EFFECT OF A TRAINING PROGRAMME ON KNOWLEDGE AND PRACTICE OF LIFESTYLE MODIFICATION AMONG HYPERTENSIVE PATIENTS ATTENDING OUT-PATIENT CLINICS

1.0 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).

1.1 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.

1.2 Aim and Objectives of the Study

The main aim 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.

1.3 Research Questions

The study came up with research questions so as to be able to ascertain the above stated objectives. The specific research questions for the study are stated below as follows:

• What is the existing knowledge level about hypertension and lifestyle modification among hypertensive patients in control and experimental group?
• What are the reported lifestyle modification practices among hypertensive patients in both groups?
• 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?

1.4 Hypotheses

In order to pursue the objective of this study, the following generalized statements have been designed to guide and aids in obtaining the result for the experiment to be conducted. For this work, the null hypothesis will be represented with H0 while the alternative hypothesis will be represented with hypothesis H1.

• H₀1: Patients who attend the training programme will demonstrate high knowledge of hypertension and lifestyle modification than those who did not
• H₀2: Patients who attend the training programme will report improved practice of lifestyle modification

1.5 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.

1.6 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.

1.7 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).

1.8 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.