KNOWLEDGE ON PREVENTION OF HYPERTENSION

A Research Proposal Presented to the Faculty School of Nursing Saint Louis University

In Partial Fulfillment Of the Course CN 107a

Submitted by:

Mangaoang, Raynor D. Moreno, Renzvan M. Silvania, Mark Darell Bautista, Florence A. Bitao, Maria L. Bobias, Abegail B. Boston, Karen Christianne B.

Guerrero, Ralaine Q. Martinez, Monica L. Mejia, Irish P. Nomil, Joy G. Pangwi, Carolina L. Pelitan, Shereen Joy Q. Sigang, Mikhaila A.

BSN III-H2 August 2012

TABLE OF CONTENTS TITLE I. Introduction .. Theoretical Framework Significance of the Study Methodology . Data Gathering Tool Data Gathering Procedure . II. III. References . Appendices Letters .. Questionnaire . 23 24 PAGE 1 10 14 19 20 21 24

Introduction Cardiovascular Disease (CVD) includes dysfunctional conditions of the heart, arteries, and veins that supply oxygen to vital life-sustaining areas of the body like the brain, the heart itself, and other vital organs. Absence of oxygen results to the death of the tissue or organ. Excess build up of fat or plaque are in the blood vessels likewise, are contributory to the occurrence of high blood pressure. High Blood Pressure (hypertension) often results from this excess fat or plaque buildup because of the extra effort it takes to circulate blood. Even though the heart works harder, blockages still shortchange the needed blood supply to all areas of the body. The body's amazing survival systems will mask the subtle damage that is occurring from this extra wear and tear, but not forever. High blood pressure is called "The Silent Killer" because the first warning sign is an angina attack or a deadly heart attack or a stroke. (CVD Facts & Statistics, n.d.) Hypertension is blood pressure that is above the normal of either a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg. Individuals with systolic pressures of 120 to 139 mm Hg or diastolic pressures of 80 to 90 mm Hg are be considered as pre hypertensive (Lewis, Heitkemper, Dirksen, OBrien, and Bucher (2007). Likewise, Lewis defines hypertension as the condition in which a person displays a systolic blood pressure of 140 mm Hg or higher and/or a diastolic blood pressure of 90 mm Hg or higher, or is a current user of antihypertensive medication. For many years, isolated systolic

hypertension was considered to be normal in elders, and was frequently not treated. Newer evidence indicates that a systolic pressure of greater than 140 mm Hg is as problematic in older adults as in younger ones and it should be aggressively treated (Joint national Committee [JNC7], 2003). Worldwide, 26.1 % of adults were estimated to have a hypertension in 2000, two-thirds of whom were thought to reside in developing countries. World Health Organization estimated about 62 % of cardio vascular disease and 49 % of ischemic heart disease burden worldwide. An increase of 60 % in those suffering from hypertension is expected by 2025, resulting in 1.56 billion hypertensive individuals within 15 years. The rate of increase is expected to be higher in developed countries as the prevalence is strongly linked to age. According to a recent report, 51 % of stroke deaths worldwide are attributed to high systolic blood pressure (SBP). Hypertension is estimated to cause 7.1 million deaths annually accounting for 13 % of all deaths globally. Sharma and Antoine M. Hakim, 2011) In the United States, despite prevention efforts, the prevalence hypertension has increased by almost one-fourth over the past 15 years among adults, increasing from 22.2 % in 1995 to 27.8 % in 2007, with estimated direct and indirect costs of hypertension totaling $73.4 % billion in 2009. This affects over 70 million people in the United States (Carter, Einhorn, Brands, He, Cutler, & Whelton, et al, 2008; Chobanian, 2009). (Mukul

