among hypertensive patients in experimental and control group

Frequency and percentage distribution of pre and post-test level of knowledge among hypertensive patients n=30+30

Level of knowledge	Experimental group				Control group
	Pre-test		Post-test		Pre-test		Post-test
	f	%	f	%	f	%	f	%
Adequate	1	3.3	28	93.3	1	3.3	3	10.0
Moderate	26	86.7	2	6.7	28	93.3	26	86.7
Inadequate	3	10.0	0	0.0	1	3.3	1	3.3

Significance of mean difference between pre-test and post-test knowledge scores on lifestyle modification in hypertension among hypertensive patients

To find the significance of mean difference between pre-test and post-test knowledge scores the following null hypothesis is stated:

H₀₁: There is no significant difference between pre-test and post-test knowledge scores on lifestyle modification in hypertension among hypertensive patients in Group I and Group II at 0 .05 level of significance.

Mean, Mean difference, standard deviation and ‘t’ value between pre-test and post-test knowledge scores n=30+30

	Mean	Mean diff.	SD	df	‘t’ value
Experimental group
Pre–test	15.93	9.17	3.46	29	16.960
Post–test	25.10	9.17	1.97	29	16.960
Control group
Pre–test	15.80	1.00	3.46	29	0.126
Post–test	16.80	1.00	3.21	29	0.126

t ₂₉=1.70, P<0.05

Hence null hypothesis is rejected and the research hypothesis is accepted. There is significant difference between mean pre-test and mean post-test knowledge score of hypertensive patients in the experimental group which indicate the effectiveness of individual teaching programme in enhancing the knowledge regarding lifestyle modification in hypertension.

Effectiveness of individual teaching on lifestyle modification in hypertension in terms of gain in practice

Frequency and percentage distribution of pre- and post-test level of practice among hypertensive patients n=30+30

Level of practice	Experimental group				Control group
	Pre-test		Post-test		Pre-test		Post-test
	f	%	f	%	f	%	f	%
Good	0	0.0	4	13.3	0	0.0	0	0.0
Average	19	63.3	26	86.7	20	66.7	29	96.7
Poor	11	36.7	0	0.0	10	33.3	1	3.3

Significance of mean difference between pre-test and post-test practice scores on lifestyle modification in hypertension among hypertensive patients.

To find the significance of mean deference between pre-test and post-test practice scores the following null hypothesis is stated:

H₀₂: There is no significant deference between pre-test and post-test practice scores on lifestyle modification in hypertension among hypertensive patients in Group I and Group II at 0.05 level of significance.

Mean, Mean difference, standard deviation and ‘t’ value between pre-test and post-test practice scores n=30+30

	Mean	Mean diff.	SD	df	‘t’ value
Experimental group
Pre–test	15.50	7.20	3.87	29	7.21
Post–test	22.70	7.20	4.19	29	7.21
Control group
Pre–test	15.63	0.47	4.33	29	0.43
Post–test	16.10	0.47	4.11	29	0.43

t ₂₉=1.70, P<0.05

Hence null hypothesis is rejected and the research hypothesis is accepted. There is significant difference between mean pre-test and mean post-test practice score of hypertensive patients in the experimental group which indicate the effectiveness of individual teaching programme in enhancing the practice regarding lifestyle modification in hypertension.

Effectiveness of individual teaching programme on knowledge and practice regarding lifestyle modification in hypertension among hypertensive patients between Group I and Group II

H₀₃: There is no significant difference in the effect of individual teaching among hypertensive patients between Group I and Group II with respect to knowledge at .05 level of significance.

Mean difference, standard deviation, and ‘t’ value of knowledge scores between Group I and Group II. n=30+30

	Mean diff	Table ‘t’ value	SD	df	‘t’ value
Group I	9.17	1.67	2.96	58	14.50
Group II	1.00	1.67	0.87	58	14.50

Hence null hypothesis is rejected and the research hypothesis is accepted. There is significant difference in the effect of individual teaching between Group I and Group II with respect to knowledge.

H₀₄: There is no significant difference in the effect of individual teaching among hypertensive patients between Group I and Group II with respect to practice at .05 level of significance.

Mean difference, standard deviation, and ‘t’ value of practice scores between Group I and Group II n=30+30

	Mean diff	Table ‘t’ value	SD	df	‘t’ value
Group I	7.20	1.67	5.47	58	4.55
Group II	0.47	1.67	5.98	58	4.55

Hence null hypothesis is rejected and the research hypothesis is accepted. There is significant difference in the effect of individual teaching between Group I and Group II with respect to practice.

Association of pre-test practice score among hypertensive patients with selected demographic variables in experimental and control group.

Association of the pre-test practice score with selected demographic variables

To find the association of the pre-test practice score with demographic variables, the following null hypothesis was formulated:

H₀₅: There is no significant association of the pre-test practice scores with selected demographic variables.

