A DESCRIPTIVE STUDY TO ASSESS THE LEVEL OF

KNOWLEDGE REGARDING LIFE STYLE MODIFICATION

AMONG HYPERTENSIVE PATIENT

INTRODUCTION:

“We cannot change our genes or sex, but we candefinitely modify our life
style there by protecting our self from hypertension”
Robert C Schlant (2000)

Hypertension, the silent killer which remains asymptomatic until the

damage effect of it can be seen. Hypertension an important and common risk
facts for considerable morbidity and mortality not only in the industrialiazed
world but also in developing countries thus, the problem of hypertension can be
truly considered as pandemic
Hypertension is one of the most significant public health problem and a
common lifestyle disease today in india. In 90% patients the cause is is
idiopathic around 50% of the population remain undiagnosed.
The Factors contributing to the increased prevalence of hypertension are
mainly environmental factors. Genetic factors and factors like alcohol intake,
highfat intake, body mass intex and hormonal problem / hypertensive when
compased to normotensives develops twice as much as coronary heart disease,
Four times as much congestive heart failure and seven times as much stroke this
risk factors can be conquered through lifestyle modification.
Life style modification are universally accepted not only as the first step in
the management of hypertension but also as a way to prevent hypertension In
addition to lowering blood pressure this measures can also reduce other
cardiovascular risk factors. cost involved is minimal and true are

hardly any risks, Hypertensive patients irrespective of this stage or grade should
be motivated to adopt this measures.

Lifestyle modification among hypertension is indicated for all

patients with hypertension, regardless of drug therapy. It may reduce,
or even abolish, the need for antihypertensive drugs.

1. Regular physical activity

2. Smoking cessation
3. Dietary modification
4. Weight reduction
5. Limiting alcohol
6. Supporting long-term lifestyle changes

Knowledge regarding hypertension is an important measure used for

decreasing the prevalence of hypertension study conducted in malicuye,
hazarika and et al (2005) reported that only 13.6% of the hypertensive were
aware of this elevated blood pressure status only 8.7% were taking regular
treatment. The increase level of knowledge on lifestyle changes will help to have
desired intervention goal in people who are most motivated.
NEED FOR STUDY:
A study conducted on prevalence of hypertension report that 972 million
people in the world are suffering with this problem. According to experts,
Hypertension is likely to end up being an epidemic in the near future likely 1/3
of the population world suffer from hypertension by the year to 2020.
In India 100 million patients are with hyper tension. Over all estimate for
the prevalence of awareness, Treatment and control of blood pressure (BP) are
25.3%, 25.1 and 10.7 for rural Indians and 42%, 37.6% and 20.2% for urban
Indian respectively.
Overall standarlized prevalence of Hypertension was 26.3% (Self report :
5.5% newly defected 20.8%) urban resisdents of Tamilnadu. Jharkhand,
Chandigarh and Maharashtra (31.5, 28.9, 30.7 and 28.1%) had significantly
higher (26.2, 21.7, 19.8 and 24.0% respectively)
The Urban and rural areas for awareness and control of hypertension
P=0.002 and 0.03 respectively) one recent study should that young people
working in IT industry have high BP because of their lifestyle youngsters spend
more time on smart phone and seem to be living in a virtual world instead of
being physically active. A study by Doris, Samuel and Stephen(2007) studied the
relation between the knowledge about hypertension and life modification in
591 hypertensive patients were acquainted with non pharmacological
treatment. Physical activity 49 percentage reduction of salt in take 54
percentage where relaxation techniques where only known to 17 percentage
this study concluded that knowledge in our population insufficient.
As per above studies increased knowledge about life style
modification helps to control blood pressure level and prevent the complications
hence the researcher have selected the study to asses the knowledge on life
style modifications.
STATEMENT OF PROBLEM:
“A Study to Assess the Knowledge, Attitude and Practice of Lifestyle
Modification among Hypertensive Patients at Selected Hospitals in Salem.