The continent of Africa has large number of occurrence of hypertension wherein 20 million people were experiencing hypertension and also in Europe has recorded 4.35 million deaths each year. Nearly one in three U.S. adults has high blood pressure, but because there are no symptoms, nearly one-third of these people don't know they have it. In fact, many people have high blood pressure for years without knowing it. Moreover more than 3.6 million Australians over the age of 25 have high blood pressure or are on medication for the condition and six million Canadian adults have high blood pressure. In Asia hypertension is also one of the main problems in health there are 19% for Vietnamese, 24% for Koreans, 28% for Japanese, and 29% for Chinese, for 32.8% and 20-30 % in urban in India and 10-15% in rural subjects in India. Hypertension is a risk factor to myocardial infarction, stroke, renal failure, congestive heart failure, progressive atherosclerosis, dementia, coronary artery disease and peripheral vascular disease. Other factors associated with hypertension include diet, weight, and stress (Polan & Taylor, 2003). Occurrence of hypertension could also be based on lifestyle of people including cigarette smoking, heavy alcohol consumption, lack of physical exercise and a high blood cholesterol levels. According to Gu et al (2002), the prevalence of hypertension increased with age in both men and women. In the study, age 30 of people in San Antonio, Nueva Ecija had the highest rate of determinant of hypertension. This is followed a familial history of hypertension and body mass index 25 kg/m2. It was also noted that BMI has a positive association to prevalence of hypertension in the Philippines (Singh et al 2000).

In the Philippines, 9.6M are hypertensive and 15.4M are predisposed to be hypertensive among adults, 20 years and over. Unfortunately, half of those who has hypertension are not aware that they have the condition, only 13.1% of them has been treated and 19.3 % has been controlled. Since hypertension may be present in an individual in years without noticeable symptoms, it is otherwise known as The Silent Assasin (Charmaine A. Duante, Wilma L. Molano, Felicidad V. Velandria and Zita VJ. Albacea). In Baguio City, Baguio Health Department statistics indicate that in the period of 6 years (2006-2011), CVD has an average morbidity case of 1385.17 and an average mortality case of 196.5. Besides that, lack of knowledge of the people about the disease has also played crucial role on the expansion of the disease. (Acharya & Chalise, 2011). The following literatures indicate diverse perception in regards to what hypertension all about. Moreover, 47% of the population of San Antonio, Nueva Ecija is under treatment of hypertension but some of the people in this population are on self medication, not knowing that hypertension might not be controlled just by self medicating. For them to achieve a better control of hypertension more attention should be given to the detection and subsequent treatment and control of hypertension. (Vanrosum 2000) In the study on Knowledge, Attitudes and Practices on Hypertension in patients attending Family Practice Clinics, more than 80% of hypertensive was

aware of the risk factors, and more than 90% had the knowledge about the main complications of hypertension. More than 85% of all participants believed that Hypertension is a serious health problem and needs lifestyle modifications to be controlled, but hypertensive were 10 times more aware that Hypertension needs lifelong treatment. This study conclude that certain aspects of hypertension specific knowledge need to be improved by training clinicians to take more active role in health education in order to influence patient blood pressure checked at least once in the last year. A study on Factors associated with hypertensive patient's Compliance with recommended lifestyle behaviors, (Heymann, Gross, Tabenkin, Porter, Porath, 2011) The results of the study shows that the majority of hypertension patients are informed and have knowledge about both hypertension and the effect of a healthy lifestyle on controlling blood pressure. Furthermore, most believed that their disease could be managed. ((Heymann, Gross, Tabenkin, Porter, Porath, 2011) A study on hypertension-related knowledge, attitudes and lifestyle practices among hypertensive patients in a sub-urban Nigerian community (Godfrey and Sarah lyalomhe, 2010), The result found out that sixty-six respondents (61%) knew hypertension to be high blood pressure, 22 (20%) thought it meant excessive thinking and worrying while 57 (53%) claimed that it was hereditary. Fourty-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.

Hypertension, indeed is a health problem related to lifestyle of an individual. Hence, it is deemed important that individuals maintain their health maximally by merely observing appropriate lifestyle change, because health is a primary concern of every individual. Health as defined by World Health Organization is a state of complete physical, mental, and social well-being. The actual definition of healthy living is the steps, actions and strategies one puts in place to achieve optimum health. Healthy Living is about taking responsibility and making smart health choices for today and for the future. Eating right, getting physically fit, emotional wellness, spiritual wellness and prevention are all apart of creating a healthy lifestyle. (WHO) Being healthy involves dealing with observing health promotion which can be described as the application of methods that foster a physical and emotional well being in order to increase the length and quality of life. The concept of optimal health reflects not merely the absence of disease, but also level of vitality to maintain enjoyment and contentment with life (American Academy of Family Physician, 2012). In order to lead a healthy lifestyle, a person must consume healthy food, exercise a healthy lifestyle and stay away from drugs and alcohol. Le Mouse states that healthy lifestyle isnt just about vanity and appearance, but about keeping a healthy heart, low cholesterol and strong bones. Its about achieving

