R e s e a r c h A r t i c l e T h e K n o w l e d g e P r o f il e o f Pa t ie n t s w it h H y p e r t e n s io n A B S T R A C T : A sample o f 62 patients a t a hypertension clinic at a tertiary care hospital was interviewed to establish which factors contributed to p o o r knowledge. Patients were interviewed to esta­ blish basic demographic data, their own risk factors, various psycho-social fa cto rs as well as their knowledge o f the disease process and risk fa c to r management. A step-wise logistic regression was done to establish which fa cto rs were predictive o f the knowledge o f patients with hypertension. It was fo u n d that a good quality o f life (p=0.003); normal sex-life (p=0.00); home language o f English or Afrikaans (p= 0.002); educational status (p=0.00) and annual income (0.01) were predictive o f p a tie n ts’ knowledge. Patients with a better quality o f life had better knowledge than those with a p oor quality o f life (p=0.05). KEYWORDS: HYPERTENSION, KNOWLEDGE, EDUCATION, LANGUAGE, SOCIO-ECONOM ICS, Q U ALITY OF LIFE STEWART AV, MSc (MED)'; EALES CJ, PhD'; DE CHARMOY S, MSc (Physio)' 1 Department o f Physiotherapy, U niversity o f the W itw atersrand. INTRODUCTION For effective m anagem ent o f hyperten­ sion, risk factor control and adherence to a prescribed m edication regimen, are essential (Green et al, 1975). To do these, patients need an understanding o f the disease process and its m anagem ent (Sotile, 1996). It is well recognised that know ledge does not im ply adherence (Glanz, 1997). H ow ever patients need basic know ledge o f disease m anage­ m ent before they can begin to adhere to m edical advice (Glanz, 1997). Once patients’ know ledge o f the disease and it’s m anagem ent has im proved various strategies to increase adherence can be im plem ented (Sotile, 1996). Patients need to know “w hat to do” before the m ore behaviour specific “how to do” can be addressed (Bloom field 1993). This study was done - to identify the knowledge level of hypertensive patients regarding their disease - to identify the factors contributing to p oor knowledge and w hich o f these factors were m odifiable The study was done at a hypertension clinic in a tertiary care hospital. METHOD Patient selection Sixty-tw o patients w ere interview ed. A ll the patients attended a hypertension clinic at a tertiary care hospital. All patients gave inform ed consent prior to being interviewed. The purpose o f the interview was to establish the basic dem ographic data o f the patients, their own risk factors, their know ledge o f the disease process and risk factors as well as various psycho­ social factors. P erm issio n to do the study was obtained from the hum an ethics com ­ m ittee o f the U niversity o f the W itw a­ tersrand. The ethical clearance num ber was M 970624. Materials The questionnaire which was used in the interview was one validated and shown to be reliable by Eales (1998) in a similar study on post CA BG patients. Changes were made to the questionnaire to make it suitable for hypertensive patients. The questio n s on k n ow ledge w ere scored by two physiotherapists experi­ enced in this field and loaded according to their im portance. The reliability o f the questio n n aire w as re-estab lish ed by having two physiotherapists fill in the questionnaire on the sam e patients at the same time. The total score obtained for the questionnaire was expressed as a percentage. The questionnaire required only the m ost basic k n o w led g e;o f the patients, nam ely a definition jbf high blood pressure, risk factors and simple risk factor m odification. As such it was fe lt that only p atien ts w ho scored 60% and above had good knowledge. Those with below 60% were considered to have poor knowledge. Statistical Analysis An analysis o f variance was done to establish the variables affecting know ­ ledge. A step-wise logistic regression, was then done to establish w hich o f ...the; above variables were predictive o f poor know ledge in this group o f patients. F ish er’s exact test was used to establish any differences in variables between the group who scored over 60% and the group who scored under 60% on the knowledge score. Significance was set at the 95% level (p=0.05). CORRESPONDENCE: