IJPHCS International Journal of Public Health and Clinical Sciences Open Access: e-Journal e-ISSN : 2289-7577. Vol. 7:No. 4 July/August 2020
SOCIODEMOGRAPHIC DETERMINANTS OF KNOWLEDGE, ATTITUDE AND PRACTICE ON LIFESTYLE PREVENTIVE MEASURES AGAINST HYPERTENSION AMONG FOUR SELECTED VILLAGES IN KUALA PILAH AND JEMPOL, NEGERI SEMBILAN
*Suriani Ismail1, Huda Zainuddin1, Norliza Ahmad1, Muthiah Sri Ganesh1, Muhammad Hanafiah Juni1, Nor Afiah Mohd Zulkefli1, Suhainizam Muhamad Saliluddin1, Ahmad Iqmer Nashriq Mohd Nazan1, Noraliza Radzali2, Ariza Zainudin 3
1 Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia 2 Kuala Pilah District Health Office, Kuala Pilah, Negeri Sembilan, Malaysia 3 Jempol District Health Office, Jempol, Negeri Sembilan, Malaysia
*Corresponding author: Suriani Ismail; email: [email protected]
ABSTRACT
Background: This study was aimed at determining the factors and predictors of knowledge, attitude and practice on lifestyle preventive measures against hypertension among residents in selected villages in Negeri Sembilan.
Method: A self-administered questionnaire was used to collect respondents’ socio- demographic characteristics and their scores on knowledge, attitude and practice of lifestyle preventive measure against hypertension, in this cross sectional study. Body mass index (BM) was measured using calibrated measuring scales.
Results: Among 787 respondents recruited, majority were of Malay ethnicity (60.2%), predominantly male (62.6%), aged between 31 to 55 years (44.2%), with normal BMI (63.4%). Significant associations were found between level of knowledge and age, (χ2 = 6.3, p= 0.043), ethnicity (χ2 = 12.1, p= 0.007), hypertensive status (χ2 = 11.25, p= 0.001), and BMI (χ2 = 17.578, p= 0.001). Factors found to be significantly associated with level of attitude were age (χ2 = 17.498, p= 0.001), hypertensive status (χ2 = 20.529, p= 0.001), and BMI (χ2 = 8.633, p= 0.035) while for level of practice, only age (χ2 = 25.09, p= 0.001). Significant predictors for good level of knowledge were older age group (p=0.021), ethnicity other than Malay, Chinese, or Indian (p=0.007), higher income (p=0.022), not being hypertensive (p <0.001) and lower BMI status (p<0.001), while for good level of attitude were older age group (p<0.001), and not being hypertensive (p<0.001). Significant predictors for good level of practice were older age group (p<0.001), ethnicity other than Malay, Chinese, or Indian (p=0.006), and not being hypertensive (p<0.001).
Conclusion: Knowledge, attitude and practice among respondents were unsatisfactory and predicts by several factors studied.
Key words: lifestyle preventive measure, hypertension, knowledge, attitude, practices
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1.0 Introduction
Hypertension is a global public health problem. Malaysia’s National Health and Morbidity Survey (2015) revealed that the commonness of hypertension (diagnosed and undiagnosed) among adults of 18 years and above was 30.3% (95% CI: 29.3, 31.2) and the survey also reported that it risen with age, from 6.7% (95% CI: 4.7, 9.4) in the 18-19 years age group, reaching a peak of 75.4% (95% CI: 70.5, 79.7) among the 70-74 years age group (1,2). There was variant between the different states, with the topmost prevalence in Kedah at 37.5% (95% CI: 33.5, 41.6), after that Sarawak at 37.3% (95% CI: 33.7, 41.1) and next Perak at 36.4% (95% CI: 33.2, 39.8). As for Negeri Sembilan, the state where this study was conducted, the prevalence was 32.5 % (95% CI: 28.2, 37.2). Overall in Malaysia, the prevalence was considerably higher in the rural areas at 33.5% (95% CI: 31.6, 35.4) contrasted to 29.3% (95% CI: 28.2, 30.4) in urban areas (1).
Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greater and or diastolic BP of 90 mmHg or greater (3). Hypertension contributes toward many other diseases such as stroke, cardiovascular and kidney disease (4). It has been reported that the total direct cost of managing hypertension per person ranges between RM 1612 - 2718 per month while total indirect cost varies from RM 6654-8000 per month depending on the stage of the disease (5). The barriers against obtaining effective hypertensive care are inadequate knowledge on the dangers of untreated high blood pressure, poor attitude and practices towards treatment including lifestyle modification (6,7,8). Knowledge on lifestyle modifications such as performance of moderate physical activity, maintenance of normal body weight, reduction of dietary sodium intake, limitation of alcohol consumption and smoking cessation should be emphasised especially among people at risk of developing hypertension (9). Studies had shown that physical exercise and consumption of fruits and vegetables can reduce blood pressure, while elevated body mass index, salt intake and alcohol consumption are connected with an increase in blood pressure (10,11). Those who are pre-hypertensives or have a clear family history of hypertension should be offered these information as part of preventive efforts as well as management of hypertension.
