Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11867 Exploring the primary health facility availability, health control, drug consumption, and healthy living behavior among patients with hypertension Israfil Israfil,1,2 Ah Yusuf,1 Ferry Efendi,1 Maria Agustina Making,3 Ni Luh Putu Inca Buntari Agustini2 1Faculty of Nursing, Universitas Airlangga, Surabaya; 2Nursing Department, Faculty of Health, Institute of Technology and Health Bali, Denpasar; 3Nursing Department, Politeknik Kesehatan Kementerian Kesehatan Kupang, Kupang, Indonesia Abstract Hypertension has been identified as a causative factor for car- diovascular disease, a leading global cause of death. The accessi- bility of health services plays a pivotal role in shaping community awareness and engagement in hypertension management. This research aimed to explore the availability of primary health facil- ities, health control practices, drug consumption, and healthy liv- ing behaviors among individuals with hypertension. Utilizing a correlation study with a cross-sectional design, the sample com- prised 130 hypertensive individuals selected through purposive sampling. Statistical analysis used the Spearman rho correlation test. The findings revealed that significant correlations between primary health facility availability and health control behavior (α=0.000, r=0.310), antihypertensive drug consumption behavior (α=0.000, r=0.461), and healthy lifestyle behavior (α=0.000, r=0.478) among hypertensive patients. These results underscore the relationship between the availability of primary health facili- ties and the behavior of hypertensive patients in terms of health control, drug consumption, and healthy lifestyle choices within the community. While the full implementation of these behaviors among hypertensive patients may not be optimal, the observed good availability of primary health facilities serves as an initial step to promote improved behaviors in the management and pre- vention of hypertension complications within the community. Introduction Hypertension is a chronic non-communicable disease diag- nosed based on high blood pressure examination results reaching ≥ 140/90 mmHg or higher. Hypertension sufferers may not feel any symptoms, so the only way to find out if there is an increase in blood pressure is to carry out routine blood pressure checks.1–3 Hypertension that is not adequately controlled will damage blood vessel walls, causing thickening and stiffness of blood vessel walls, accumulation of fatty atherosclerotic plaque, and ultimately causing various complications such as coronary heart disease, angina pectoris, myocardial infarction, heart failure, retinopathy, and kidney failure.4–6 Hypertension has also become a causative factor for cardiovascular disease, one of the causes of death glob- ally.7–9 One of the global targets for non-communicable diseases is reducing hypertension prevalence by 33% between 2010 and 2030.1 It is estimated that 1.28 billion adults aged 30-79 years worldwide suffer from hypertension, and around 46% of people with hypertension are not aware that they have hypertension. Less Correspondence: Ah Yusuf, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia. E-mail: ah-yusuf@fkp.unair.ac.id Key words: healthy behavior, hypertension, primary health facilities. Contributions: II, conceptualization, data collection, analysis, and manu- script writing; AY, supervised, corrected data and manuscripts, and pro- vided input for improvements; FE supervised, corrected data and manu- scripts, and provided input for improvements; MAM, methodology, for- mal analysis, validation, and writing–original draft, review & editing; NLPIBA, data curation, formal analysis, methodology, validation, visu- alization, writing–original draft, review & editing. Conflict of interest: the researcher stated that there was no conflict of interest in this study. Ethics approval and consent to participate: this research has received eth- ical approval from the Health Research Ethics Committee, Faculty of Nursing, Universitas Airlangga with Ethical Approval number 2640- KEPK. During the study, the researcher pays attention to the ethical prin- ciples of information to consent, respect for human rights, beneficence, and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this study was funded by the Directorate of Research, Technology and Community Service, the Ministry of Education, Culture, Research and Technology No: 0162/E5.4/DT.05.00/2023. