RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA,

BANGALORE
ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

1. Name of the candidate and address JOHN SHINE

FIRST YEAR M. Sc. NURSING
CITY COLLEGE OF NURSING,
CITY ENCLAVE,
SHAKTHINAGAR,
MANGALORE 575016

2. Name of the Institution CITY COLLEGE OF NURSING,

CITY ENCLAVE,
SHAKTHINAGAR,
MANGALORE 575016

3. Course of study and subject M. Sc. NURSING

MEDICAL SURGICAL NURSING

4. Date of admission to the course 15.06.2012

5. Title of the study

A QUASI EXPERIMENTAL STUDY TO ASSESS THE

EFFECTIVENESS OF INDIVIDUAL TEACHING

PROGRAMME ON KNOWLEDGE AND PRACTICE

REGARDING LIFESTYLE MODIFICATION AMONG

PATIENTS WITH HYPERTENSION IN SELECTED URBAN

COMMUNITY AT MANGALORE

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6. Brief resume of the intended work
Introduction

Cardiovascular disease is the leading cause of morbidity and mortality worldwide

(Marais 2003:7). Waeber and Brunner (2002:8) also confirmed that despite all the effort
to diagnose and treat patients with high blood pressure, hypertension remains the leading
cause of cardiovascular morbidity and mortality1. Hypertension has become a significant
problem in many developing countries experiencing epidemiological transition from
communicable to non communicable disease. Every individual puts in an effort to make
his living comfortable, but doesnt realize how much stress and anxiety he exerts on his
body in the process. The stress and anxiety have adverse effect on the body systems, one
of which being the circulatory system. But the individual continues to remain
asymptomatic owing to the gradual onset and progressive damage occurring to the blood
vessels leading to hypertension.2 Hypertension or high blood pressure, is defined as a
persistent systolic BP 140 mmHg, diastolic BP 90 mmHg, or current use of anti
hypertensive medications.3 The 5th report of joint national committee in 1997 said that
there has been 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.4

6.1 Need for the study

Hypertension is associated with an increased risk of mortality and morbidity from

stroke, coronary artery disease, congestive heart failure and end stage renal disease. 4
Statistics shows that hypertension exists worldwide at an epidemic rate affecting an
estimated 1 billion people. It was found in 2000 that 26% of the adult population of the
world had hypertension, and by 2025, 29% were projected to have this condition. It was
also estimated that 972 million adults had hypertension in 2000, and it is predicted that
by 2025 the number of adults with hypertension will increase to a total of 1.56 billion. 1
The prevalence of hypertension in Indians is 25% in urban and 10% in rural population.
According to estimates, there are nearly 31.5 million hypertensives in rural and 34
million in urban population. Hypertension is directly responsible for 57% of stroke
deaths and 24% of coronary artery disease deaths in India.3 The latest statistics from the

Health Ministry of Karnataka shows that the lifestyle diseases are rampant in Bangalore;
14% of people among the total population are suffering from diabetes and high blood

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pressure5.

Hypertension cant be eliminated because there are no vaccines to prevent the

development of hypertension, but its incidence can be decreased by reducing the risk
factors for its development, which include obesity, high dietary intake of fat and sodium,
and low intake of potassium, physical inactivity, smoking and excessive alcohol intake. 4
Much of the risk associated with hypertension can be prevented by establishing effective
blood pressure control. Although there is increasing emphasis on treatment by
medication, lifestyle modification is an important part of hypertension management. 6

A study was conducted to assess the knowledge, attitude and practice of

hypertensive patients in Seychelles islands (Indian Ocean). A random sample of 1067
adults aged 25 to 64 years was selected for the study. A structured knowledge
questionnaire was used to assess the knowledge, attitude and practice. The study revealed
that the age-standardized prevalence of hypertension (screening blood pressure [BP]
160/95 mm Hg or taking antihypertensive medication) was 36% in men and 25% in
women aged 25 to 64 years (p<0.001). Among hypertensive persons, 50% were aware of
the condition, 34% were treated, and 10% had controlled BP (i.e., BP <160/95 mm Hg)
(p<0.01). Most persons, whether non-hypertensive, unaware hypertensive, or aware
hypertensive, had good basic knowledge related to hypertension determinants and
consequences. The study concluded that these data point to the need to maximize the
efficiency of hypertension prevention and control programs so that delay in achieving
effective hypertension control can be minimized.7

