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International Journal of Caring Sciences January-April 2021 Volume 14 | Issue 1| Page 392
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Original Article
Effect of Nursing Intervention on Knowledge and Practice of Salt and Diet
Modification among Hypertensive Patients in a General Hospital
South-West Nigeria
Ajiboye, Rachael Oluwafunmilayo
Senior Nurse Tutor, School of Nursing, Lagos State College of Nursing, Midwifery and Public Health,
Igando, Lagos, Nigeria
Okafor, Ngozi Antonia
Senior Lecturer, Department of Nursing, Babcock University, Ilishan-Remo, Ogun State, Nigeria
Olajide, Tayo Emmanuel
Lecturer II, Department of Nursing, Babcock University, Ilishan-Remo, Ogun State, Nigeria
Emmanuel Olayemi Tosin
Principal Nurse Tutor, School of Nursing, Lagos State College of Nursing, Midwifery and Public Health,
Igando, Lagos, Nigeria. [email protected]
Correspondence: Ajiboye, Rachael Oluwafunmilayo School of Nursing, Lagos State College of Nursing,
Midwifery and Public Health, Igando, Lagos, Nigeria. E-mail:[email protected]
Abstract
Background: Hypertension is the most common non-communicable disease and the leading cause of
cardiovascular disease in the world. Current management of hypertension stressed the importance of salt and
diet modifications. Unfortunately, many hypertensive patients do not have proper knowledge of this, which
results to inadequate practice. Therefore, there is need to develop strategies that will help to improve knowledge
and practice of salt and diet modifications among hypertensive.
Objective: To determine the effect of nursing intervention on knowledge and practice of salt and diet
modifications among hypertensive patients.
Materials and Methods: A quasi experimental design was conducted using purposive sampling to select the
sample size of 38 participants. A researcher-developed questionnaire derived from the literature review and
Hypertension Self-Care Activity Level Effects (H-SCALE) adapted from Warren-Find low and Seymour (2011)
was used to measure knowledge and practice of salt and diet modification among the participants. Data gathered
from participants were expressed using tables and percentages while research questions were answered with
descriptive statistics of mean and standard deviation through statistical package for the social science software
version 21.
Results: the study revealed that higher percentage of the participants (81.6%) had poor of knowledge of salt and
diet modification pre-intervention, also 92.1% of the participants reported poor practice before intervention.
Intervention was given to the participants and results showed a positive change in knowledge and practice of salt
and diet practice post-intervention.
Conclusion: regular training should be given to hypertensive patients by nurses to improve their knowledge and
practice of salt and diet modification for effective blood pressure control.
Keywords: Hypertension, Knowledge, Practice, Salt and Diet modification, Nigeria
Introduction
The burden of hypertension and other non-
communicable diseases is rapidly increasing and
this poses a serious threat to the economic
development of many nations. Hypertension is a
global public health challenge due to its high
prevalence and the associated risk of stroke and
cardiovascular diseases in adults.
Globally, hypertension is implicated to be
responsible for 7.1 million deaths and about
12.8% of the total annual deaths (World Health
Organization (WHO), 2018). Africa, among
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other WHO regions was rated highest with
increased prevalence of high blood pressure,
estimated at 46% from age 25 years and above in
which Nigeria contributes significantly to this
increase (Okwuonu, Emmanuel, & Ojimadu
2014; Ekwunife, Udeogaranya, & Nwatu, 2018;
WHO, 2018). This is so in spite of the
availability to safe and potent drugs for
hypertension and existence of clear treatment
guidelines, hypertension is still grossly not
controlled in a large proportion of patients
worldwide.
Current national recommendations for the
prevention and treatment of high blood pressure
emphasized non-pharmacological therapy, also
termed “lifestyle modification” which includes
salt and diet modification. However, there is a
dearth of information on the knowledge and
practice of salt and diet modification among
hypertensive patients attending Nigeria’s health
institutions (Abubakar et. al, 2017). Hence, poor
knowledge of salt and diet modifications, and
inability to practice these were one of the
identified patient- related barriers to hypertension
control (Tesema et.al, 2016). This gap may also
be attributed to the type of information or
training programmes given to patients on salt and
diet modification.