Stewart A D epartm ent o f Physiotherapy Wits M edical School 7 York Road Parktown 2193 Tel: (011)488-3450 Fax: (011)488-3210 Email: 159aimee@ chiron.wits.ac.za SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 17 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:159aimee@chiron.wits.ac.za RESULTS The dem ographic data o f the patients is show n in Table 1. TABLE 1. Demographic Data Sex Female 50 Male 12 Age 57 range 29 - 77 Population Group White - 8 Black - 13 Coloured - 32 Asian - 9 Home Language Afrikaans - 28 English - 21 An African language - 11 Another language - 2 Family Lived with partner - 34 Lived with family - 23 Lived alone - 5 Annual Income > R15000 - 31 < R15000 - 31 Educational Level < Grade 7 - 2 1 < Grade 9 - 26 > Grade 9 - 1 5 Employment 39 - unemployed or retired 23 - employed Physically Active 20 - active 42 - inactive The majority o f the patients were female. The majority spoke either English or Afrikaans. H alf the patients earned less than R 15000 per annum. Only 20 o f the patients were physically active at the time o f the study. Table 2 illustrates the risk factors present in this group o f patients. TABLE 2. Risk Factors Type Present-(no patients) Absent-(no patients) Hypercholestralaemia 22- (35%)- 40-(65%) Current smoker 14-(23%) 48-(77%) Physically active 20-(32%) 42-(68%) Family history 37(60%) 25-(40%) Stressed 33-((53%) 29(47%) Presence of diabetes 8-(13%) 54-(87%) BMI>30 32-(52%) 30-(48%) Drink alcohol 17-(27%) 45(73%) Very few o f this group o f patients were smokers and very few drank alcohol. Slightly m ore than 50% o f the patients were obese and slightly more than 50% were stressed. Table 3 illustrates the psycho-social factors m easured in this group o f patients. TABLE 3. Psycho-Social Factors Good-(no patients) Poor-(no patients) Control of emotions 19-(31%) 43-(69%) Sex-life 23-(37%) 39-(63%) Social support 41 -(66%) 21-(34%) Quality of life 26(42%) 36-(58%) Satisfaction with treatment 56-(90%) 6-( 10%) Forty-tw o percent o f the patients said that they had a good quality o f life. Two thirds o f the patients felt that they had enough social support. The majority o f the patients were satisfied with their treatm ent at the clinic. 18 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 4 illustrates the know ledge score o f this group o f patients. The patients are divided into those with good knowledge and those with poor know ledge. TABLE 4. Mean knowledge score of hypertension No patients Define high BP Total (4) Manage disease Total (7) Chronic disease Total(l) Conseq of disease Total (2) Actual BP Total (2) Above 60% 12(19%) 1 4.4 1 1 1.6 1.3 Below 60% 50-(81%) 0.5 3 0.8 1 1 Very few o f the patients in both groups were able to define high blood pressure. In addition neither group knew how to manage their condition. Table 5 illustrates the know ledge score o f the risk factors and the m anagem ent o f hypertension in this group o f patients. TABLE 5. Mean knowledge score of risk factors and management Above 60% Below 60% No patients 12 50 Obesity & Diet Total(5) 4.2 3 Alcohol Safe intake Total(4) 2.2 1 Salt Safe intake Total(4) 3.5 3 Age & Menopause Total(2) 2 1 Smoke-Effect heart & lungs Total(5) 4. 53 Stress & Control Total(2) 2 2 Exercise Dist & Freq Total(5) 0.2 0.1 Med Total(2) 2 1.5 A lthough both groups had som e idea o f risk factor m anagem ent neither group had any idea o f how to exercise. - The mean know ledge score o f the whole group was 47% ranging from 5% to 74%. - The mean know ledge score o f the patients above 60% was 64% - The m ean know ledge score o f the patients below 60% was 44% The results o f the step-w ise logistic regression analysis done to establish which factors predict know ledge are presented in Table 6. TABLE 6. Factors predicting knowledge Factor Coefficient Std Err t P Quality of life -8.78 2.84 -3.08 0.003 Sex-life 12.39 3.14 3.9 0.000 Language -10.83 3.36 -3.22 0.002 Education -12.13 2.92 -4.15 0.000 Income -12.57 4.76 -2.63 0.011 None of the factors predictive o f know ledge are m odifiable. H ow ever com ponents o f quality o f life are modifiable. SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 7: Differences in quality o f life in the groups with know ledge above 60% and below 60%. TABLE 