In Malaysia, there is a community-initiated program to help to reduce the prevalence of non- communicable disease including hypertension. The program is named Komuniti Sihat Pembina Negara (KOSPEN) which means ‘Healthy community, building the country’ (12). This program is aimed at transforming the community’s health and quality of life by involving the participation of the society in all health programs organised mainly by the government. Negeri Sembilan (the state of the study location) is one of the states in which KOSPEN is actively operating. However, the program might not reach all populations especially in the rural areas.
In Malaysia, hypertension remains as a significant public health challenge and had caused a heavy economic burden on the healthcare budget. Effective lifestyle modification can lower blood pressure and could decrease the morbidity and mortality rates of hypertension. One of the purposes of selecting this rural setting was because NHMS 2015 had reported that the prevalence of hypertension was higher in the rural as compared to urban areas. The aim of this study is to look into the factors and predictors of knowledge, attitude and practice on lifestyle preventive measures against hypertension among residents in four selected villages in Kuala Pilah and Jempol districts, Negeri Sembilan. The information obtained can assist the planning
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of future lifestyle preventive measures programs against hypertension specifically in rural Negeri Sembilan.
2.0 Methods
This cross-sectional study was conducted in Kampung Serting Ilir, Taman Desa Melang, Taman Desa Aman and Kampong Gajah Mati in Kuala Pilah and Jempol Districts, Negeri Sembilan. Kampung Serting Ilir is about 56 km from Seremban (capital city of Negeri Sembilan state), Taman Desa Melang and Taman Desa Aman are about 35 km from Seremban while Kampong Gajah Mati is 30 km from Seremban. Sampling frame was the list of residents aged more than 18 years old and Malaysian citizens, while exclusion criteria were mentally and physically challenged and illiterate residents. Sample size calculated was 959. However, finally the distribution of respondents recruited according to study locations were 213 respondents from Kampung Serting Ilir, 259 respondents from Taman Desa Melang, 103 respondents from Taman Desa Aman and 212 respondents from Kampong Gajah Mati. Data was collected using a self-administered questionnaire. Content and face validation were carried out among villagers in a village near study location but not included as one of the selected study locations. Cronbach's alpha obtained was 0.94. The socio-demographic characteristics (age, gender, ethnicity, monthly household income and educational level) and status of hypertension were the independent variables in this study while the knowledge, attitude and practice on lifestyle preventive measure against hypertension were the dependent variables.
The questionnaire consisted of 4 parts; Section A is to collect the respondents’ characteristics (information consists of age, gender, ethnicity, monthly household income, educational level and status of hypertension). Section B is to evaluate knowledge on lifestyle preventive measure against hypertension. This part consists of 8 items covering knowledge on lifestyle preventive measures of hypertension such as diet (including regarding healthy diet and salt intake), physical exercise, obesity, smoking, alcohol consumption. For each question 3 options was given (yes, no or don’t know). For every correct answer, 1 mark was given. The maximum score for knowledge is 8 and minimum score is 0. Section C assessed the attitude on lifestyle preventive measure against hypertension. This section also consists of 8 items and the responses used Likert’s scale made up of 5 option ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ and ‘strongly disagree’. The maximum score for knowledge is 40 and minimum score is 8. Section D assessed the self-reported practice on lifestyle preventive measure against hypertension. This consists of 9 items and it was also assessed using Likert’s scale, ‘always’, ‘most of the time’, ‘sometimes’ ‘seldom’ and ‘never’. The maximum score for knowledge is 45 and minimum score is 9. For attitude and practice statements, score was counted as 5 to 1 points for positive statements and score was reversed for negative statements. The knowledge, attitude and practise scores were then categorized into good and poor based on a cut-off point at median score. Scores above the median was considered as good level while equal and less were considered as poor.