things in other areas of your life, feeling confident and providing a role model for friends and family. (Le Mouse, 2012) In relation to hypertension, lifestyle changes are also especially important for people with so-called non-modifiable risk factors or those that cannot be changed such as family history, gender, race or age. Dr Lynn Gomez states that there is nothing that can be done about the non-modifiable risk factors but one can influence his other risk factors to prevent hypertension and metabolic disorders such as diabetes and hypercholesterolemia. (Department of Health, 2012). The Department of Health and Philippine Society of Hypertension also advocate the importance of health eating plan in helping prevent or control hypertension. One such plan is the Dietary Approaches to Stop

Hypertension or DASH diet, which could help yield positive results in lowering blood pressure and preventing the onset of full-blown metabolic disorders such as diabetes, high cholesterol and obesity. Under the DASH diet, one is required to avoid processed foods that are high in sodium, as well cut down on total fat and saturated fat intake, while getting at least 8-10 servings of potassium-rich fruits and vegetables and three servings of low-fat dairy products which are high in magnesium and calcium daily. Whole grains, fish, poultry, nuts, seeds and dried beans (legumes) are also recommended as part of the diet. In general, vegetarian diets which comply with the requirements of the DASH diet can also reduce high blood pressure, as these tend to be higher in

potassium, magnesium and calcium, as well as fiber and unsaturated fats, than other diets. The DASH diet could be a vegetarian diet with legumes substituting meat as a protein source. (Department of Health, 2012) For hypertension, health education remains to be the main tool for preventive and promotive health (Action Plans for Preventive, n.d.) However, crucial to this is the basic knowledge of individuals in relation to what is best for them to do to make themselves healthy likewise, what can they do in their daily lives that could prevent them from having hypertension. The above literatures indicate that there are variety of knowledge or impression of different individuals regarding hypertension; considering that they have different diverse information on hypertension, there could be an issue of their failure to practice promotive and observe preventive measure to prevent occurrence of hypertension. The study aims to determine the extent of knowledge on prevention of hypertension along diet and physical activity. Specifically it seeks to determine if there is a difference on the extent of knowledge on prevention of hypertension when respondents are grouped according to their age, gender and educational attainment.

Theoretical Framework Health Promotion Model by Nola Pender will be used in the study. Health Promotion Model (HPM) was created to serve as a multivariate paradigm for explaining and predicting health promoting component of lifestyle (Pender, 1990, p.326). This model is used to assess an individuals background and perceived perceptions of self among other factors to predict health behaviors. Pender however, wanted to define health as not just being free of disease but the actualization of inherent and acquired human potential through health-directed behavior, competent self-care, and satisfying relationships with others while adjustments are made as needed to maintain structural integrity and harmony with relevant environments (Pender, 2006), which includes measures taken to promote good health and includes the patients own view of themselves and their lifestyle (Peterson &Bredow, 2009). Health promoting behaviors can lead to a patient s overall sense of well-being as well as protection from disease and chronic illnesses. Health promotion describes behaviors an individual can perform to bring greater longevity and a high quality of life. Health promotion can bring about a sense of wellbeing and harmony to the individual, can increase energy, and can also decrease social problems including violence and suicide (Peterson & Bredow, 2009). In relation to Penders health promotion model, the study wants to know the extent of knowledge on the prevention of hypertension. Since illness

prevention is one of the aspects the researchers are going to use, this model can be utilized because it supports the study by giving us an idea that promotive aspect of health is very important in avoiding the occurrence of disease that needs to be emphasized to every person. With healthcare costs rising, health promotion has been of increasing interest not only to health care workers, but to the general public. Public attention to a positive state of health began escalating in the late 1980s (Pender, 1996) and a variety of health programs began developing as a result (Galloway, 2003). An important point is that health promotion is not just about disease prevention. In the study, the respondents will be adolescence to adulthood, and since the health promotion theory can ideally be applied to all population especially important in the adolescent population because they are at a critical time in their life for making independent health care decisions. Penders model also support the study that there are personal factors that affects promotive aspect such as the biological, psychological, socio-cultural, and also environment into what she defines as interpersonal influences(family, peers, and providers) to assess the extent of knowledge on the prevention of hypertension. These factors are predictive of a given behavior and shaped by the nature of the target behavior being considered. Personal biological factors include variables such as age and gender which will be used in the study because the target population must be aged 18-65 y/o and gender in which subjects are either male or female. On the other hand, psychological factors