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgments: we thank the Directorate of Research, Technology and Community Service, Ministry of Education, Culture, Research and Technology, and the Health Office in Kupang City, East Nusa Tenggara Province; the Head of the Community Health Center in the City of Kupang, the Community Nurses, and all respondents. Received: 23 September 2023. Accepted: 11 December 2023. Early access: 11 January 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11867 doi:10.4081/hls.2024.11867 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 138] [Healthcare in Low-resource Settings 2024;12:11867] Non -co mmerc ial us e o nly than half, or 42%, of hypertension sufferers have been diagnosed and have received treatment. However, only 1 in 5 people who suf- fer from hypertension can control their blood pressure well.1 In Indonesia, the prevalence of hypertension continues to increase.10 The five-year national health research of the Ministry of Health of the Republic of Indonesia in 2018 found that hypertension in Indonesia had increased from 25.8% in 2013 to 34.1% in 2018. The prevalence of stroke had increased from 7% in 2013 to 10.9% in 2018, and the prevalence of heart disease reached 1.5% in 2018.11 Health checks and blood pressure measurements, taking anti- hypertensive medication, and changing to a healthier lifestyle are essential efforts that must be made to control blood pressure within normal limits and reduce the risk of complications. The level of education, knowledge, and access to health services can influence community awareness and participation in controlling hyperten- sion.12–14 Health facilities that do not have adequate equipment will affect the success of treating hypertension in the community.15 Health Service Facilities are tools and/or places used to provide health service efforts, whether promotive, preventive, curative, or rehabilitative to patients.16 The main challenges in managing hypertension in primary health facilities are shortages of equip- ment and personnel, drug stockouts, and poor patient attendance at health care visits.17 Primary healthcare facilities in Indonesia known as community health centers are a type of first-level health service that is easily accessible to the community, especially in areas with a gap in health development background with larger urban areas.18 The availability of primary healthcare facilities or Community Health Centers is the first door to discovering various cases of non-com- municable diseases in the community, including hypertension.19 Accessibility to primary health services is an essential factor influ- encing the success of hypertension management in the community.18 Inadequate availability of primary healthcare facili- ties is the cause of the low level of handling of hypertension cases in the community at various stages, namely screening, diagnosis, treatment, and follow-up efforts to treat hypertensive patients.19 The research aimed to explore the primary health facility availabil- ity, health control, drug consumption, and healthy living behavior among patients with hypertension. Materials and Methods Research design This research was a correlation study with a cross-sectional design. A cross-sectional design was adopted to examine correla- tions between different elements without manipulating variables over time. Population, sample, sampling The population in this study were hypertensive patients in the community. The sample size was 130 people taken using the pur- posive sampling technique. Hypertensive patients who have suf- fered from hypertension for > 6 months, have not experienced complications, can read and write, do not experience mental disor- ders, and are willing to be respondents are the inclusion criteria for this study. This research was carried out in the work area of 11 Kupang City Health Centers, East Nusa Tenggara province, in the eastern part of Indonesia, from September to November 2022. Variable The independent variable of this research was the availability of primary health facilities, and the dependent variables were health control behavior, drug consumption behavior, and healthy lifestyle behavior in hypertension patients Instrument Data collection was carried out using a questionnaire that had been developed by the research team from several sources, and validity and reliability tests had been carried out according to research needs.20,21 The health facilities availability questionnaire has three answer choices, namely “Yes”, “No” and “Don’t Know”. Answers are accumulated and a presentation is made in the cate- gories of availability of health facilities, namely good 76-100%, enough 60-75%, and less <60%. The questionnaire on health con- trol behavior, consumption of antihypertensive drugs, and healthy lifestyle has four answer choices, namely “always”, “sometimes”, “rarely”, and “never”. Answers are accumulated and made into a presentation with categories of good behavior 76-100%, enough 60-75%, and less <60%. The questionnaire has been tested for validity and reliability with the results of the validity test being declared valid if the r count is more The value of the r table is 0.373, and is declared reliable if the Cronbach’s Alpha value is > 0.388.22 The results of the validity test which have been confirmed are that the calculated r of the questionnaire on the availability of health facilities is r = 0.525-0.930, health control behavior r = 0.812-0.899, drug consumption r = 0.728-0.914, and healthy lifestyle r = 0.449-0.763. Meanwhile, the results of the reliability test showed that the Cronbach’s Alpha value of the health facility availability questionnaire was 0.870, health control behavior 0.872, drug