Therefore, this study might help to improve the
knowledge of hypertensive patients on salt and
diet modification which in turn may affect its
practice thus reducing the death burden,
complications and economic cost of poorly
controlled hypertension among patients and in
the society.
Objective
The aim of the study was to determine the effect
of nursing intervention on knowledge and
practice of lifestyle modification among
hypertensive patients. The following research
questions were expected to be answered:
1. What is the pre-intervention knowledge
and practice of salt and diet modification among
hypertensive patients?
2. What is the post-intervention knowledge
and practice of salt and diet modification among
hypertensive patients?
Methods
It is a quasi-experimental study, which adopted
one pre-test-post-test design, conducted between
February and September 2019, at a secondary
health facility (General Hospital), South-west,
Nigeria. The study was carried out among
hypertensive patients attending medical out-
patients department (MOPD) in the general
hospital. The hospital was purposively selected
being the only secondary health facility located
in one of the densely populated communities in a
major commercial city of South-west, Nigeria.
Sample size and sampling procedure: Sample
size was calculated using Taro Yamane method
of sample size determination, n = calculated
sample size, Population size (N) = 42 based on
daily clinic attendance of hypertensive patients,
and margin of error = 0.05 with a confidence
level of 95% given a sample size of 38
participants. Inclusion criteria were male and
female patients who were ≥18 years of age,
diagnosed to be hypertensive and attending
medical out-patients department (MOPD),
available and willing to participate in the study,
who could communicate either in English or
Pidgin English. Exclusion criteria were other
patients at MOPD who were not diagnosed to be
hypertensive, or with any co-morbidity that could
interfere with participation in the training, and
have attended previous educational programme
on salt and diet modification. Participants were
selected based on the inclusion criteria using
purposive sampling.
Data collection tools and procedures: Data
were gathered using researcher-developed
questionnaire derived from the literature review
with the opinions of experts in the field to assess
participants’ knowledge of salt and diet practice
and modified Hypertension Self-Care Activity
Level Effects (H-SCALE) developed by Warren-
Findlow and Seymour (2011) to assess practice
of salt and diet modification among the
participants.The questionnaire consists of three
parts. The first part includes the demographic
characteristics of the participants with eight (8)
items; the second part assessed the participants’
knowledge of salt and diet modification. The
knowledge of salt and diet modification
questions includes twelve (12) items with
maximum and minimum scores of 12 and 0
respectively. Participants’ knowledge scores of
9-12 points indicate high knowledge, 6-8 points
indicate moderate knowledge and scores <6
points indicate poor knowledge. The third part
assessed the practice of salt and diet modification
among the participants with seven items which
were used to assess practices related to eating a
healthy diet, avoiding salt while cooking and
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eating, and avoiding foods high in salt content.
Responses were coded ranged from never (1) to
always (3). Responses were summed up creating
a range of scores from three (3) to twenty one
(21). Scores of eleven (11) and above indicates
that participants followed the low-salt diet and
was considered as having good low salt diet
practice while score <11 indicate poor salt diet
practice. The psychometric properties of the
instrument was checked by experts in the field
using face and content validity criteria, the
reliability of the instrument was determined
using split-half method and the Cronbach’s alpha
reliability coefficient on knowledge of salt and
diet modification was 0.78, while salt and diet
practice was 0.72 which showed high reliability
of the instrument. The method of data collection
involved three phases:
Phase 1: this involved meeting with the
consultant and nurses in charge of MOPD of the
General Hospital to explain the purpose of the
study and its benefits, and to seek their co-
operation for the success of the study. This took
place during the first week of the study. In the
second week of the study, the researcher with
two research assistants visited the MOPD to
listen to health talk given to the patients by the
nurses and other health personnel, gaps were
identified which was used to modify the training
modules. The participants were met to discuss
the purpose, course and potential benefits of the
study. Interested participants were enrolled for
the study after obtaining their consent. Further
selection of the participants continued in the third
and fourth week. A pre-test instrument
(questionnaire) was given to the selected
participants to complete during the selection. No
external interference was allowed during data
collection, researcher and research assistants
stayed with the participants throughout the
period of completing the questionnaire after
which they were thoroughly checked for
completeness before retrieval from the
participants.The results from this phase were also
used to modify the training module for better
intervention. Reminder for the training
programme was given through phone calls, text
messages and visits on the clinic- days prior to
the training.
