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KNOWLEDGE
AND PERCEPTION OF HYPERTENSION AND IT’S MANAGEMENT AMONG CLIENTS/PATIENTS
ABSTRACT
Hypertension
is an important public health challenge at Auchi Nigeria. The purpose of this
qualitative phenomenological survey was to determine hypertensive patients’
knowledge, perceptions, attitudes and life-style practices so as to optimize
their health and treatment needs. We examined a cohort of 108 randomly selected
hypertensive by means of a self-structured questionnaire and a detailed interview.
Analysis was by statistical package for social sciences (SPSS) and chi- square
was used for significance tests at 0.05 level. More males 60 (55.6%) than
females 48 (44.4%) were assessed. Their age range was 35 – 80 years (mean =
59.05 ± 9.06 years), the modal age group was 56 – 60 years (24.1%). 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. Symptoms attributed to hypertensionwere headache, restlessness,
palpitation, excessive pulsation of the superficial temporal artery and
“internal heat”, but 80 (74%) attested to its correct diagnosis by BP
measurement. Although 98 (90.7%) felt the disease indicated serious morbidity,
only 36 (33.3%) were adherent with treatment and fewer practiced life-style
modification. Thirty-two (30%) knew at least one antihypertensive drug they
use. Psychosocial factors like depression and anxiety fear of addiction and
intolerable drug adverse effects impacted negatively on patients’ attitude to
treatment. We conclude that patients’ knowledge of hypertensionin Auchi is low
and their attitudes to treatment negative. Patient education, motivation and
public enlightenment are imperative.
CHAPTER ONE
INTRODUCTION
1.1 Background of Study
Hypertension
remains a major global public health challenge that has been identified as the
leading risk factor for cardiovascular morbidity and mortality (Kearney,
Whelton, Reynolds, Muntner, Whelton& He, 2004). It increases hardening of
the arteries, thus predisposing individuals to heart diseases, peripheral
vascular diseases, stroke, heart failure and kidney failure. Hypertension is
the commonest non-communicable disease in the world and all races are affected
with variable prevalence. Castelli (2004) explained that its prevalence is on
the increase in developing countries where adoption of western lifestyle and
stress of urbanization, both of which are expected to increase morbidity
associated with unhealthy lifestyle are not on the decline. Andreoli, Carpenter,
Grigs and Loscalzo (2004) were of the opinion that hypertension produces
disruptions in health, disability and death in the adult population worldwide.
Ejike, Ezeanyika and Ugwu (2010) stated that hypertension causes one in every
eight deaths worldwide, making it the third leading killer disease in the
world. They also estimated that about one billion adults, the world over, had
hypertension in the year 2010 and the number is expected to rise to 1.56
billion in the year 2025 if positive intervention programme is not made. Aram,
George, Henry, Williams, Lee, and Joseph (2003) indicated that fifty million
Americans have high blood pressure, approximately one in three adults.
In United
States of America, approximately twenty eight (28) to thirty one per cent of
adults have hypertension (Fields, Burt & Cutler (2004). Of this population,
90 to 95 per cent have primary hypertension (high blood pressure related to
unidentified cause). The remaining five to tenper cent of this group have
secondary hypertension (high blood pressure related toidentified cause). In
China, almost 130 million people aged 35-74 years are estimated to be
hypertensive(Camel &Delene, 2006). Similarly in Ghana, studies revealed a
hypertension prevalence of forty per cent among rural dwellers and eight per
cent to thirteen per cent in the urban areas. In sub-Saharan Africa, it is the
most rapidly rising cardiovascular disease and affecting over 20 million people
(Kadiri, 2005). He also stated that in Nigeria, hypertension is the commonest
non-communicable disease with over 4.3 million Nigerians above the age of
fifteen years classified as being hypertensive.