The weight and height were measured with measuring scale placed on a flat and firm surface and the respondents were instructed to remove any heavy clothing and belongings when measuring their weight and height. The instruments used were calibrated. The body mass index (BMI) was then calculated using the BMI formula (weight/ height2) to determine the category
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of BMI (underweight <18.5kg/m2, normal weight 18.5-24.9kg/m2, overweight 25-29.9kg/m2 2 and obese ≥ 30kg/m ). Data was analysed using SPSS version 22.0. Chi-square test was used to determine associations and multiple logistic regression was used to determine the predictors. Level of significance was set at p<0.05, 95% CI does not include 1. Ethical approval was obtained from Ethics Committee for Research Involving Human Subjects, Universiti Putra Malaysia (reference number JKEUPM-2018-088)
3.0 Results
A total of 787 respondents participated in this study (82% response rate). Table 1 show that most of the respondents were Malay, male, aged 31-55 years, had secondary level of education and monthly earning of RM2000 (USD490) or less. Most are not hypertensive and neither overweight nor obese. The median score and inter quantile range for the knowledge, attitude and practice on preventive measures against hypertension were 8 (IQR 2.0), 34 (IQR 6.75) 33 (IQR 9.00) respectively.
Table 2 shows the association between level of knowledge, attitude and practice on lifestyle preventive measures against hypertension among the respondents and their characteristics. The level of knowledge was associated with age, ethnicity, hypertension status and body mass index. The level of attitude was associated with age, hypertension status and body mass index while the level of practice was only associated with age.
Table 3 shows the odd of good level of knowledge on lifestyle preventive measures against hypertension was better among older age. The odd of good level of knowledge among Chinese is 1.6 time and among other ethnic group is 2.8 times more compared to Malay. The odd of good level of knowledge on lifestyle preventive measures against hypertension is 1.5 times better among those with primary education compared to those without formal education, and those with income RM 2001-4000 per month group compared to those with income less than RM 2000 per month. The odds of having good level of knowledge on lifestyle preventive measures against hypertension is also 1.8 times better among those without hypertension compared to those with hypertension and finally the odds are 2.5 and 4.0 time better among normal weight and underweight respondents in this study compared to those who are obese..
Table 3 also shows that the odd of having good attitude towards lifestyle preventive measures against hypertension are 1.2 time better in respondent age group 31-45 compare to age group less than 30 and 1.7 times better in those with tertiary education compared to those with no formal education. The odds of having good attitude towards lifestyle preventive measures against hypertension is 2.0 times better among those not hypertensive compared to those who are hypertensive. However the odd of good level of attitude toward lifestyle preventive measures against hypertension is better among those who are overweight compared to those with normal weight.
Finally, Table 3 also shows the odd of good practice of lifestyle preventive measures against hypertension are better with older age group compared to younger age group and 1.7 times better among the Chinese compared to Malay, and 2.4 time more among other ethnicity (besides Indian) compared to Malay. The odds of good practices of lifestyle preventive
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measures against hypertension 1.5 times better among those who are not hypertensive compared to those who are hypertensive
Table 1 Respondents’ characteristics (N=787) Respondents’ characteristics Frequency (n) Percentage (%) Age (years) 18-30 272 34.6 31-55 348 44.2 >55 167 21.2 Gender Male 493 62.6 Female 294 37.4 Ethnicity Malay 474 60.2 Chinese 95 12.1 Indian 170 21.6 Others 48 6.1 Education level No Formal Education 44 5.6 Primary 149 18.9 Secondary 377 47.9 Tertiary 217 27.6 Monthly household income (RM) Low