Phase 2: A developed intervention package was
implemented based on feedback obtained from
pre-intervention knowledge and practice score
with learning modules which was used for the
educational training of hypertensive patients on
salt and diet modification. The intervention
package had two modules of learning which was
delivered for two hours weekly for two weeks.
Different instructional methods were utilized to
deliver the programme including lectures, group
discussion, questions and answers, chats/pictures
and educational hand out. Follow-up through
phone calls and text messages was done every
week after intervention to ensure adequate
practice before the post-intervention test.
Phase 3: A post-test was given one month post-
intervention with the same instruments used
during the pre-test. Data collected were coded
and processed using statistical package for social
science (SPSS), version 21. Frequency table was
constructed and data were expressed on it. The
research questions were answered using
descriptive statistics of mean and standard
deviation.
Ethical Consideration: The ethics committee of
the researcher’s institution approved the study
with approval reference BUHREC102/19 dated
27th February, 2019 and written permission of the
State Health Service Commission was also
obtained to conduct the study. Participants were
informed about the purpose of the study and their
consents both verbal and written were taken
before the study commences. Participation was
voluntary and participants have the right to
withdraw at any stage of the study.
Results
The socio-demographic data reveals that greater
number of the participants was females (68.4%)
possibly, because females tend to pay more
attention to their health and engaged more in
physical and emotion stress than their male
counterparts. Majority, (44.7%) participants were
between the ages of 46 to 60 years, also many of
the participants (28.9%) have primary education
and 42.1% were self-employed. This could also
be related to the fact that the study was carried
out in one of the largest commercial city in
South-west Nigeria and research facility was
located in one of the densely populated
communities in the state which often require
constant subsidized health care services (Table 2)
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Table 1: Intervention programme module about salt and diet modification
Goals Learning content
At the end of the module, the
participants will:
Have a background knowledge of
hypertension
Know and identify the risk factors of
hypertension
Understand the contribution of salt and
diet modification to blood pressure
control.
Describe salt intake reduction and the
recommended quantity of salt intake
for blood pressure control.
Week One
Background knowledge of hypertension
Hypertension is the leading cause of heart and blood vessels diseases
worldwide.
About 7.1 million deaths worldwide (~12.8% of total deaths) are
estimated to be caused to hypertension.
Africa has the highest numbers of people with hypertension.
In Nigeria, hypertension is graded as number one of all terrible diseases
among the people.
It affects both men and women, rich and poor people in rural and urban
communities.
Hypertension is also called high blood pressure. Blood pressure is the
measurement of force against the walls of your arteries when your heart
pumps blood through your body. It has two numbers; the top number is
called systolic blood pressure while the bottom number is diastolic
pressure.
Your blood pressure is normal when these numbers are lower than
120/80mmHg most of the time. Whenever these numbers are
120/80mmHg or higher most of the time but below 140/90mmHg is
called pre-hypertension. Any time the number is 140/90mmHg or higher
most of the time is hypertension.
The risk factors of hypertension
These are situations that can make one to have hypertension.
Those situations that you can control
Unhealthy (bad) diet
Too much of salt intake
Overweight or obese
Sedentary lifestyle (lack of physical activity)
Tobacco usage
Excessive alcohol usage
Stress
Lack of sleep
Those situations that you can control
Age
Race
Family History
The contribution of salt and diet modification to blood pressure control.
Salt restriction: when you take not more than 2.4 g of sodium per day it
reduces your blood pressure by 2-8 mmHg.
Adopt DASH eating plan: when you eat a diet rich in fruits, vegetables,
and low fat dairy products with a reduced content of saturated (solid
fats) and total fat it reduces your blood pressure by 8–14 mmHg.
Salt intake reduction and recommended quantity of salt intake for blood
pressure control.