Chi-Square value of pre-test practice scores with selected demographic variables n=30+30

Demographic variables	Experimental group			Control group
Demographic variables	< median	≥ median	c² value	< median	≥ median	c² value
1. Age
a. < 44 years	3	7	0.424	3	10	1.635
b. ³44 years	10	10	0.424	9	8	1.635
2. Gender
a. Male	9	10	0.042	8	11	0.000
b. Female	4	7	0.042	4	11	0.000
3. Religion
a. Hindu	3	9	1.630	6	7	0.362
b. Others	10	8	1.630	6	11	0.362
4. Marital status
a. Married	12	15	0.000	10	16	0.000
b. Other	1	2	0.000	2	2	0.000
5. Educational status
a. Primary and below	7	6	1.033	5	9	0.201
b. Above primary	6	11	1.033	7	9	0.201
6. From how many years you are suffering from hypertension?
a. < 4 years	8	13	0.233	8	16	1.050
b. ³ 4 years	5	4	0.233	4	2	1.050
7. Do you have the habits of smoking?
a. Yes	7	8	0.136	4	7	0.000
b. No	6	9	0.136	8	11	0.000
8. Do you have the habits of taking alcohol?
a. Yes	7	11	0.362	7	11	0.023
b. No	6	6	0.362	5	7	0.023
9. Do you have any previous information on lifestyle modification in hypertension?
a. Yes	2	2	0.000	3	3	0.009
b. No	11	15	0.000	9	15	0.009

There is no association between the pre-test practice score and the selected demographic variable such as age, gender, religion, marital status, duration of hypertension, smoking, and drinking habits in both the groups. Hence the null hypothesis (H₀₅) is accepted for age, gender, religion, marital status, duration of hypertension, smoking, and drinking habits.

DISCUSSION:

Findings of the study and discussion:

Assessment of pre-test level of knowledge and practice of hypertensive patients regarding lifestyle modification in hypertension.

Findings of the present study reveal that in the pre-test of the hypertensive patients in the experimental group 10% obtained inadequate knowledge score, 86.7% obtained moderate and 3.3% had adequate knowledge score. Most of subjects (63.3%) had average practice, and 36.7% had poor practice. Whereas in the control group 3.3% obtained inadequate knowledge score, 93.4% obtained moderate and 3.3% had adequate knowledge score. Most of subjects (66.7%) had average practice, and 33.3% had poor practice.

The above findings are consistent with the descriptive study conducted to explore the knowledge, awareness and practice of lifestyle modification in hypertension at Chengdu city China. Study findings revealed that among 4141 subjects higher proportion of hypertensive patients (71.3%) showed inadequate knowledge on lifestyle modificational measures in hypertension and 41.4% had poor lifestyle practices⁷.

Section III: Assessment of post-test level of knowledge and practice of hypertensive patients regarding lifestyle modification in hypertension.

Findings of the present study reveal that in the post-test of the hypertensive patients in the experimental group 93.3% obtained adequate knowledge score and 6.7% obtained moderate knowledge score. The majority of subjects (86.7%) had average practice, 13.3% had good practice whereas in the control group 86.7% had moderate knowledge score, 3.3% obtained inadequate knowledge score and 10% had adequate knowledge. The majority of subjects (96.7%) had average practice, 3.3% had poor practice.

The above findings are consistent with the explorative study conducted on outcome following lifestyle changes among hypertensives in Goteberg, Sweden. Study findings revealed that one third of the study subjects (34.8%) had changed to good lifestyle practices and 93% has got adequate knowledge on lifestyle modifications in hypertension⁸.

Effectiveness of individual teaching on lifestyle modification in hypertension in terms of gain in knowledge and practice score

Findings of the present study reveal that Paired ‘t’ test value computed for the experimental group for knowledge 16.96 was more than the table ‘t’ value 1.70 at p<0.05. This shows there was a significant improvement between the pre-test post-test knowledge scores. Paired ‘t’ test value for the experimental group regarding the practice 7.21 was more than the table ‘t’ value 1.70 at p<0.05. This shows there was a significant improvement between the pre-test and post-test practice scores in the experimental group. Whereas in the control group Paired ‘t’ test value computed for knowledge 1.29 and for practice 0.49 was less than the table ‘t’ value 1.70 at p<0.05. Hence there was no significant improvement in the pre-test and post-test knowledge and practice score in the control group.

To check the effectiveness of individual teaching between experimental and control group unpaired ‘t’ test was computed. Calculated ‘t’ value for knowledge (14.50) and practice (4.55) were higher than the table ‘t’ value 1.70 which shows the effectiveness individual teaching with respect to knowledge and practice between experimental and control groups.

The above findings are consistent with the study conducted to assess the effectiveness of a PTP on knowledge and practice of lifestyle modification in hypertensive patients at Mediscope hospital Bangalore. Study revealed that Paired ‘t’ test value for knowledge 14.2 and for practice 6.3 were more than the table ‘t’ value 1.64 at p<0.001. Study concluded that there was a significant difference between the pre-test and post-test knowledge and practice scores.³

ACKNOWLEDGEMENT:

Author express sincere thanks to the experts for their valuable judgements, constructive recommendations and enlightening suggestions while validating the tool. Also extremely grateful to the district medical officer of Mangalore for granting the permission to conduct the study in their community area.

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Received on 06.10.2016 Modified on 22.12.2016

Asian J. Nur. Edu. and Research.2017; 7(2): 139-146.

DOI: 10.5958/2349-2996.2017.00028.3