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Table 2 Association between respondents’ characteristics and knowledge, attitude and practice level on lifestyle preventive measures against hypertension (N=787)
Knowledge level Attitude level Practice level Variable Good Poor χ2 p Good Poor χ2 p value Good Poor χ2 p value 374 413 value 394 393 393 394 (54.2%) (45.8%) (50.1%) (49.9%) (49.9%) (50.1%) Age ≤ 30 115(42.3) 157(57.7) 6.316 0.043* 115(42.3) 157(57.7) 17.498 <0.001* 103(37.9) 169(62.1) 25.090 <0.001* 31-54 years 182(52.3) 166(47.7) 203(58.3) 145(41.7) 191(54.9) 157(45.1) > 55 years 77(46.1) 90(53.9) 394(50.1) 393(49.9) 99(59.3) 68(40.7) Gender Male 229(46.5) 264(53.5) 0.608 0.461 236(47.9) 257(52.1) 2.540 0.064 241(48.9) 252(51.1) 0.584 0.245 Female 154(49.3) 149(50.7) 158(53.7) 136(46.3) 152(51.7) 142(48.3) Ethnicity Malay 217(45.8) 257(54.2) 12.056 0.007* 245(51.7) 229(48.3) 6.416 0.093 223(47.0) 251(53.0) 7.021 0.071 Chinese 53(55.8) 42(44.2) 51(53.7) 44(46.3) 55(57.9) 40(42.1) Indian 72(42.4) 98(57.6) 71(41.8) 99(58.2) 85(50.0) 85(50.0) Others 32(66.7) 16(33.3) 27(56.3) 21(43.8) 30(62.5) 18(37.5) Education level No Formal 21(47.7) 23(52.3) 5.272 0.153 20(45.5) 24(54.5) 1.687 0.640 25(56.8) 19(43.2) 6.590 0.086 Primary 68(45.6) 81(54.4) 70(47.0) 79(53.0) 67(45.0) 82(55.0) Secondary 194(51.5) 183(48.5) 189(50.1) 188(49.9) 203(53.8) 174(46.2) Tertiary 91(41.9) 126(58.1) 155(53.0) 102(47.0) 98(45.2) 119(54.8) Household income ≤ RM 2000 203(44.1) 257(55.9) 5.334 0.069 224(48.7) 236(51.3) 0.837 0.658 233(50.7) 227(49.3) 0.228 0.892 RM 2001 to 152(52.8) 136(47.2) 150(52.1) 138(47.9) 141(49.0) 147(51.0) 4000 > RM 4000 19(48.7) 20(51.3) 20(51.3) 19(48.7) 19(48.7) 20(51.3) Hypertensive Yes 106(39.3) 164(60.7) 11.252 0.001* 105(38.9) 165(61.1) 20.529 <0.001* 126(46.7) 144(53.3) 1.758 0.106
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No 268(51.8) 249(48.2) 289(55.9) 228(44.1) 267(51.6) 250(48.4) Body mass index(BMI) Under 105(58.0) 76(42.0) 17.578 0.001* 95(52.5) 86(47.5) 8.633 0.035* 95(52.5) 86(47.5) 0.814 0.846 weight Normal 234(46.9) 265(53.1) 240(48.1) 259(51.9) 244(48.9) 255(51.1) weight Over weight 24(33.8) 47(66.2) 33(46.5) 38(53.5) 35(49.3) 36(50.7) Obese 11(30.6) 25(69.4) 26(72.2) 10(27.8) 19(52.8) 17(47.2) * Significant at p<0.05
Table 3 Predictors of good knowledge, attitude and practice level towards lifestyle preventive measures against hypertension among the respondents (N = 787)
Knowledge Attitude Practice Variables a OR 95% CI p value a OR 95% CI p value a OR 95% CI p value Lower Upper Lower Upper Lower Upper Age(years) ≤ 30 1 1 1 31-54 1.520 1.093 2.114 0.013* 1.194 1.398 2.707 <0.001* 2.110 1.515 2.938 <0.001* > 55 1.688 1.101 2.590 0.016* 1.336 0.9876 2.034 0.179 3.084 2.007 4.740 <0.001* Gender Male 1 1 Female 1.236 0.899 1.701 0.192 1.145 0.835 1.568 0.401 1.172 0.853 1.610 0.327 Ethnicity Malay 1 1 1 Chinese 1.622 1.018 2.585 0.042* 1.230 0.775 1.954 0.380 1.655 1.035 2.646 0.035* Indian 1.067 0.720 1.581 0.748 0.850 0.575 1.255 0.413 1.406 0.950 2.080 0.089 Others 2.756 1.416 5.362 0.003* 1.442 0.764 2.722 0.258 2.433 1.269 4.666 0.007* Education
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No formal 1 1 1 Primary 1.576 1.086 2.285 0.017* 1.094 0.757 1.582 0.632 0.892 0.615 1.293 0.545 Secondary 1.356 0.687 2.663 0.090 0.881 0.562 1.380 0.579 0.818 0.519 1.288 0.385 Tertiary 1.176 0.469 1.927 0.503 1.675 1.045 2.686 0.032* 0.828 0.517 1.326 0.432 Income (RM) ≤ 2000 1 1 1 2001-4000 1.554 1.136 2.125 0.022* 1.164 0.845 1.573 0.368 1.046 0.767 1.429 0.775 >4000 1.172 0.592 2.319 0.771 0.860 0.416 1.616 0.567 0.941 0.475 1.866 0.863 Hypertensive Yes 1 1 1 No 1.763 1.279 2.430 0.001* 2.094 1.530 2.865 <0.001* 1.502 1.097 2.057 0.011* BMI Underweight 3.996 1.788 8.927 0.001* 0.501 0.231 1.181 0.119 1.030 0.483 2.196 0.940 Normal weight 2.480 1.149 5.352 0.021* 0.404 0.194 0.931 0.032* 0.917 0.446 1.889 0.815 Overweight 1.203 0.498 2.909 0.681 0.343 0.139 0.14 0.016* 0.822 0.358 1.888 0.644 Obese 1 1 1 * Significant at p<0.05
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4.0 Discussion
This research assessed the factors and predictors of knowledge, attitude and practice against hypertension among residents in four selected villages in Kuala Pilah and Jempol districts, Negeri Sembilan. The factors studied were age, gender, ethnicity, education level, household income, being hypertensive and body mass index.