Ways to reduce your salt intake:
Salt intake should be reduced to less than 2,400 milligrams (mg) a day (1
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teaspoon).
Aim for less than 1,500 mg a day (not more than ½ teaspoon), if
possible.
Do not add extra salt at the table.
Remove or reduce the amount of salt used in cooking and baking.
Reducing salt to less than 2,400mg (1 teaspoon) can reduce your blood
pressure to 2-8 mm Hg.
At the end of the module, the
participants will:
Adopting Dietary Approaches to Stop
Hypertension eating plan (DASH diet)
that lowered blood pressure
Components of Dash eating plan
Examples of daily and weekly servings
that meet DASH eating plan targets for
a 2,000 to 2,100-calorie-a-day diet.
Examples of food items that make up
the DASH eating plan.
Week Two
Adopting Dietary Approaches to Stop Hypertension eating plan (DASH
diet) that lowered blood pressure
Food is an essential measure in prevention and treatment of
hypertension.
DASH diet is a simple and complete eating plan that helps produce a
heart-healthy eating style for life.
It requires no special foods but provides daily and weekly nutritional
goals.
Studies have shown that the DASH diet can lower blood pressure within
2 weeks.
Adopting DASH eating plan can produce blood pressure lowering
effects of 8-14mmHg, comparable to drug monotherapy.
Components of Dash eating plan
The plan recommends
eating vegetables, fruits, and whole grains
fat-free or low-fat dairy products
limiting foods that are high in saturated fat,
Avoiding /limiting sugar-sweetened beverages and sweets
Examples of daily and weekly servings that meet DASH eating plan
targets for a 2,000 to 2,100-calorie-a-day diet
Food Group Daily Servings
Grains 6–8
Meats, poultry, and fish 6 or less
Vegetables 4–5
Fruit 4–5
Low-fat or fat-free dairy products 2–3
Fats and oils 2–3
Sodium (salt) 2,300 mg*
Weekly Servings
Nuts, seeds, dry beans, and peas 4–5
Sweets 5 or less.
Examples of food items that make up the DASH eating plan.
1. Rich in potassium, calcium, magnesium (fruits and vegetables).
Examples: Avocado, Bananas, Carrots, Beans, orange, Pears (fresh),
Peanuts, Spinach, Tomatoes, Skimmed Milk, Pawpaw, Oysters, Soy
milk, Tofu.
2. Low in saturated and trans- fat or low-fat dairy products :
Examples: fish, yogurt, mayonnaise, unsalted nuts and seeds such as
almonds, peanuts, walnuts, vegetable oils: canola, olive, peanut,
sunflower, corn, soybean, cottonseed.
3. Good source of fibre and protein
Examples: Whole grains, Whole wheat bread, Brown rice, oats, barley,
wheat , White beans, kidney beans, northern beans.
4. Avoid food high in saturated diet
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Example:
Meat: fatty/red meats, processed meats like hot dogs, organ meat
Full-fat dairy products: whole milk, whole-milk products and 2% milk
Tropical oils: coconut oil, palm oil or palm kernel oil.
Fats: Margarines, cocoa butter, vegetables cooked in excessive amounts
of sauce and butter, fried foods.
Snacks and Sugar: chocolate, ice cream, cakes, candy (sweet), butter
rolls, egg breads, and commercial doughnuts.