7. Differences in quality of life Good knowledge Poor knowledge Total Good quality of life 8 18 26 Poor quality of life 4 32 36 Total 12 50 62 There was a significant difference in quality o f life between the patients with good know ledge and those with poor knowledge. (p=0.05). DISCUSSION Only 12 patients in this study were considered to have sufficient know ledge o f the management o f their hypertension. This is sim ilar to other findings (Ley 1985 and Green et al 1975). Health behaviour change cannot take place with a lack o f know ledge o f hyperten­ sion (Prochaska et al 1992). The “core” know ledge needed as a basis for health b eh av io u r m o d ificatio n is “w hat is hypertension; how is it measured; what is normal blood pressure; what causes hypertension: why it must be treated and what can be done to control it” (Hill 1989). B etw een 35% - 92% of patients do not understand the inform ation that is given to them. I f com prehension, memory and satisfaction is increased adherence im proves (Ley 1985). Both groups o f patients (that is those w ith k n o w led g e and those w ithout know ledge) had difficulty in defining h y p erten sio n and they w ere m ostly unsure o f their blood pressure readings (See Table 4). They had some idea of diet, salt ingestion and obesity as risk factors for hypertension. The knowledge­ able group scored som ewhat better (See Table 5). Sim ilar results were found for smoking and stress. As many o f these patients did not drink alcohol for religious reasons their know ledge o f acceptable alcohol ingestion levels was poor. Both groups mostly knew how many tablets they w ere taking even though they were not sure o f the effect o f the m edi­ cation. T hey said that they adhered to their m edication regimen. N either group considered a lack o f regular exercise as a risk factor, nor as an im portant m odifier o f their disease. Both groups o f patients scored less than 1 out o f a possible 5 points (See Table 5). N either did they know how m uch to exercise. Patients becom e aw are o f the health benefits o f exercise within a few w eeks o f regular exercise (Benetos et al 1997). The contribution o f regular exer­ cise to weight control and the im pact o f weight control on hypertension m an­ agem ent needs to be stressed in any risk factor m odification or rehabilitation pro­ gram m e (Hill 1989). A lthough these patients had som e idea o f the diet that they should follow they seldom consid­ ered obesity as a risk factor (See Table 5). N either group cam e from an exercise background. This may be cultural or could be as a result o f the lack o f adequate schooling for this com m unity during the apartheid era. Bloom field (1993) show ed that white Am ericans were more likely than black Am ericans to consider lack o f exercise as a risk factor. Predictive factors contributing to the know ledge o f the patients were their quality o f life, their sex-life, language, education and incom e (Table 6). Patients who did not understand either English or Afrikaans because it was not their home language had poorer know ledge o f the disease (p=0.002). As most o f the inter­ actions in the hospital take place in either o f the above languages any advice or inform ation that was being given was probably not being understood. In addi­ tion any inform ation available in the m edia is m ost likely to be available in English or Afrikaans. B lack patients in South A frica tend not to ask questions, largely due to the cultural differences betw een them and the health-care p rovider (de Villiers 1991). T h e health p ro v id er-p atien t relationship can affect know ledge and behaviour. From observations at the clinic the interactions are very brief and patients tend to be passive. Patients do not understand what the health-prac- titioner is talking about and so do not adhere (Heggenhougen 1986). It requires far m ore than b rie f in te ra c tio n s to bring understanding to patients. M uch more focussed intervention is required to ensure adherence (Sotile 1996). To prom ote adherence health-care providers must -educate about the condition and treatm ent; develop an individualised regimen; provide reinforcement and sup­ port; prom ote social support; and colla­ borate with other health