One of the consistent predictors for good level of knowledge, attitude and practice on lifestyle preventive measures against hypertension are older age group. The finding that predictors of knowledge on lifestyle preventive measures against hypertension are better in older age groups in this study is inconsistent with the findings of a study in Iran which reported that average knowledge regarding healthy lifestyle among their studied population decreased with increasing age (13). The difference in results could be due of different sociodemographic characteristics. In this study, the predictor of practice of healthy life style was also better with older age group. This finding reflect inconsistency with the findings of a survey among 770 Malaysia from Selangor, Penang, and Terengganu, which reported negative relationship concerning age and total physical activity, specifically moderate and vigorous activity (14). Nevertheless the attitude was only better in age group 31-54 age group.
The other constant predictor of good level of knowledge, attitude and practice measures against hypertension was being non-hypertensive. Studies had shown that correlation between knowledge, attitude and practice to outcome of present of disease or disease risk. For example a study in Sri Lanka among adult showed that better knowledge and practices are associated with decrease in cardiovascular diseases risk markers and another among diabetic patient in South Africa showed study positive correlation between the attitude level and practice level regarding lifestyle modification (15,16). This could also indicate that although most hypertensive patients had received advice on lifestyle modification against hypertension, the information may not be enough and applicable in changing their attitude and behaviour. This finding is similar to the finding- of a study on knowledge, attitude and practice among hypertensive patients at primary health care in Ethiopia (17).
Other ethnicity (besides Malay, Chinese and Indian) was a predictor for good knowledge. However in term of literacy, a study in the state of Sarawak, Malaysia that reported Malays have the highest scores for health literacy component on preventive lifestyle compared to the other ethnic groups (18). On the other hand the predictors of good practices in this study reported that other ethnic groups and Chinese have better practices than the Malays. This also contradicts the survey of more than two thousand adult Malaysia which show there is no significant different between Chines and Malay but otherwise reported that Indians tend to engage in less physical activity and consume fewer fruits and vegetables than the other two ethnic groups (19). The difference in factors that predict knowledge and practices in this study could be because of differences in demographic characteristics of the study population, such as the different study locations. This study was conducted in rural areas while the 2 other studies were in urban area- or included the urban areas as well. This study shows that gender was not a significant predictor in either in the level knowledge, attitude and practice measures against hypertension. In other the study in Sarawak and another community study in Brazil reported that women to have healthier lifestyles than men (18,20). Nevertheless, in general men engaged in more risky health practices than females (21).
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Education level was also not a significant predictor for good practice toward measures against hypertension in this study population, although those who have primary education are better knowledge compared to those with no formal education. This could indicate that the information on measures against hypertension was received by almost all respondents regardless of their formal education. Although those with tertiary education had better attitude compared to those without formal education, ther were no differences in practices. This is contrary to a research conducted on causal relationship between education and healthy habits such as improved diet and regular exercise in Australia, Sweden and South Korea (21,22,23). This could indicate that the scenario of practices against hypertension in Malaysia specifically in this study or practices of healthy life style in general are influence by other factors which should be explored such as the influence of culture and norms related to it. As the proxy to education level, income category showed similar patterns of education level as predictor of good knowledge regarding measures against life style preventive measure against hypertension.
Another interesting finding was that good knowledge and good attitude on measures against hypertension was better among those in lower BMI categories compared to obese category. The ability to maintain body weight could be associated to their overall knowledge and attitude towards healthy lifestyle although not specifically on life style preventive measure against hypertension. This is supported by studies reporting positive correlation between knowledge ad practices (15,16).This study has its limitations since it is a cross sectional study and is unable to determine the cause-effect relationship. The other limitation of this study was it didn’t look into barriers contributing to poor practice of lifestyle preventive measures against hypertension.
5.0 Conclusion and recommendation
The knowledge, attitude and practice of lifestyle preventive measure against hypertension among the respondents in this study population is not satisfactory, especially among those with known hypertension. It could indicate that more research is needed in assessing and improving knowledge and literacy regarding not only lifestyle measures against hypertension but also in controlling hypertension among diagnosed hypertensive patients.
Acknowledgement
The authors would like to thank fourth year medical students from Group A, B, C and D who attended the Community Medicine Posting batch 2017/2018. The authors would also like to thank the respondents who participated in this study.
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