Hypertension,
also known as high blood pressure is the persistent blood pressure in the
arteries above ninety millimetres of mercury (mmHg) between the heart beats
(diastolic) or over 140 millimetres of mercury (mmHg) at the beats (systolic)
(Aquilla, 2008). According to Hyman and Parlik (2003), hypertension is the
persistent raised levels of blood pressure in which the systolic pressure is
above 140 mmHg and diastolic pressure above 90 mmHg. The normal blood pressure
is below 120/80 mmHg; blood pressure between 120/80 and 139/89 is called
‘Pre-hypertension, and a pressure of 140/90 or above is considered high
(abnormal) blood pressure. According to Expert Committee on Non-Communicable
Diseases (1993), blood pressure of 120/80 mmHg is considered normal for a 30
year old person, while blood pressure of 140 mmHg is considered high for such a
person. Similarly, blood pressure of 150/90 mmHg is considered normal for a
60-year old person, while blood pressure of 160/100 mmHg is high for such a
person. Hypertension is sometimes called “the silent killer” because people who
have it are often symptom-free. In this study, hypertension is perceived as a
systolic blood pressure greater than 140 mmHg and a diastolic blood pressure
greater than 90 mmHg among adults. The top number which is the systolic
pressure corresponds to the pressure in the arteries as the heart contracts and
pumps blood forward into the arteries. The bottom number which is the diastolic
pressure represents the pressure in the arteries as the heart relaxes after
contraction. The diastolic pressure reflects the lowest pressure to which the
arteries are exposed. Blood pressure is normally measured at the brachial
artery with a sphygmomanometer (pressure cuff) in millimeters of mercury (mmhg)
and given as systolic over diastolic pressure. Hypertension is classified into
two namely; primary and secondary hypertension.
According to
Stanler (2004), hypertension is categorized into primary and secondary
hypertension. Primary hypertension has an unknown cause and accounts for ninety
per cent to ninety five per cent of all hypertension cases (Chris, 2009). This
type of hypertension is strongly associated with lifestyle. Usually, the
patients do not have many signs and symptoms but may experience frequent
headache, tiredness, dizziness or nose bleeds. Although the cause is not known,
obesity, smoking, alcohol, diet and heredity play a role in essential or
primary hypertension.
Secondary
hypertension has a known cause and accounts for five per cent to ten per cent
of all hypertension cases. Chris (2009) maintained that the most common cause
of secondaryhypertension is an abnormality in the arteries supplying blood to
the kidneys. Other causes include airway obstruction during sleep, stress,
diseases and tumors of the adrenal glands, lifestyle, spinal cord injury,
hormone abnormalities (oral contraceptive estrogen replacement), thyroid disease,
toxemia of pregnancy, renal problems such as vascular lesion of renal arteries,
diabetic neuropathy, pains as well as anxiety and hypoglycemia. There are some
factors which predispose adults to hypertension.
The risk
factors of hypertension are genetic factor which can be inherited from parents,
age which when the body does not retain the amount of elasticity as it used to
in the early years of life, obesity which is an increase in weight of over ten
per cent above normal body index due to generalized deposition of fat in the
body, excessive salt intake which increases blood pressure, stress which
produces chemical substances that cause generalized vasoconstriction, oral
contraceptive which contains estrogen that causes salt retention that increases
the volume of blood, sedentary lifestyle which has the tendency of increasing
body weight and directly raises blood pressure, elevated levels of plasma
lipids particularly cholesterol, excessive alcohol consumption which increases
blood pressure and tobacco use (cigarette smoking) that contains nicotine which
causes constriction of the blood vessels.
The signs
and symptoms of hypertension recognized by Thatch and Schultz (2004) include
occipital headache, dizziness, restlessness, failing vision, shortness of breath,
and rapid increased heartbeat. Adults should possess the knowledge of risk
factors in order to prevent hypertension. This will help them recognize and
prevent or treat hypertension when these signs occur.