Poorly controlled hypertension ultimately can cause damage to blood vessels in

the eye, thickening of the heart muscle and hardening of the arteries of the heart (MI),
brain (stroke), and kidney (kidney failure).2 In recent years prevention, detection and
treatment of hypertension remains an important public health challenge. Hypertension is
associated with increased risk of mortality and morbidity from stroke, coronary artery
disease, congestive heart failure and end stage renal disease. It also has a negative impact
on the quality of life. The WHO in 2008 stated that hypertension is a silent killer that
affects 600 million persons and causes 5 million premature deaths a year worldwide. 4

A study was conducted to assess the effectiveness of a SIM on the knowledge of

lifestyle modification in hypertensive patients in Mediscope Hospital, Bangalore. The

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sample consisted of 30 patients with hypertension, both male and female. A structured
knowledge questionnaire organised on the basis of lifestyle modification aspects such as
general health, stress reduction, and psychosocial wellbeing was used as the data
collection tool. The study revealed that 25 patients (83.3%) had inadequate knowledge, 5
(16.7%) of them had moderately adequate knowledge and none of them had adequate
knowledge in the pre-test. Post-test knowledge score revealed that majority 21 (70%) of
them had moderately adequate knowledge, 9 (30%) had adequate knowledge, and none
had inadequate knowledge. The study concluded that there was a significant difference
between the pre-test and post-test knowledge scores. Hence the SIM was effective in
imparting knowledge on lifestyle modification of hypertensive patients.4

The nurse plays an important role in teaching patients with hypertension,

especially in the community set up, since without any lifestyle changes hypertension
cannot be treated. To lower the risk associated with hypertension, modification of
lifestyle or behaviour is necessary. The nurse should provide ongoing education and
reinforcement while monitoring the patients progress and compliance with the treatment
regimen. Hence nursing care of patients with hypertension is critically important. 11 After
extensive review of literature, the researcher has taken up this study to educate the
hypertensive subjects on lifestyle modification.6

6.2 Review of literature

A phenomenological survey study was conducted to determine the knowledge,

perception and attitude of hypertensive patients in central hospital Auchi, Nigeria. A
cohort of 108 hypertensive patients was selected randomly with their age ranging from
35-80 years (mean=59.059.06 years) and the modal age group was 5660 years
(24.1%). A self-structured questionnaire and detailed interview were conducted to collect
the data. The study revealed that sixty-six respondents (61%) knew hypertension to be
high blood pressure (BP), 22 (20%) thought it meant excessive thinking and worrying
while 57 (53%) claimed it was hereditary. Forty-three (40%) felt it was caused by
malevolent spirits, 32 (30%) believed it was caused by bad food or poisoning. A few

(18%) knew some risk factors. Although 98 (90.7%) felt the disease indicated serious
morbidity, only 36 (33.3%) were adherent with treatment and fewer practiced lifestyle
modification. Thirty-two (30%) knew at least one antihypertensive drug they used. The

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study concluded that patients knowledge of hypertension was low and the attitudes to
treatment were negative. Patient education, motivation, and public enlightenment are
imperative.8

An explorative study conducted on outcome following lifestyle changes with

hypertensive patients in Goteborg, Sweden. All 177 patients diagnosed with hypertension
visiting a health centre were selected for the study. A structured nursing intervention
programme was conducted on hypertension care and lifestyle modification. The study
revealed that systolic blood pressure decreased overall in 3 patients (p < 0.01) with high
alcohol consumption, two smokers stopped smoking, two new diabetics were discovered,
physical activity increased (p=0.035) and one-third of the patients changed their
medication. The study concluded that as a result of the intervention the lifestyle of the
people was changed, the level of exercise increased, a reduction in systolic blood
pressure and in womens weight were obtained. The study also stated that counselling
following a hypertension programme gives hypertensive patients a chance to execute
lifestyle changes and have their medication adjusted to achieve goals for blood pressure
control.9