which includes variables such as motivation, personal competence, perceived health status and definition of health, also supports the study since the researchers aimed to explore the extent of knowledge or perceptions on the prevention of hypertension. And lastly, the personal socio-cultural factors which also include variables such as race, ethnicity, culture, education and socioeconomic status. This factor also supports the study since one of the variables to be used is educational attainment. Nola Penders Health Promotion Model supports the study in a way that Health Promotion programs like health teachings and wellness programs can be implemented by health organizations such as the DOH when the extent of knowledge on hypertension may be determined and identified. Disease prevention describes behaviors which can be performed to bring greater longevity and a high quality of life. However, this aspect always depend on the knowledge and perception of an individual and thereby, the need for disease prevention may vary depending on the extent of knowledge of every individual when they are grouped according to age, gender and educational attainment.

Significance of the study This will allow the Department of Health to evaluate their health program related to hypertension. The study likewise will give an idea to health care practitioners on which aspects of their teachings on preventive aspects of hypertension that needs to be strengthened in their health teachings to their patient. This study can be a basis for future research and moreover, make the respondents evaluate current practice and lifestyle changes that they need to observe to help prevent the occurrence of hypertension.

Methodology and Procedure The study will utilize the quantitative-descriptive survey. Descriptive statistics are used to describe and summarize the researchers observation and measurements. The measurement may include means (average), frequencies and percentages. (Polit and Beck, 2006). Locale and Population The study will be conducted in top three (3) barangays with the highest total population of ages 20-64 years old. These barangays are Irisan, Asin Road and Camp 7. Barangay Irisan is located along Naguilian Road with a total population of 28,357 and the total population from age 20 -64 years old is 12,903 (NSO, 2010 and 2007 Census and Housing Population). It comprises of thirty two (32) puroks and it is four (4) kilometers away from town proper. Barangay Asin Road has a total population of 11,454 and the total population from age 20 64 years old is 5,880 (NSO, 2010 and 2007 Census and Housing Population). It comprises of eight (8) puroks and it is three (3) kilometers away from town proper. Barangay Camp 7 is located along Kennon Road with a total population of 9,726 and the total population from age 20 -64 years old is 5,086 (NSO, 2010 and 2007 Census and Housing Population). It comprises of seven (7) puroks and it is four (4) kilometers away from town proper. The total population of ages 20-64 years old for the three barangays is 23,869, by utilizing the Slovins formula the target population would be 393. These barangays are geographically

accessible in gathering data since vehicles such as jeepneys and taxis can be utilized as a medium of transportation. The researchers will use simple random purposive sampling. It is simple random because the researchers will utilize fishbowl technique in selecting respondents and purposive because respondents must meet the inclusion criteria. If there will be more than one member of the household that will meet the criteria the researcher will only select one to become the respondent. Criteria for respondents will be male and female aging from 20-64 years old, and should not be diagnosed to have hypertension. Data Gathering Tool A questionnaire will be used as a tool in gathering the data. Part one of the questionnaire would be the fly cover addressed to the chosen respondents which contain the title of the study, the purpose and consent. Part two will contain needed information for the study such as age, gender and educational attainment. Part three will be the main questionnaire. Questions are divided into two categories which are mainly the diet and physical activities of hypertension. The questions will be answerable by yes or no by simply checking their preferred choice. The questionnaire is based from books, journals and pamphlets. Under the diet category items 5, 7, 9, 11, 14, 16, 17 and 18 are correct and items not mentioned are incorrect while under the physical activity category items 1, 2, 5, 6, 8 and 10 are correct and items not mentioned are incorrect.