Knowledge is
used to cover such related terms as facts, information, understanding,
awareness, insight, wisdom, reasons, comprehension, meaning, concept and
experience (Albelum, 1987). It is an organized body of knowledge shared by
people. Nnachi (2007) conceptualized knowledge as the ability to understand or
comprehend phenomena, the acquisition of positive information by the exercise
of some capacity which humans presumably have in common. Health knowledge could
be said to mean putting into reality the art of mobilization of resources by an
individual, intellectually, physically and emotionally. Hamburg and Russell
(2000) opined that health knowledge and understanding of related factors have a
favourable effect on quality of overall well-being. They went further to state
that one’s exposure to proper health knowledge will influence positively the
person’s health attitude and practice, and thus, one could rightly say that
knowledge is the key to optimum well-being. Umaru (2003) pointed out that
knowledge comes about as a result of learning through cognitive, affective and
psychomotor domains. In this study, knowledge is referred to as all
understanding and familiarity gained by learning and experience that will
enable adults to recognize risk factors as well as recognizing and use of
preventive measures of hypertension. Knowledge of hypertension is an important
prerequisite for an individual to implement desirable behavioural practices
towards its prevention. Lack of suchknowledge will lead to aggravated health
problems. Adults should therefore, possess adequate knowledge of risk factors
of hypertension in order to prevent the disease.
Risk factors
are defined by Lothar, Gottfried and Heide (2011) as individual characteristics
which affect the person’s chances of developing a particular disease or group
of diseases within a defined future time period. According to Lucas and Gilles
(2003), risk factor is anything that has been identified as increasing an
individual’s chances of getting a disease or developing a condition. They will
be considered to be at risk of developing hypertension, those with habits or
characteristics which increase the likelihood of developing hypertension. Risk
factors in this study, refers to the characteristics, conditions or behaviors
such as excess salt intake and smoking which increase the probability of
hypertension to occur. When risk factors are related to hypertension, they are
known as risk factors of hypertension. Risk factors of hypertension are of two
types: those ones that can be changed and those that cannot be changed. The
risk factors that can be changed are obesity, excess salt intake, smoking,
environmental stress, oral contraceptives, sedentary lifestyle, elevated levels
of plasma lipids and unregulated secretion of aldosterone. Risk factors that
cannot be changed are genetic predisposition, age and gender. Adults should
have adequate knowledge of the risk factors to be able to prevent hypertension.
Preventive
measures are interventions directed to avert the emergence of specific disease,
reducing their incidence and prevalence in population. Starfield, Hyde, and
Gervas (2007) defined preventive measures as all measures that limit the
progression of a disease at any stage of its course. In this study, preventive
measures is referred to as all the activities whose primary purpose is to
promote, restore and maintain health, and those practices which are directed
towards preventing hypertension among adults. There are two types of preventive
measures; primary and secondary. Primary prevention is the intervention that averts
the occurrence of a disease or actions taken prior to the onset of disease
which removes the possibility that a disease will occur. It signifies
intervention in the pre-pathogenesis phase of a disease or health problem. It
may be accomplished by measures designed to promote general health and
well-being, and quality of life of adults (health promotion) or by specific
protective measures (specific protection). Secondary prevention is action which
slows the progression of a disease at its incipient stage and prevents
complication. Salama (2011) opined that the specific intervention in secondary
prevention is early detection of hypertension which involves screening test. It
attempts to arrest the disease process, restore health by seeking out
unrecognized disease and treating it before irreversible pathological changes
take place especially among adults.
Adulthood is
the longest period of a man’s life. Hornby (2001) defined an adult as a person
who has grown to full size or strength, intellectually and emotionally mature,
and legally a person old enough to vote or marry. Ebiringa and Nwagbo (1997)
defined an adult as someone who has reached the age of maturity, who covers his
nakedness, who lives on his own, who can answer avillage call and who is
taxable. They went further to state that an adult is someone who has developed
a sense of perspective, more balanced in thinking, and is responsible for his
own actions and that of others. Samuel (2006) defined adulthood as the period
whereby an individual has acquired all the adolescent developmental tasks,
reached accepted age bracket and is responsible for his actions without
parental or social restrictions. Samuel (2006) also categorized adults into
three stages; young adulthood (21- 40), middle adulthood (41-65) and older
adulthood (65 years and above). Young adulthood which commences at around 21 to
40 years is the period when full physical fitness is generally experienced. It
is a stage of critical transition. Adults in this age group are filled with
vitality and enthusiasm. Middle adults falls within the ages of 41 to 65 years
which is a period of pleasant plateau (Ejifugha, 2003). Adults within this
group are at a stage of physical and psychological development. Adults in this
group tend to eat too much and may fail to take regular exercise. Many are
overweight and actually obese. Psychological stress causes adults in this group
to smoke, drink and abuse drugs. Older adults are between the ages of 65 years
and above. The factors in ageing set in to influence the individual gradually
which may cause cardiovascular diseases like hypertension. In this study, an
adult is referred to as an individual who has reached the age of maturity and
falls within the age bracket of thirty five years and above.