A study was conducted to evaluate the knowledge, perception and practices of

lifestyle modification measures among adult hypertensives in University of Nigeria
Teaching Hospital, Enugu, Nigeria. A sample of 260 patients attending the clinic was
selected for the study. A pre-tested structured interviewer-administered questionnaire was
used to collect data. The study revealed that more than half (54.2%) of the 260
respondents had no formal, or just primary, education. About 25% were no longer taking
their antihypertensive medication. Fifty percent of the patients thought that hypertension
was caused by stress. Most knew about the lifestyle measures through health personnel.
More than 50% adopted the lifestyle-modification measures once they became aware of
their effects (p<0.001). The study concluded that participants had a poor perception of
hypertension and awareness of the lifestyle-modification measures through the mass
media, but a high level of willingness to adopt the lifestyle measures.10

A cross-sectional study was conducted to assess the effect of practice on lifestyle

risk factors on hypertension among bank employees in Surat, India. A sample consisting
of 1493 bank employees were studied (1177 males and 316 females). A pre-tested semi-
structured questionnaire was used, which collected information on demographic

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characteristics and risk factors for hypertension. Clinical observation was also done. The
result revealed that overall prevalence of hypertension was found to be 30.4%
(455/1493). Among 455 (30.4%) hypertensives, only 197(43%) were aware about their
hypertensive status. And among these known hypertensives, 139 (70.5%) were on
regular treatment, 71 (51%) were having controlled hypertension among the employees
who were on regular treatment. As age increased, the incidence of hypertension also
increased significantly in both sexes (p<.001). Cases of hypertension were significantly
higher among male employees 382 (32.5%) as compared to female employees 73
(23.1%), (p<.01). hypertensive cases were higher 35.53% (81) among smokers than non-
smoker 29.57% (374). Incidence of hypertension was higher 37.8% (114), in tobacco
chewer than non-chewer 28.6% (341). Hypertensive cases were higher 40.1% (149)
among alcohol consumers than non-drinkers 27.2% (306). Comparatively hypertension
found significantly higher among employees who was not having any healthy habit like
walking, jogging, exercise; it was found to be 28.7% (122) excluding patients on
treatment (p<.01). The study concluded that lifestyle affects blood pressure so the
healthy habits should be promoted among this type of group using different types of
interventions.11

A study was conducted to assess the effect of lifestyle modification on

hypertensive patients in America. A sample of 36 individuals participated in the 12-week
project, with a 67% retention rate. Weekly sessions included interactive educational and
walking components. Initial and final BMI measurements were recorded (p<01).
Participants completed health risk assessments; pre- and post-questionnaires; and, daily
logs of blood pressure measurement, dietary consumption, and physical activity levels.
Data were collected from the logs, BMI measurements, and questionnaires. The study
revealed that 30 participants (84%) experienced an increase in healthy lifestyle
modification adoption resulting in blood pressure control improvement (p<0.001). The
study concluded that Implementation of healthy lifestyle modifications is crucial in
providing quality patient care to hypertensive individuals.12

A study was conducted to assess the knowledge, attitude and practice of non-
pharmacological measures to control hypertension in the geriatric population in a civil
hospital, Ahmedabad. A total of 50 hypertensive patients were interviewed. Their
demographic details and responses to the questions were noted in the questionnaire. The

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result revealed that the mean age of the population was 66.7 years. Sample consisted of
35 males and 15 females. About 76% of respondents said that walking had a correlation
with hypertension but about 67% of patients with hypertension said they practiced
walking as a measure to control hypertension. Only 15 of the total respondents were
aware of the normal values of blood pressure. About 82% of respondents said that blood
pressure should be monitored regularly and about 62% of hypertensives used to measure
their blood pressure regularly. About 54% of all respondents said that there is a direct
correlation between blood pressure and salt intake. About 42% of respondents were not
aware whether salt intake should be reduced in patients with hypertension or not. Only
22% of respondents said that body weight had a correlation with hypertension. Only 32%
of respondents said that fruit consumption was related to blood pressure. Only 50% of
hypertensives said that they consumed fruits in good amount. About 22% of all
respondents said that blood pressure can be controlled with drugs alone. The study
concluded that knowledge and practice regarding salt intake, tobacco consumption
remains satisfactory, but regarding body weight, fruit intake and correct levels of
hypertension remains poor in the study group.12