The tool will undergo content validity index and pretest procedure. Content validity index will be done by Mrs. Purificacion Serna and Mrs. Florence Pulido. Mrs. Serna is the chief nurse at the Baguio Health Department while Mrs. Pulido has a Masters of Science in nursing degree and is also teaching medical surgical nursing. A communication letter will be given to them. Each question will be rated according to four categories: 4 very relevant, 3 relevant, 2 minimally relevant and 1 not relevant. After the content validity index, the researchers will conduct a testretest method for reliability. Ten (10) respondents will be randomly selected from Bayan Park barangay in Aurora Hill. The respondents will be chosen from the neighbors of one of the researchers. For the pretest, questionnaires will be given to the respondents and will be collected on the same day. After two (2) days the researchers will again give questionnaires to the same respondents and will also be collected on the same day. The respondents will be asked to comment on how well they have understood the questionnaire given to them. Pearson Product Moment Correlation Coefficient will be used to treat the pretest questionnaire to test its reliability. The respondents that will be chosen for the pretest will not be included in the target population that will be used for the study. Data Gathering Procedure The researchers will make a communication letter addressed to the respective Barangay Captains of Irisan, Asin Road and Camp 7. The letter will be duly signed by the group representative, research adviser, Department Head and to be noted by the school Dean. The researchers will initially coordinate with the

Barangay Captain; the group representative will introduce herself, the name of the school and explain the reason and the purpose of visit. Once the Barangay Captain gives the approval to the researchers to conduct the study in their Barangay, the researchers will proceed to locate of the respondents who will meet the inclusion criteria. Initially, the researchers will be doing ocular survey, noting the different streets and the position of households for the researchers spot map that will be used as a reference for spotting households. The researchers will divide the target population into three and the outcome will be divided again according to the number of puroks of each barangay. The researchers will utilize the fishbowl technique in selecting respondents for representativeness. In any case that there will be no resident that will meet the inclusion criteria in a particular household and if there is a household that is impossible to reach or will risk the safety of the researchers, the researchers will make another draw lots to select another respondent, the researchers will have another draw lots in selecting the next respondent. There are thirteen researchers that will conduct the research in three Barangays specifically at Barangay Irisan, Barangay Asin Road and Camp 7. The thirteen researchers will be divided into three groups which consist of four members. There will be one group who will have five members and will take Barangay Irisan because it is ranked number one in having the biggest population, and the other two groups which consists of four members will take Barangay Asin Road and Camp 7 respectively. These groups will be divided into

two subgroups, consisting of two members. The one that will be left without partner in Barangay Irisans group will be joining the subgroup who will get the large purok in that Barangay. The researchers in that specific Barangay will equally divide the puroks. When the researchers decided which puroks belongs to each subgroup, the researcher will proceed to their chosen purok and start floating the questionnaires to the household that will be drawn. Once the researchers reach the target household the researchers will show respect by greeting the household members. The group representative will introduce him/herself to the residents, give the letter that was presented to their Barangay Captain and state the purpose of the visit. The researchers will establish rapport with the resident upon entering the residents household. If there will be a respondent that will meet the inclusion criteria in that household, the researchers will ask consent from the respondent if he/she wants to participate in the study and state the following conditions to the respondents: first, the respondents has the right to refuse in participating to the study; second, the data that will be gathered will be treated confidentially and only the researchers can read and use the data; third, the identity of the respondent will remain private and will not be exposed to others aside from the researchers and the panelists. If the respondents refuse to participate in the study or withdraw in the middle of the study, the researchers will politely accept the decision and proceed to the next household that will be drawn. However, if the respondent is willing to participate in the study, the researchers will give the questionnaire to the respondent and explain how he/she will answer the questionnaire, and state

that all questions should have answers and should not leave any questions unanswered.

Dear Respondents,

Greetings!

We, the Third year Block H group 2, will be conducting a study about the Extent of Knowledge on Hypertension among Selected Barangays in Baguio City. In line with this, we would like to get your permission to be one of the respondents of this study.

Your responses will be kept confidential and they will be used for academic purposes only.

Thank you and we are hoping for your active participation.