consumption 0.884, and healthy lifestyle 0.600. Data collection process Data collection was carried out by identifying respondents who met the inclusion criteria, respondents were explained the purpose, benefits, and procedures for collecting research data, and respon- dents were asked for approval and signed informed consent. Respondents are then given a questionnaire to fill out, filling in the questionnaire is done directly accompanied by a researcher or accompanying enumerator to avoid misunderstandings in filling out the questionnaire. The completed questionnaires were collect- ed and then tabulated for analysis. Data analysis The research data were explained statistically using the Spearman Rho Correlation Test with the help of SSPS 20 software, with the significance level used being α = 0.01. Ethical clearance This research has received ethical permission from the Health Research Ethics Committee, Faculty of Nursing, Airlangga University with Ethical Approval number 2640-KEPK. Results The majority of respondents were aged 55-65 years (43.1), female (71.5%), had secondary education (44.6%), suffered from hypertension for ≤5 years (39.2%), and suffered from hypertension grade 1 (51.5%) (Table 1). According to the majority of patients, primary health facilities were considered good in terms of availability (87.7%). However, only 15.4% of hypertensive patients exhibited good behavior in Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11867] [page 139] Non -co mmerc ial us e o nly terms of health control, while a larger proportion, 46.2%, demon- strated positive behavior in taking antihypertensive medication. In addition, the majority of hypertensive patients showed good behavior in adopting a healthy lifestyle, accounting for 43.1% (Table 2). Based on the Spearman rho statistical test, the results obtained were the availability of primary health care facilities with the health control behavior of hypertensive patients (p-values=0.000, r=0.310), with the behavior of consuming antihypertensive drugs (p-values=0.000, r=0.461 ) and with Healthy Lifestyle Behavior (p-values=0.000, r=0.478). These results indicate a relationship between the availability of primary healthcare facilities and health control behavior, antihypertensive drug consumption behavior, and healthy lifestyle behavior in hypertensive patients. The behavior that has the most vital relationship to the availability of primary healthcare facilities is healthy lifestyle behavior (Table 3). Discussion This study found that the availability of primary health facili- ties in the community has a significant relationship with health control behavior, antihypertensive drug consumption behavior, and healthy lifestyle behavior in hypertensive patients. Although the availability of primary health facilities in the local area was mostly reported to be good, this study found that the expected good behav- ior of hypertensive patients was still not achieved optimally. The availability of primary health facilities in the community is an essential and effective strategy to handle and reduce the burden of non-communicable diseases, including hypertension and the dan- ger of its complications.23 Primary health facilities are the main supporting facilities and health services providers to hypertensive patients in the communi- ty to get support in carrying out and improving healthy living behavior to control hypertension and prevent complications. The availability of good primary health facilities will produce good capacity in integrating strategies for preventing and controlling non-communicable diseases in the community, including hyper- tension.24 In line with this study’s results, primary health facilities’ availability is said to be good if it has the availability of health human resources, medical equipment, infrastructure, medicines, a referral system, and community outreach.24 Behavior is a factor that can be modified and is expected to be implemented well by hypertensive patients to control and prevent the worsening of hypertension. The desired behavior in hyperten- sive patients is health control behavior, consumption of antihyper- tensive drugs, and healthy lifestyle behavior. Hypertensive patients with poor behavior in controlling high blood pressure have a 17.23 Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of respondents (n=130). Characteristics of respondents n % Age 35-44 years 14 10.8 45-54 years 31 23.8 55-65 years 56 43.1 66-74 years 23 17.7 75-90 years 6 4.6 Gender Male 37 28.5 Female 93 71.5 Level of education Primary education 44 33.8 Secondary education 58 44.6 Higher education 28 21.5 Long suffered from hypertension ≤ 5 years 51 39.2 6-10 years 23 17.7 ≥ 10 years 22 16.9 Forget 34 26.2 Classification of hypertension Grade I hypertension 67 51.5 Grade II hypertension 15 11.5 Grade III hypertension 8 6.2 Isolated hypertension 40 30.8 Table 2. Description of primary health facilities availability, health control behavior, drug consumption behavior, and healthy lifestyle behavior in hypertensive patients (n=130). Variable n % Availability of primary health