6.3 Statement of the problem

A quasi-experimental study to assess the effectiveness of individual teaching

programme on knowledge and practice regarding lifestyle modification among patients
with hypertension in selected urban community at Mangalore.

6.4 Objectives of the study

1. To determine the pre-test level of knowledge on lifestyle modification among

patients with hypertension in both Group I (experimental) and Group II (control)
using a self-structured knowledge questionnaire.

2. To determine the pre-test level of practice on lifestyle modification among

patients with hypertension in both Group I and Group II using a practice rating
scale.

3. To evaluate the effectiveness of individual teaching programme on knowledge on

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 lifestyle modification among patients with hypertension in Group I and Group II.

4. To evaluate the effectiveness of individual teaching programme in practice on

lifestyle modification among patients with hypertension in Group I and Group II.

5. To find the association between pre-test practice scores on lifestyle modification

in Group I and Group II and selected demographic variables.

6. To find the association between post-test practice scores on lifestyle modification

in Group I and Group II and selected demographic variables.

6.5 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 I and Group II.

Knowledge: Knowledge refers to the right responses given by the patients with
hypertension to the questionnaire related to lifestyle modification in hypertension.
Knowledge includes both theoretical and practical aspects.

Practice: In this study practice refers to the score obtained from practice rating scale
rated by patients with hypertension on the following aspects: regular exercise, weight
reduction, diet modification, and intake of hypertensive 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 non-

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

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Hypertension: In this study patients with hypertension are in the age group of 40-60
years, those who are diagnosed to have essential hypertension (a rise in BP of unknown
cause) and on treatment for more than one year.

6.6 Assumptions

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

hypertension.

2. Individual teaching programme has some effect on the knowledge and practice of
lifestyle modification in patients with hypertension.

6.7 Hypotheses

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

H1: There is significant difference between mean pre-test level of knowledge on

lifestyle modification among patients with hypertension in Group I.

H2: There is significant difference between mean pre-test level of practice on lifestyle
modification among patients with hypertension in Group I.

H3: There is significant difference between post-test knowledge and practice scores in
Group I and Group II among patients with hypertension.

H4: There is significant association between pre-test level of knowledge on lifestyle

modification in Group I and Group II and selected demographic variables among
patients with hypertension.

H5: There is significant association between pre-test level of practice on lifestyle

modification in Group I and Group II and selected demographic variables among
patients with hypertension.

6.8 Delimitations

The study is delimited to:

Patients with hypertension only.

Patients with hypertension who are available during the study.

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7. Material and methods

7.1 Source of data

Data will be collected from the patients with hypertension residing at selected
urban community of Mangalore.

7.1.1 Research design

A quasi-experimental non-equivalent pre-test, post-test control design will be

employed.

Experimental group O1 X O2

Control group O1 - O2

7.1.2 Setting

The study will be conducted in selected urban community, Mangalore.

7.1.4 Population

Target population of the study is patients with hypertension residing in selected

urban community, Mangalore.

7.1.5 Variables

Dependant variable: Knowledge and practice of patients with hypertension on lifestyle

modification.

Independent variable: Individual teaching programme.

Extraneous variables: Age, gender, marital status, religion, income, diet, and other
associated disease.

7.2 Method of data collection

7.2.1 Sampling procedure

In this study purposive sampling technique will be used to select the sample

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based on inclusion and exclusion criteria.

7.2.2 Sample size

The sample of the study will be 60 hypertensive patients 30 in the experimental

group and 30 in the control group will be taken from selected urban community,
Mangalore.

7.2.3 Inclusion criteria

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

Adults in the age group of 40 to 60 years are included in the study.

Adults who are suffering with hypertension since one year.