________________________ Abegail S. Bobias Group representative

________________________ Carolina Pangwi Adviser

Instructions: On the space provided for, please indicate the following information needed: 1. Age 2. Gender _______ _______

3. For educational attainment, check appropriate item:

a. Elementary level b. High School level c. College level

_______ _______ _______

The following are items that would enhance ones health through healthy diet. Check YES if you think this item would enhance ones health and check NO if this item does not enhance ones health. ITEMS 1. Eating chicken skin 2. Frequent drinking of coffee 3. Intake of tocino 4. Eating in Jollibee 5. *Eating citrus fruits 6. Eating instant noodles 7. *Eating foods with garlic 8. Eating canned tuna 9. *Oat meal for breakfast 10. Drink water after eating lechon 11. *Taking plenty of vegetables 12. Use seasoning 13. Drinking canned pineapple juice 14. *Low fat diet 15. Eating shrimp 16. *Low salt diet 17. *Taking plenty of water 18. *Limiting coffee intake 19. Putting vetsin in food 20. Eating hotdog YES NO

The following are items that would enhance ones health through healthy physical exercise. Check YES if you think this item would enhance ones health and check NO if this item does not enhance ones health. ITEMS 1. *Regular exercising 2. *Swimming 3. Sleeping for more than 12 hours 4. Using the computer for 6-8 hours 5. *Walking instead of riding a jeepney 6. *Daily checking of weight 7. Sitting for hours after eating 8. *Jogging at Burnham park every morning 9. Sleeping immediately after eating 10. *Playing badminton for leisure time YES NO

*Items with asterisk are those that are answerable by YES.

Please check appropriate score for each item according to its relevance. 4 -very relevant 3 - relevant 2 minimally relevant 1 not relevant

ITEMS DIET: 1. Eating chicken skin 2. Frequent drinking of coffee 3. Intake of tocino 4. Eating in Jollibee 5. *Eating citrus fruits 6. Eating instant noodles 7. *Eating foods with garlic 8. Eating canned tuna 9. *Oat meal for breakfast 10. Drink water after eating lechon 11. *Taking plenty of vegetables 12. Use seasoning 13. Drinking canned pineapple juice 14. *Low fat diet 15. Eating shrimp 16. *Low salt diet 17. *Taking plenty of water 18. *Limiting coffee intake 19. Putting vetsin in food 20. Eating hotdog ITEMS PHYSICAL EXERCISE: 1. *Regular exercising 2. *Swimming 3. Sleeping for more than 12 hours 4. Using the computer for 6-8 hours 5. *Walking instead of riding a jeepney 6. *Daily checking of weight 7. Sitting for hours after eating 8. *Jogging at Burnham park every morning 9. Sleeping immediately after eating 10. *Playing badminton for leisure time

Statistical treatment The researchers will treat the specific question number one by using the Likert scale. The researchers will get the mean of each question according to diet and physical activity. Not knowledgeable if the mean would be 1.00 1.75, partially knowledgeable if the mean would be 1.76 2.50, moderately knowledgeable if the mean would be 2.51 3.25 and highly knowledgeable if the mean would be 3.26 4.00. For specific question number two, the researchers will use the t-test to treat the age and gender, to assess whether the means of the categorically different means are statistically different from each other. For educational attainment the researchers will utilize the f test. If there will be a difference in the mean the researchers will utilize ANOVA to assess the significant difference between elementary level to high school level, high school level to college level, and elementary level to college level.

Saint Louis University School of Nursing Bonifacio St., Baguio City September 8, 2010

Ms. Florence Pulido R.N Clinical Instructor Dear Maam, We, the students of Saint Louis University, School of Nursing presently enrolled in Level III are undertaking a study on Knowledge on Prevention of Hypertension. We kindly request you to check the validity of the content of our questionnaire. Thank you!

Respectfully yours, Abegail B. Bobias BSN III-H2, Group Representative Noted: Carolina L. Pangwi Level III DH Noted: Mary Grace C. Lacanaria Dean SON

Saint Louis University School of Nursing Bonifacio St., Baguio City September 8, 2010

Ms. Purificacion Serna R.N

Dear Maam, We, the students of Saint Louis University, School of Nursing presently enrolled in Level III are undertaking a study on Knowledge on Prevention of Hypertension. We kindly request you to check the validity of the content of our questionnaire. Thank you!

Respectfully yours, Abegail B. Bobias BSN III-H2, Group Representative Noted: Carolina L. Pangwi Level III DH Noted: Mary Grace C. Lacanaria Dean SON