Table 2: Socio-demographic data of the participants n=38
Variable Experimental (n=38)
Age (years) Freq. (%)
18-30 years 2 (5.3)
31-45 years 3 (7.9)
46-60 years 17 (44.7)
>60 years 16 (42.1)
Total 38 (100.0)
Gender
Male 12 (31.6)
Female 26 (68.4)
Total 38 (100.0)
Educational Level
No formal education 11 (28.9)
Primary education 11 (28.9)
Secondary education 5 (13.2)
Tertiary education 11 (28.9)
Total 38 (100.0)
Occupation
Employed 8 (21.1)
Retired 10 (26.3)
Self employed 16 (42.1)
House keeper 4 (10.5)
Total 38 (100.0)
Duration of Hypertension
1-5 years 16 (42.1)
6-10 years 21 (55.3)
>10 years 1 (2.6)
Total 38 (100.0)
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Table 3: Summary of responses on knowledge and practice of salt and diet modification
pre-intervention
Knowledge Level n=38
Poor knowledge
(0-5 points)
Moderate knowledge
(6-8 points)
Good knowledge
(9-12 points)
Total
Pre-
intervention
31 (81.6%) 7 (18.4%) 0 (0.00%) 38 (100%)
Practice Level n=38
Poor practice (0-10
points)
Good practice (11-21
points)
Total
Pre-
intervention
35 (92.1) 3 (7.9) 38 (100%)
Table 4: Comparing pre – and post-intervention knowledge and practice of salt and diet
modification.
Knowledge and Practice Level n=38
Knowledge of salt
and diet
modification n=38
Poor knowledge
(0-5 points)
Moderate
knowledge (6-8
points)
Good
knowledge (9-12
points)
Total
Pre-intervention 31 (81.6%) 7 (18.4%) 0 (0.00%) 38 (100%)
Post-intervention 1 (2.6%) 0 (0.0%) 37 (97.4%) 38 (100.0%)
Practice of Salt and
Diet Modification
Poor practice (0-10
points)
Good practice (11-
21 points)
Total
Pre-intervention 35 (92.1) 3 (7.9) 38 (100%)
Post-intervention 4 (10.5) 34 (89.5) 38 (100%)
Table 3 summarily shows participants responses
on knowledge and practice of salt and diet
modification pre-intervention. 81.6% of the
participants had poor knowledge of salt and diet
modification, 18.4% had moderate knowledge
level and none of the participants had high
knowledge level (0.00%) of salt and diet
modification. Participants also demonstrated
poor practice of salt and diet modification as
92.1% of the participants reported poor practice,
while only 7.9% of the participants reported
good practice of salt and diet modification before
intervention. However, Table 4 reveals a positive
change in the participants’ level of knowledge
and practice of salt and diet modification after
intervention. Only 2.6% of the participants
demonstrated poor level of knowledge of salt and
diet modification post intervention as against
81.6% before intervention. While 97.4%
demonstrated high knowledge level post-
intervention training as opposed to none (0.00%)
before intervention. When comparing pre and
post intervention practice of salt and diet
modification, the practice of diet and salt
restriction was good (≥11) from 7.9% pre-
intervention to 89.5% post intervention. While
poor practice level (≤10) was reduced to 10.5%
from 92.1% after intervention.
Discussion
The study revealed that the pre-intervention
knowledge of participants about salt and diet
modification was poor (81.6%). This finding
corroborates the findings of a study done in India
in 2011 and South Ethiopia (2017) that majority
of the respondents have poor knowledge of salt
and diet modification (Subramanian et. al 2011;
Buda et.al, 2017). The finding is also in
agreement with Okwuonu, Emmanuel, and
Ojimadu (2014) that most hypertensive patients
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are not fully aware of the impact of unsaturated
oil, reduction in diary food, whole grains,
consumption of fruits and vegetables in the
control of blood pressure and salt reduction The
study also showed poor practice of salt and diet
modification (92.1%) among the participants
before intervention. This finding was a bit higher
compare with a similar study done in China that
about 70% of the participants had poor adherence
to modification practices (Lu, et. al, 2017). This
may be attributed to poor knowledge of salt and
diet modification which in turn affects its
practice among the participants. This agreed
with Babu, (2015) who said that the desired
changing level in patients’ attitude toward
knowledge and practice of salt and diet
modification was not achieved due to insufficient
information in relation to effect of salt and diet
modification on blood pressure control given by
the health care professionals. Hence, an intense
effort should be made by health care givers for
effective improvement.
According to the findings of the study, poor
knowledge and practice of salt and diet
modification as demonstrated by the participants
may affect effective blood pressure control
which may be attributed to poor health seeking
behavior on the part of patients or inadequate
information provided by the health personnel.