OBJECTIVES OF THE STUDY:

  To assess the Knowledge of hypertensive patients regarding life
style modification
 To associate the level of knowledge of hypertensive patients with
their selected demographic variables
 To associate the knowledge of hypertensive patients with their
demographic variables.
OPERATIONAL DEFINITIONS:
 Assess : Gathering information about knowledge on lifestyle
modifications among Hypertensive patients
 Knowledge : Verbal response from hypertensive patients regarding
lifestyle modifications
 Attitude : It refers to complex mental state evolving believes ,
feelings, values, and disposition to act in certain ways
 Lifestyle modification : Changing the activities of life such as
physical activity, diets, and behavioral modification which maintain
healthy living.
 Hypertensive patients : a person (male or female) who is between
35 to55 years of age and Having systolic blood pressure more than
140 mm Hg and diastolic blood Pressure more than 90 mmHG at
the time of data collection .

HYPOTHESIS:
 H0-There will be significant relation ship between knowledge attitude
and practice regarding life style modification among hypertensive
patients
 H1-There is significant difference between knowledge and attitude
regarding prevention of hypertension
 H2- There is significant difference between knowledge and practice
regarding prevention of hypertension
ASSUMPTION:
 Hypertensive patients may have inadequate knowledge regarding
prevention and Control of hypertension
 Adopting lifestyle modification can prevent complication of
hypertension.
DELIMITATION:
Study is limited to patients with hypertension who are attending the out patient
department and general wards of the selected hospitals at Salem.

PROJECTED OUTCOME:
The study will provide knowledge to patient about the lifestyle modification.

REVIEW OF LITERATURE
Review of literature of an essential component of research study as it
provides a broad understanding of the research problem. The investigator has
made a thorough study on the available research sources, which has helped in
projecting the widened perspective of the study.

 Studies related to incidence and prevalence

 Studies related to risk factors of hypertension
 Studies related to complication of hypertension
 Studies related to life style modifications
 Studies related to knowledge on life style modifications

REVIEW OF LITERATURE RELATED TO INCIDENCE AND PREVALENCE

Kearney,Practicia, whelton and et al 2004 carried a study on world wide
prevalence of hypertension a systematic review of published studies. result
revealed was prevalence of hypertension of varied around the world , with the
lowest prevalence in rural India 3.4%in men and 6.8%in women and highest
prevalence in Poland 68.9 % in men and 72.5% in women and were concluded
that hypertension is an important public health challenge in both economically
developing and developed countries
Burt,whelton,Rocella and et al (2000) conducted a study on prevalence
on hypertension in US adult population . the study revealed that 24 % of US
adults had hypertension. The need for intense campaign to reduce the
prevalence of hypertension was explained in study
Shyamal Kumar, Kalian and et al 2007 conducted a study of urban
community survey in India; growing trend of high prevalence of hypertension in
a developing country . participants were1609 under cross sectional survey of
validated and structured questionnaire followed by blood pressure
measurement result showed that systolic hypertension is greater than or equal
to 140 mm of hg was present in 40.9% and diastolic hypertension greater than
or equal to 90 mm of hg in 29.3%
Deshmukh , guptha , barambe and et al conducted a study on the
prevalence of hypertension in rural Wardha , central India it was a cross section
study . the study revealed that over all prevalence of hypertension was found to
be 20.6% and concluded that prevalence of hypertension is high an appropriate
programme shall be launched considering modifiable risk factors in the area are
BMI and waist and hip ratios .
Joshi , chowdary and et al 2007 done a simple randomized study to
measure prevalence of hypertension in 20 villages broadly represent of east and
west godawari region of Andhra Pradesh random sample of 4535 adults of age
30 years and over reported that 26.6 % are of male hypertensive patients and
27.5% are of female hypertensive the researcher emphasize the need of
prevention of hypertension.
Review of literature related to the risk factors
Nanette Lawrence Jeanne and et al 2005 studied the ethnic differences in
th association between age and hypertension A randomized control trait shows
that hypertension was present in 40% of elderly men and 50% of elderly women
and 60% in non Hispanic white , 71%of non Hispanic African Americans and
61%of Mexican Americans older than 60 tears of age concluded that age and
ethnicity is risk factor for hypertension.
Burke, hender,loe and et al 2007 done a study on alcohol intake
incidence of coronary disease in Australians. The participants were 258 men and
256 women . the study reported that those who were drinking 41 to60 gram per
day in men are 21 to 40 gram per day in women that hazard ratio is 95 % and
91% respectively conclusion is that alcohol consumption should be limited to
reduce the heart disease risk.
Stevens, obarzanek, appel and et al (2001) conducted a study on
association of BMI and hypertension . a random control trials shows that 65% of
US adults have a body mass index greater than or equal to 25 kg meter square
among 30% are of hypertensive, the study concluded that there is an increased
association of BMI and hypertension.