There are
many variables that may impinge on knowledge of hypertension. Literature shows
that studies on knowledge of hypertension examined socio-demographic factors of
age, race, level of education, parity, gender, income, location, occupation and
marital status (Hamdan, Saeed, Kutbi, Choudhry&Nooh, 2010). However the
present study is concerned with demographic factors of age, gender, location,
and level of education.
Age has been
identified as a strong factor that that can limit the ability of adults to
acquire adequate knowledge of hypertension. Age determines growth, development,
maturity and death. Age brings about maturity and maturity puts one in a
position to rationalize, concretize, accept or reject concept, information,
habit, attitude and practice (Ejifugha, 2003). It is believed that the more one
add years to life, the more knowledge he acquires and the more exposed to
situations that can cause health problems including hypertension. Adults
because of their exposure and experience must have come to understand the
concept of hypertension, signs and symptoms, risk factors and preventive
measures of hypertension and because of lack of exposure or experience may not
adequately acquire the knowledge of diseases (Bagunyoke, 2003) such as
hypertension.
Gender has
influence on knowledge of hypertension. Akinkugbe (2003) observed that women
have more hypertension than men. However, after menopause, the incidence of
hypertension due to arteriosclerosis in women rapidly increases than in men and
even become higher in old age. From adolescence through 54 years, men have a
much greater risk of developing hypertension compared with women of the same
age. The reverse is the case after 54 years.
Women then
are seen to have more incidence of hypertension due to the disappearance of
female stronger hormone that provides protective effect against hypertension.
Location is
an environmental factor which may limit the ability of adults to seek adequate
knowledge of hypertension. Hamdan, Saeed, Kutbi, Choudhry and Nooh (2010)
indicated that hypertension was significantly associated with age, gender,
geographical location. Similarly, Lech and Piotr (2009), stated that
hypertension was more frequently diagnosed among rural than urban adults. The
adults in urban areas have more opportunities and access to attend seminars,
health talks, workshops and medical check ups on hypertension (accessibility to
health information). Unfortunately, those in the rural areas may not have such
opportunities as such programmes may not exist in the rural areas. These
programmes are in most cases accessible to a smaller privileged group in the
society, who are living in well-developed towns, at the expense of greater
majority who wallow up in diseases and ignorance in rural areas.
Studies have
indicated that level of education is associated with knowledge, which may
include the risk factors and preventive measures of hypertension. According to
Hamdan, Saeed, Kutbi, Choudhry and Nooh (2010) observed that adults who were
more knowledgeable adopted positive lifestyles, while the iliterate adults
adopted unhealthy lifestyles. The higher the educational attainment, the higher
the acquisition of knowledge, attitude and behaviour, while the lower the level
of education, the lower increase in knowing risk factors and prevention
measures of hypertension. Similarly, Myo, Thaworn, Janthila, Nongluk ,Suchart ,
Wilawan , Phatchanan , Puangpet, Nara , and Apiradee (2012) reported that those
with primary school education were likely to be aware of hypertension than
those who did not have primary school education. The variables of age, gender,
location and level of education were examined in the study. Knowledge of
hypertension by adults will surely influence their health behaviour. Therefore,
some behaviour change theories will be applied to explain knowledge of
hypertension.