This is particularly supported by a group of
researchers who posited that targeted health
education strategies are obviously necessary to
enhance the knowledge level of hypertensive as
this will help to prevent adverse effect of poor
blood pressure control, and that health care
givers are needed to provide appropriate cost-
effective programmes on management of
hypertension with a lot of reinforcement and
motivation for effective practices (Gnanaselvam
et. al, 2016). In addition, patients need to be
taught the basic underlying principles behind
every part of their care for them to be motivated
and adopt any change of behavior. Therefore,
patient education should be strengthened on the
use of salt and different type of diets that are
suitable for prevention and effective control of
blood pressure (Okwuonu, Emmanuel, and
Ojimadu, 2014); Tesema et.al, 2016).
The study findings revealed a notable
improvement on knowledge and practice of salt
and diet modification after the intervention
training programme as shown by post-
intervention test score. This shows that
intervention programme was very effective as the
participants gained more insight salt and diet
modification in relation to blood pressure
control. This agreed with Babu (2015) that when
a structured instructional module is used to
divulge facts on salt and diet modification among
hypertensive patients this will in turn affect their
practice and thus lowered blood pressure.
The findings validate the report of a randomized
controlled clinical trial which states that increase
in knowledge about the role of lifestyle in the
occurrence of high blood pressure would cause
people to start modifying their lifestyles and
enhance their preventive behaviours (Jafari et.al,
2016). This was proven with the result of a meta-
analysis of 37 randomized controlled trials by
Aburto et. al, (2013) who demonstrates the
strong and consistent relationship that has been
observed between dietary sodium and blood
pressure that reduced sodium intake reduces
blood pressure in both non-acutely ill adults and
children. The largest controlled feeding study of
potassium supplementation effects on blood
pressure was conducted among Chinese adults by
Gu et. al (2013) the study demonstrated a
significant reduction in blood pressures that was
reproducible after an average of 4.5 years. Even
more encouraging are the results of magnesium
supplements decreasing systolic and diastolic
blood pressure 3 to 4 mmHg and 2 to 3 mmHg,
respectively, with greater dose-dependent effects
at supplementations >370 mg/day (Kupetsky-
Rincon & Uitto, 2012). In subgroup analyses
involving five trials conducted among
hypertensive, fiber intake significantly reduced
both systolic and diastolic blood pressure by 5.95
and 4.20 mmHg, respectively (Bazzano et.al,
2015). Buda et al. (2017) added that irrespective
of other treatments options, if all hypertensive
patients are given needed information and
support required in controlling blood pressure it
will assist in achieving and maintaining salt and
diet practices. Hence, educational programs are
essential in increasing knowledge, improving
self-management, and controlling dietary habits
that are detrimental to effective blood pressure
control (Beigi et. al, 2014)
Conclusion and Recommendation: The study
helped to validate that a nurse-led intervention
programme has significant effect in improving
knowledge and practice salt and diet
modification among hypertensive patients.
Therefore, it is recommended that nurses should
ensure adequate provision of such programme in
a continuous and intermittent way with accurate
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information while providing care for these
patients.
Limitation of the Study: There are other
variables that are effective in control of blood
pressure which were not included in the study
such as measurement of patients’ clinical
parameters like cholesterol level and
triglycerides due to financial constraints. Another
important limitation was follow-up time, hence,
future studies should be conducted given enough
time for follow-up.
Acknowledgements: The researchers show their
appreciation management of the health facility
used as well the State Health Service
Commission for permission to use their facility
for the study. Appreciation also goes to all
participants that took part in the study.
References
Abubakar, S., Muhammad, L. U., Ahmed, A., &Idris,
F. (2017). Knowledge, attitude, and adherence to …
1. Appraise and debate the quality of the data collection methods and determine whether the conclusions of the study were supported by the statistical results. Consider the following questions:
· Were the measurement instruments reliable and valid? Why or why not?
· Was treatment fidelity for the intervention ensured? Why or why not?
· Were the conclusions of the study were supported by the statistical results, as indicated by the variable values and the p-values if reported?
2. Identify and discuss the following:
· dependent variable(s) and the instrument(s) used to measure them.
· how the data for the dependent variable(s) were collected.
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