facilities Good 114 87.7 Enough 16 12.3 Less 0 0 Patient behavior for health control Good 20 15.4 Enough 35 26.9 Less 75 57.7 Patient behavior regarding consumption of antihypertensive drugs Good 60 46.2 Enough 30 23.1 Less 40 30.8 Patient behavior for a healthy lifestyle Good 56 43.1 Enough 55 42.3 Less 19 14.6 Table 3. Relationship between the availability of primary health facilities and health control, drug consumption, and healthy living behav- ior among patients with hypertension (n=130). Availability of primary Health control Drug consumption Healthy living behavior healthcare facilities Good Enough Less Good Enough Less Good Enough Less Good 20 35 59 60 29 25 56 50 8 Enough 0 0 16 0 1 15 0 5 11 Less 0 0 0 0 0 0 0 0 0 p 0.0001 0.0001 0.0001 r 0.310 0.461 0.478 *Correlation is significant at the 0.01. [page 140] [Healthcare in Low-resource Settings 2024;12:11867] Non -co mmerc ial us e o nly times greater risk of experiencing complications than those who have good behavior in controlling hypertension.25 Patient beliefs about hypertension, knowledge about the dangers of hypertension, and its management have been reported to influence patient com- pliance in implementing healthy behavior or lifestyle.26 Family support also correlates with hypertensive patients’ adherence to antihypertensive drugs, according to recommendations from health workers.27 Self-efficacy, individual coping, and social support from family and health workers are also related to the behavior of hypertensive patients in controlling blood pressure and preventing cardiovascular complications.28 Apart from that, hypertensive patients’ self-awareness of the dangers of hypertension complica- tions such as stroke can also influence the behavior of hypertensive patients to better prevent hypertension complications.29 Various efforts by good primary health facilities to improve health control behavior, consumption of antihypertensive drugs, and healthy lifestyles must continue to be carried out, such as train- ing health workers on preventing and controlling hypertension as part of their daily practice in the community.24 It must be realized that the patient’s level of awareness influences the behavior of hypertensive patients in utilizing primary health facilities, the per- ceived level of severity, the perceived effectiveness of therapy, the side effects of the treatment received, and the patient’s fear of life- long dependence on the hypertension medication given.30 Health workers working in primary health facilities must move to support compliance in managing hypertensive patients by maintaining per- suasive communication with hypertensive patients, providing suf- ficient time for patients to ask questions and receive recommenda- tions, and taking a hypertension management approach that is responsive to individual needs according to ethnicity. Culture and community that provide benefits.31 Apart from that, it is also essential to increase the commitment of the government to plan a regular hypertension skinning program in the community, provide adequate medicines, provide modern equipment, and empower health workers who work in primary health facilities to research various factors that influence hyperten- sion patient compliance in following the treatment program pro- vided.32 Another strategy that can be implemented is a task division model, which involves transferring specific tasks from doctors to nurses and local community health workers, which will be very important to improve primary care health services in controlling hypertension and preventing cardiovascular disease in hyperten- sive patients in the community.33 Future work should focus on developing and validating performance indicators to facilitate an orderly and systematic review of data on the management of hypertensive patients in the community to improve outcomes and more targeted follow-up planning.17 The results of this study provide evidence to the government and managers of primary health facilities that the availability of primary health facilities is related to the behavior of hypertensive patients in controlling their health, consuming anti-hypertension drugs, and implementing a healthy lifestyle. The role of primary health facilities must continue to be improved to produce better behavior of hypertensive patients in the community to control and prevent complications of hypertension. This research has limita- tions in only looking at the correlation between the availability of primary healthcare facilities and the behavior of hypertensive patients in the community. Research on other factors that influence the behavior of hypertensive patients in the community needs to be carried out further. Conclusions The availability of primary health facilities in the community was good, but their use by hypertensive patients was still not opti- mal. The availability of primary health facilities in the community has a significant relationship with the health control behavior, drug consumption, and healthy living behavior among patients with hypertension. 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