professionals (Hill 1989). Key to the above beha­ viours is the prom otion o f self-responsi- bility in the patients. (Eales et al 1998). P atien ts from p o o rer educatio n al (p= 0 .0 0 ) and so cio-econom ic b ack ­ grounds (p= 0 .0 1 ) also had p o o rer know ledge. These patients often have a m ultiplicity o f problem s to cope with. They may be sole bread -winners and be responsible for the care o f the family (Green 1975). They are often confused about what they have to do to change th eir b eh av io u r (G reen 1975). T he patients in this sample were also unsure o f w hat to do. If the patients are confused it is very unlikely that fam ily mem bers under­ stand the problem s. As such they will not offer the support that is im portant for good adherence (Hill 1989 Sotile 1996). It is im portant to understand patients’ beliefs about their condition as if they do not understand exactly w hat it is that needs to be done they do not believe that they have to adhere. F o r education to be effective it has to concentrate on the here and now o f benefits (Brown and 20 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Segal 1996). Long -term consequences such as stroke do not mean as much. An example o f short -term benefits are feel­ ing fitter and coping with activity more easily (Brown and Segal 1996) In this study patients’ quality o f life (p=0.003) and a perceived norm al sex life (p=0.00) were predictive o f good know ledge. Patients who consider their quality o f life to be good and their sex lives as norm al are possibly more confi­ dent, assertive and self- responsible. Because o f m ore know ledge they are m ore likely to change th eir health behaviour. The quality o f life score was signifi­ cantly different between the two groups (p= 0.05). P atien ts w ith k n ow ledge scores above 60% had better quality o f life than those who scored below 60%. A lthough quality o f life is a non-modi- fiable variable there are com ponents o f quality o f life that can be modified. M odifiable factors are an increase in functional capacity and a decrease in sym ptom s (W enger 1984). In hyperten­ sion it w ould be im portant to improve patients’ functional capacity. H yperten­ sive patients very often do not have symptoms. The rehabilitation outcom es in chron­ ic diseases such as hypertension should focus on im proving the quality o f life o f patients (Eales et al 1998). In order to increase quality o f life one needs to focus on the com ponents o f quality o f life m entioned above. To im prove the health status o f hypertensive patients the rehabilitation program m e should focus on increasing functional capacity. In order to do this, patients have to adhere to a basic risk factor m odification pro­ gram m e to control their high blood pres­ sure. R isk factor m anagem ent cannot occur without the patients understanding their condition. This makes education o f the patient a critical health-provider activity (Hill 1989). CONCLUSIONS A lthough patients had been hyperten­ sive for som e considerable tim e (a mean o f 10 years) their know ledge o f the disease process and m anagem ent was poor. Only 12 patients were considered to have sufficient know ledge to begin m anaging their disease. Factors predic­ tive o f know ledge were quality o f life, sex life, language, education and income. Quality o f life was significantly different between the group w ith good know ledge and the group with poor knowledge. W ith p o o r know ledge patients have difficulty m anaging their disease, as know ledge is the basis for change in health behaviour. So one w ould strive to m ake patien ts kn o w led g eab le about th eir condition because this should im prove their quality o f life. REFERENCES Benetos A, Safar M, Rudnichi A, Smulyan H, Richard JL, Ducimeticere P, Guize L 1997 Pulse pressure: a predictor o f long term cardiovascular mortality in a French male population. Hypertension 30:1410-1415 Bloom field R, Young L, Graves J 1993 Racial differences in Perceptions C oncerning Hypertension and its Consequences. Southern M edical Journal 86: 767-770 Brown C, Segal R 1996 Ethnic Differences in Temporal Orientation and Its Implications for Hypertension Management. 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