7.2.4 Exclusion criteria

Patients with hypertension who are not willing to participate.

Those who are unavailable during the time of study.

7.2.5 Instruments intended to be used

Self-structured knowledge questionnaire.

Practice rating scale.

7.2.6 Data collection method

Permission will be obtained from the concerned authority.

Using purposive sampling technique, 60 samples will be selected from the

selected urban community and will be divided control and experimental group,
with both group containing 30 members each.

Purpose of the study will be explained and informed consent will be taken from

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 the subjects.

A self-structured knowledge questionnaire to assess the knowledge of

hypertensive patients and a practice rating scale to assess their practice also will
be administered to both the groups.

Pre-test will be conducted for both the groups to check the knowledge and
practice level.

A systematically organised individual teaching programme will be given on

lifestyle modification and its practice for the patients with hypertension in Group
I.

Post-test will be conducted using the same tools for both the groups after seven
days.

7.2.7 Data analysis plan

The collected data will be analysed using descriptive and inferential statistics.

Descriptive statistics: Mean, standard deviation, frequency, and percentage distribution

will be calculated based on the obtained scores. Unpaired t test will be carried out to
find out the effectiveness of teaching programme.

Inferential statistics: Chi-square test to find association between knowledge and

practice on lifestyle modification in hypertension and selected demographic variables.

Analysed data will be presented in the form of tables and squares to present the
data.

7.3 Does the study require any investigation or intervention to be conducted on

patients or other humans or animals?

Yes.

7.4 Has ethical clearance been obtained from your institution?

Yes, ethical clearance will be obtained from the institutional ethical committee.

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1. Bolle A. Knowledge of the hypertensive patient regarding prevention strategies

for CAD. Dissertation. [online]. 2009 Mar;1(2). Available from:
URL:http://uir.unisa.ac.za/bitstream/handle/10500/2608/dissertation_boulle_a.pdf
?sequence=1

2. Thayamanavn M. Effect of structured teaching on care of patients with

hypertension in selected urban areas of Bangalore. Nightingale Nursing Times

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 2012 Aug;1(8):29.

3. Lewis SL, Driksen SR, Heitkemper MM, Obrien PG, Bucher L. Lewis medical
surgical nursing. Philadelphia: Elsevier Publication; 2011.

4. Chandrababu R. Effectiveness of self instructional module on the knowledge of

lifestyle modification of hypertensives among patients with hypertension.
Nightingale Nursing Times 2012 Aug;1(8):30.

5. http://www.indushealthplus.com/karnataka-health-statistics

6. Charles RH. Knowledge and management of hypertension. Nightingale Nursing

Times 2012 Aug;1(8):39.

7. Bowet P. Knowledge attitude and practice on hypertension in a country in

epidemiological transition. AHA Journals 2012 Dec;31(5):1136.

8. Godfrey BS, Lyalomhe, Sarahl. Hypertension related knowledge attitude and

lifestyle practices among hypertensive patients in sub urban Nigerian community.
Journal of Public Health and Epidemiology 2010 Jul;2(4):71-7.

9. Drivenhorn E, Kjellgren KI. Outcome following programme for lifestyle changes

in people with hypertension. Journal of Clinical Nursing 2005 Sep;16(7):144-51.

10. Ike SO, Anieubue PN, Aniebue UU. Knowledge perception and practice of
lifestyle modification measures among adult hypertensives in Nigeria. Trans Sr
Soc Trop Med Hyg 2010 Jan;104(1):55-60.

11. Mohammadirfan MH, Desai VK, Kavishvar A. A study on effect of lifestyle risk
factors on prevalence of hypertension among white collar job people of Surat.
The International Journal of Occupational Health 2011 Nov;1(1):131.

12. Jane H, Johan D. Hypertension improvement through healthy lifestyle

modification. The International Journal of Occupational Health 2011
Apr;1(3):188.

13. Patel CH. To study knowledge attitude and practice of non-pharmacological

measures to control hypertension in geriatric population. Indian Journal of

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Applied Basic Medical Science 2012 Dec;14(19):34-42.

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