REVIEW OF LITERATURE RELATED TO COMPLICATIONS OF HYPERTENSION

Giovinna ,leoneni, franeesa and et al 2003 conducted a study on renal
dysfunction in renal hypertension in 358 untreated patients with hypertension
.the study revealed the prevalence of renal dysfunction left ventricular
hypertrophy and carotid plague was 18% , 48%,28% respectively the study
concluded that the presence of renal dysfunction and cardio vascular mortality
and morbidity rates in high in patients with hypertension.
Toni Rizzo, Angela, Thomson and et al 2004 conducted a study on risk of
coronary heart disease and stroke in hypertension . a prospective study with
418,343 participant aged 25- 84 years. None of the study participants had
clinical evidence of coronary heart disease and hypertension and they were
followed for an average of 10 years the study revealed that prolonged difference
in usual diastolic blood pressure of 5,7.5 and 10 mm of hg were respectively
associated with at least 34 % ,46%,56%% lower incidence of stroke and at least a
21 % ,29% and 37% lower incidence of coronary heart disease
REVIEW OF LITERATURE RELATED TO LIFE STYLE MODIFICATIONS
Miller ,Erlinger,Young and et al 2002 done a study on the result of the
diet, exercise and weight lose intervention trail .A randomized controlled trail of
44 hypertensive over weight adults on a single blood pressure medications ,
participants were randomized to a life style are controlled group. Result at the
end of intervention was the mean weight loss in the life style group, met of
control was 4.9 kg and also met reductions in systolic and diastolic blood
pressure in conclusion among in hypertensive over weigh adults , already on
anti hypertensive medications a comprehensive life style intervention can
substantially lower blood pressure and improve blood pressure control
Dekat and Balzo 2000 conducted a study on a 5 years follow up preventive
approach patients with essential hypertension researcher examine the effect of
a 4-56 week programmed consisting of hypertension control education, physical
education and smoking cessation on a long time risk factor control participants
were 220 hypertensive males .at 5 year follow up 80%of cases, the Bp was either
the same or lower than initially , 84% of patients improve their general health.
Thus intensive short term intervention studies made help to reduce some cardio
vascular risk factor temporarily
Stewart, noakes,Eales and et al 2005 conducted a study adherence to
cardio vascular risk factors modification in patients with hypertension. A
randomized control trial in patients with hypertension the thing primary
outcome measured after the 24 weeks intervention was blood pressure change.
Secondary outcome included patients adherence to the proggramme, their
knowledge about hypertension exercise capacity, body weight, self reported
ability control stress adherence to medication and salt restriction. Secondary
outcomes did show positive changes as a result of the given intervention and
concluded that patience in a supportive environment such as the one in this
study were able to modify their cardio vascular risk factors
Dunn, Marcus, Kampert and et al 2000 done a study on comparison on life
style and structured intervention to increase the physical activity and cardio
respiratory fitness , a randomized trail .participants were sedentary men N=116
and women N=119 the intervention was made for 6 months of intensive and 18
months of maintenance. Intervention on either a life style physical activity on a
traditional structured exercise program. They concluded that both the life style
and structured activity groups had significant and comparable improvements in
physical activity and cardio respiratory fitness.