This study
was anchored on three theories. These are the critical knowledge theory, health
belief model, theory of reasoned action. According to Diagnam (1992), Critical
knowledge theory states that when an individual is ignorant or holds a belief
about a health matter, the health educator attempts to change or ascertain the
individual’s level of knowledge towards the health matter or concept through
questioning the respondent.
The health
belief model has its focus on explaining and predicting preventive health
behaviour by focusing on the attitudes and beliefs of individuals (Rosenstock,
Strecher and Beckar, 1999). This is useful because the model examined the
perceptions, beliefs and behaviours of adults and to provide information on the
lifestyle practices related to preventing hypertension. Adults who believe that
certain lifestyles such as excess salt intake and inactivity can predispose
them to hypertension will achieve good health by avoiding such lifestyles.
Theory of
reasoned action show how attitude impacts on behaviours. It states that a
person’s attitude towards a particular behaviour is influenced by belief
outcome of the behavior. Adults who develop positive attitude towards high salt
intake, excess alcohol and inactivity consumption are likely going to develop
hypertension; conversely, those who have negative attitude may not get
hypertension. The study was carried out in Auchi in Edo State.
Owerri
senatorial zone is in Imo state located in the South Eastern part of Nigeria.
The senatorial zone covers around 1,700sqkm and shares common boundaries with
Abia State by the east, and Rivers State by the south. It also shares common
boundaries with OhajiEgbema, Orlu, Obowo, Ihitte-Uboma, and Mbano local
government areas all of which are in Orlu and Okigwe zones of Imo State. There
are nine local government areas which make up Owerri Senatorial Zone (see
Appendix A). The inhabitants are engaged in agriculture, businesses and civil
service works. These activities occupy much of their time with little or no
time left for them to have rest and take care of their health, and they undergo
lots of stress which can lead to hypertension. Furthermore, there are places
which serve as tourist attractions in the zone such as Mbari exhibition centre,
Imo Concorde hotel and lots of hotels and guest houses where people come for
relaxation. These places expose adults to excessive alcohol consumption. Owerri
Municipal which is the major urban area is cosmopolitan being the Imo State
Capital and commercial nerve centre. These activities made the location to
qualify for the study.
1.2 Statement of Problem
Hypertension
has been shown to have series of consequences, and adequate knowledge of risk
factors can help in the prevention of hypertension. Therefore, adults in Owerri
Senatorial Zone need to have the knowledge of hypertension to reduce the
prevalence of hypertension disease, improve health and optimum well-being. But
it is likely that adults in the area may or may not have adequate knowledge of
hypertension. Evidence regarding the knowledge of hypertension does not seem to
exist. Therefore, this study on knowledge of hypertension becomes necessary.
Regrettably,
most adults due to ignorance of risk factors and preventive measures of
hypertension engage in unhealthy lifestyles such as excessive consumption of
alcohol, sedentary lifestyle, excess consumption of sodium intake, tobacco and
cigarette smoking, obesity, reduced intake of fruits and vegetables, stress and
consumption of foods rich in cholesterol. These unhealthy lifestyle practices
have increased the prevalence of hypertension in the world including Nigeria,
which culminates into high cases of deaths. Hypertension is one of the problems
affecting especially a great portion of the adult population and currently
causes one in every eight deaths worldwide, making it the third leading killer
disease in the world. Ejike, Ezeanyika and Ugwu (2010) estimated that about one
billion adults had hypertension in the year 2010, and the number is expected to
rise to 1.56 billion in the year 2025. In addition, hypertension is the
commonest non-communicable disease in Nigeria with over 4.3 million Nigerians
classified as being hypertensive. In Nigeria, many people lose their lives to
hypertension. This is not an acceptable situation, considering the fact that
hypertension is preventable and manageable to reduce its impact on the health
and lives of people in Nigeria.
However,
some studies have been conducted on the knowledge of hypertension in many parts
of the world including Nigeria. The literature reviewed showed that related
studies were conducted among pregnant women, workers in banking industry,
hypertensive patients, primary care patients, urban elderly and in rural
communities, and in different countries. Incidentally, there are no studies, to
the best knowledge of the researcher that have been carried out in Auchi in Edo
State to determine the level of knowledge of hypertension among adults. In view
of the above, the need arose to determine if adults in Auchi in Edo State have
adequate knowledge of hypertension. This was the task of the present study.