Svelte, Erlanger, voliner and et al 2005 conducted a study on effect on life

style modifications on blood pressure by race , sex, hypertension status and
age . A randomized trail tested multy component life style interventions on BP in
demographic and clinical sub groups . this study population was 810 individuals
they concluded that divorce groups of people can adopt multiple life style
changes that can lead to improved BP control and reduced coronary vascular
risk .
REVIEW OF LITERATURE RELATED RELATED TO KNOWLEDGE ON LIFE STYLE
MODIFICATION
Jiang, Tang, lie and et al 1999 studied on the awareness treatment and
control of hypertension in patients attending hospital clinics in China.
Participants were the patients over the age of 35 years who were attending out
patients clinics in 18 major hospitals in China a cross sectional survey , a total of
9703 volunteers enrolled , of which 4510(46%)were hypertensive . among of
those hypertensive 24% were unaware of control of hypertension
Megan, eynolds,kristi and et al 2004 conducted a study on level of
awareness , treatment and control of hypertension in different world regions . it
was the systematic review of published studies and the search was restricted to
studies published from in January 1980 through July 2003. result was awareness
of hypertension was reported for 46% of studies and varied from 25.2% in Korea
to 75% in Barbados.

Annette and stantum 2001 carried a study on determinants of adherence to

medical regiments by hypertensive patients.50 adults hypertensive patients at
health maintenance organization as attend the questionnaires and home
interviews over a ten week period. Structural modeling procedures revealed
that greater expectancy for internal control over health and hypertension,
greater knowledge treatment regimen and stronger social supports were
significant determinants of adherence, in turn higher level of adherence
facilitated blood pressure reduction.
 METHODOLOGY
This chapter deals with overall plan for addressing a research question,
including specifications for enhancing the study’s integrity. Research methods
are used to structure a study and to gather and analyze information in a
systematic fashion. The research incorporates some of the most important
methodological decisions that researchers make.

This research study was to assess the life style modification (exercise and
diet)parameters of Adults with Hypertension. This chapter includes various
aspects such as Research Approach, Research Design, Variables, Setting,
Population, Samples, Criteria for Sample Selection, Sampling technique ,
Sample size, Development and Description of the Tool, Content validity of the
tool, Reliability of the tool, Ethical Considerations, Pilot Study, Method of
Data Collection, data collection schedule, dropout analysis.
RESEARCH APPROACH

A Quantitative - evaluative approach using pre-test and post-test

was adopted in order to accomplish the main objective of this study. The
primary objective of this study is to determine the extent life style
modification (exercise and diet) level of Blood Pressure, Body Mass Index,
Cholesterol, Anxiety and Stress level among adults with Hypertension. Basic
distinction in quantitative experimental research are manipulation, control
and randomization. An experimental approach is characterized by
manipulation of independent variable and random assignment of subjects to
different conditions

RESEARCH DESIGN
The research design implied for this study was True experimental study in
nature i.e., before and after control group design. The strength of true
experiment lies in the fact that experimenter can achieve greater confidence in
the genuineness of casual relationships because they are observed under
controlled conditions [159].

Intervention & post

Pre assessment of
Group assessmen Biophysiopsychological
t parameters

Study group O1 X O2
Control group O1 -----

O1 : Pre-test assessment of Biophysiopsychological parameters like blood

pressure(sphygmomanometer), BMI(height & weight) Adults with
Hypertension

X : Administration of life style modification (exercise and diet)

O2 is the post- test assessment of Blood pressure every 2nd week.

VARIABLES
Independent Variables

It is the Variable that is believed to cause a change in dependent

variable. In this research study the independent variables are life style
modification for adults with Hypertension.