Despite
effective therapies and lifestyle interventions, optimal prevention of
hypertension remains very health challenge to health professionals especially
in most developing countries like Nigeria. Kadiri (2005) noted that 4.3 million
Nigerians are suffering from this silent killer disease called hypertension.
The inability to adequately prevent or manage hypertension in Nigeria can be
attributed to inadequate knowledge of hypertension. Thus reaching the healthy
people vision 2020 objective may be difficult if necessary actions are not
taken to prevent this disease. If health promotion programmes are to be
appropriate and effective, adults’ knowledge of hypertension need to be
identified. Therefore, the researcher was motivated to determine the level of
knowledge of hypertension possessed by adults in Auchi in Edo State. This
became necessary against the backdrop that identification of gaps in adults’
knowledge of hypertension is capable of aiding the development of adequate
information to enhance the knowledgeand perception of hypertension and its
management among clients/patients.Therefore, as part of a quality assessment to
improve the management outcome of hypertensive patients, we evaluated by means
of a descriptive, cross-sectional qualitative phenomenological survey,
hypertensive patients’ knowledge, perception, attitudes and life- style
practices in Auchi, Nigeria.
1.3 Purpose of Study
The general
purpose of this research work is to assess the knowledge and perception of
hypertension and its management among patients. The specific objectives
include;
1. To evaluateknowledge, perception, attitudes
and life- style practicesof hypertensive patients in Auchi.
2. To describe the barriers to effective
management of hypertension.
3. To determine the level of knowledge and
perception of hypertension and its management possessed by hypertensive
patients.
1.4 Research Questions
1. What is the knowledge, perception,
attitudes and life- style practices of hypertensive patients in Auchi?
2. What are the barriers to effective
management of hypertension?
3. What is the level of knowledge and
perception of hypertension and its management possessed by hypertensive
patients?
1.5 Significance of Study
The results
of this study will be useful to health educators, medical and paramedical
officers, public health officers, counsellors, media educators, researchers,
curriculum planners, government and adults in many ways. The study may help to
develop a positive regard towards hypertension. The ministry of health may
benefit from the study by discovering a gap in knowledge of the population, and
emphasize strategies to teach the adult population on how to prevent the risk
factors. It may also be useful to other researchers to carry out this study in
areas where disease prevention measures and health promotion are needed with
regards to hypertension.
Answering
the research questions associated with the research project offers insight into
managing hypertension by revealing an understanding of individual’s health
related knowledge, perceptions and behaviours.
1.6 Scope of the Study
The study
covered all the local government areas in Auchi in Edo State. The study was
restricted to adults between the ages of fifty years and above, and who were
found within the urban and rural areas. The study was concerned with
determining the level of knowledge and perception of hypertension and its
management among patients. This consisted of the concept of hypertension, signs
and symptoms, risk factors and preventive measures of hypertension. The
demographic factors of age, gender, location and level of education as they
relate to knowledge of hypertension were all explained.
1.7 Limitation of Study
The
researcher faced a number of restraints in the course of carrying out this
research project. They include; time constraints, financial constraints,
uncooperative attitude of some of the respondents. These constituted
limitations of this research project as some of the respondents did not return
their questionnaire. The researcher only made do with responses of the
respondents whose questionnaire were correctly completed and returned.
1.8 Operational Definition of Terms
Hypertension:
abnormally high blood pressure, a state of great psychological stress.
Hypertension
Management: Hypertension is managed using lifestyle modification and
antihypertensive medications. Hypertension is usually treated to achieve a
blood pressure of below 140/90 mmHg to 160/100 mmHg.
Knowledge:
facts, information, and skills acquired through experience or education; the
theoretical or practical understanding of a subject.
Perception:
Perception is the organization, identification, and interpretation of sensory
information in order to represent and understand the presented information, or
the environment.
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