Dependent Variable
 It is the variable that is hypothesized to depend on or caused by
another variable. In this research study the dependent variables are Blood
Pressure, BMI.

Demographic Variables

Age, Gender, Education, Marital status, Work nature.

Clinical Variables

Duration of illness, Regularity of medications and Experience of

physical symptoms.

Extraneous Variables

It is the variable that confounds the relationship between independent

variable, Dependent variable and that needs to be controlled either in the
research design or through statistical procedures. In this study the extraneous
variables are Any life events in last year and Mass media.

SETTING

The research study was conducted at shri shellapha hospital OP Department

at Salem.

POPULATION
Target Population

It is the aggregate of cases about which the investigator would like to

generalize the findings. The target population for this study was all adults with
Stage 1(140-159mm of hg systole and 90- 99 mm of hg diastole) and Stage 2
(160-179mm of hg systole and 100- 109 mm of hg diastole) level of
hypertension.

Accessible Population

It is the aggregate of cases that confirm to designated criteria and that

are accessible as subjects for the study. The Accessible population for this
study was all adults with Stage 1 and Stage 2 level of hypertension at shri
shellapa hospital OP block.

SAMPLE

A sample is a portion of the study that has been selected to represent the
population of interest. In this study, the samples were adults with
Hypertension and those who fulfilled the inclusion criteria and who are
residing at shri shellapa hospital OP block.
CRITERIA FOR SAMPLE SELECTION
Inclusion Criteria

 Male and female adults who were in Stage 1 and Stage 2 level of
hypertension in the range of 140-179 systolic and 90-109 diastolic mm of
Hg
 Adults who were willing to participate in the study.
 Adults who knows Tamil and/or English.
 Adults who were taking anti-hypertensive medications (beta blockers)
 Adults who were in treatment for more than one year upto 5 years.
 Adults who were in the age group of 30-59 years.

Exclusion Criteria

 Adults who were alcoholics ,smokers, panparag and tobacco users.

 Adults who were having any past and present medical conditions
likediabetic mellitus, asthma, tuberculosis, cardiac problems, epilepsy,
vascular diseases, renal problems and hypercholestremia.(>240mg/dl as
per WHO criteria)
 Adults who were in antenatal, postnatal period and other like
gynaecological problem Dysfunctional utrine bleeding and prolapsed
uterus.
 Adults who were having musculoskeletal condition like arthritis,
osteoporosis.
 Adults with history of any exercise or regular yoga practice followed
after diagnosed as hypertension.

SAMPLING TECHNIQUE

Sampling is the process of selecting units for study from a

population. It is a process of selecting the subjects of the population in order to
obtain information regarding phenomenon in a way that represents the entire
population. The purpose of using a sampling technique is to increase
representativeness and to decrease bias and sampling error. Totally 30 samples
of 15 Study and 15 control group were selected by Simple Random
Sampling technique. From the shri shellapa hospital OP Block.

SAMPLE SIZE & SAMPLE SIZE CALCULATION

The sample size of this study was 30 Adults with hypertension

who were residing in selected villages,shri shellapa hospital OP Block. The
Study group consists of 15 samples and control group consists of 15 samples.
The sample size calculation was based on the pilot study findings of Blood
pressure using sphymonometer.

Power Analysis Formula:

N =2(Z +Z1 )2 (S12+S22)

(m 1- m 2) 2

DEVELOPMENT, DESERIPTION AND SCORING INTERPRETATION

OF THE TOOL.
Extensive review of Literature, discussion and views of experts
enhanced the development of the tool. The tool consists of 3 Sections
and explained as follows

Section A
It consists of Part I and Part II
part I: Demographic variables : It Consists of Questions related to
Socio-demographic variables like Age, Gender, Education, Marital
status, Work nature, Dietary pattern.

Part II: Clinical Variables: Duration of illness, Any life events,

Regularity of medications and Experience of physical symptoms.
Scoring interpretations for the clinical parameters

1) Blood pressure: (Joint National Committee Criteria – VII)

[163]
i) Systolic pressure
a) < or 120- 139 mm - Normal SBP / Pre
of Hg Hypertension
 b) 140 - 159 mm of
Hg - Stage 1 Hypertension
c) 160 - 179 mm of
Hg - Stage 2 Hypertension
d) > 180 mm of Hg - Stage 3 Hypertension

ii) Diastolic pressure

a) < or 80 -89 mm of - Normal DBP/ Pre
Hg Hypertension
b) 90 - 99 mm of Hg - Stage 1 Hypertension
c) 100 – 109 mm of
Hg - Stage 2 Hypertension
d) > 110 mm of Hg - Stage 3 Hypertension

DESCRIPTION OF THE INTERVENTION

 The intervention for the study group consists of selected exercise

and diet. On the first day of the intervention, introduction about
hypertension, its management and needs related to hypertension
were assessed.

 The intensive training on steps of exercise was given to adults with

hypertension for 5 days continuously for 2 hrs per day by
investigator.

CONTENT VALIDITY OF THE TOOL

The content of the tool was validated by Various Experts

from the Fields of Nursing, Community medicine, and Research
Experts. Suggestions from the Experts were incorporated in the tool.
RELIABILITY OF THE TOOL

Reliability of the tool was assessed by using Cronbach

Alpha method and test retest method. Reliability correlation
coefficient value was

r = 0.78 for the Hypertension need assessment tool by

test retest method
The Correlation coefficient value showed a positive correlation. Hence
the tool was considered reliable for proceeding with the main study.

ETHICAL CONSIDERATIONS
Human rights
Formal approval was obtained from the Institutional review
board and Institutional ethical committee of shri Bharani College of
Nursing, Salem.
Dignity

 Informed consent was obtained from the samples related to

the study purpose, type of data, nature of commitments,
participation and procedure.
 Pilot study was executed to check the feasibility and time
requirement of the study.
 Adults with hypertension have the “rights to with draw
the/withhold the information was enforced before data
collection.
  Investigator’s contact information was disseminated to all
adults with hypertension those who have participated in the
study.
Confidentiality:

 Confidentiality and anonymity pledge was ensured.

Justice:

 The control group received hospital routine treatment which

includes Counseling on diet, exercises, and regular

 monitoring of blood Pressure.

 Level of satisfaction for yoga was assessed in the study group.

METHODS OF DATA COLLECTION.

Data collection process was as follows: The data

collection was done separately in the study and control group
from the selected villages respectively. The total data collection
process was carried out into three phases as follows.
First Phase
It includes the administration of pre-test to control and study group.

The investigator has collected the required

data about sociodemographic and clinical variables from all the
adults of study and control group by means of personal interview
on the first day of contact with them. The investigator has spent
approximately 5-10 minutes per sample to collect the required
data.
 Then the investigator assessed the State Trait
Anxiety Inventory and Perceived Stress Scale for all samples in
study and control group. The investigator has spent
approximately 30 minutes per sample to collect data.

Second Phase
After the completion of baseline investigations, Life stye
modification based education was taught and demonstrated step
by step by the Investigator..
The intervention was given to the study group alone(15
adults in each group) for 5 days subsequently. This Intense
training includes demonstration of exercise by the Researcher
and return demonstration by the Adults with Hypertension and to
improve the level of confidence in the practice of exercise
clearing their doubts if any.
Adults of study group were strongly instructed and
motivated to follow their practice in their home for the period of
12 weeks and even after that to maintain optimum health.
The exercise practice was enforced by Participatory
approach every week, practice scores were assessed and more
than 80% scores were eligible to continue the study and they were
reminded through telephones.

Third Phase

The post-test assessment of Blood pressure was done at the

end of 2nd week to the study group and same assessment was done
to the control group too.
4. Adults who were having musculoskeletal conditions like arthritis, osteoporosis.

5. Adults with history of any exercise or regular yoga practice followed after diagnosed
as hypertension.