Knowledge related to nutrition and hypertension management practices of adults in Ga-Rankuwa day clinics

Curationis 33 (2): 33-40 Hypertension is a global, non-communicable chronic disease being asymptomatic and known as the silent killer with signs and symptoms only occurring when a target organ is damaged. Being a condition common in South Africa, hypertension is also a risk factor for cerebro-vascular incidents, myocardial infarction, left ventricular hyper­ trophy, renal disease and retinopathy. Black adults in an urban environment appear to be especially vulnerable to excessive increases in blood pressure. The research question explored was what was the knowledge of hypertensive adults attending day clinics in Ga-Rankuwa regarding nutrition and hypertension management prac­ tices. An exploratory strategy was used as no similar research had previously been conducted in Ga-Rankuwa. A cross sectional survey design was used to investigate hypertensive adults attending the three primary health clinics in Ga-Rankuwa. The sampling method was convenient and the sample size 101 participants. Two data gathering methods were used, these being physical measurements and self-report. For the self-report, a structured interview was conducted. The data were analysed using descriptive statistics. The results indicated a lack of knowledge regarding nutrition and management of hypertension. The proportion of participants with un­ controlled hypertension was high (58.6%) and non-compliance with medication oc­ curred frequently (58.1%). A third (28.7%) of the sample lacked knowledge of the complications of hypertension (28.7%). A community-based intervention, based on the results of the study, is recommended. Correspondence address SD Wright Private Bag X680 Pretoria 0001 Fax (012)3825033 Work (012) 382 5470 Mobile: 0828211186 Email: wrightscd@tut.ac.za


Introduction
Hypertension is a global, non-communicable chronic disease and is largely asymptomatic.Known as the silent killer, a person experiences very few signs and symptoms until damage oc curs to a target organ.Hypertension is a common condition in South Africa and is a risk factor for cerebrovascular incidents, myocardial infarction, left ventricular hypertrophy, renal disease and retinopathy (Steyn, 2005:80).In 2000 in South Africa, non-communicable diseases caused 37% o f deaths and 21% o f premature mortality (Ijumba, Day & Ntuli, 2004:176).Van Rooyen, Huisman, Eloff, Laubsher, Malan, Steyn and Malan (2002:69) report that black adults in an urban environment appear to be especially vulnerable to exces sive increases in blood pressure, lead ing to hypertension in later life.In sup port, Peltzer (2001:52) reported that of the estimated 5.5 million people in South Africa with elevated blood pres sure, 3 million are black males.Hyper tension however, does not develop in isolation, as several risk factors are as sociated with hypertension.
Besides being a heredity trait, obesity, unhealthy diet, diabetes mellitus, exces sive alcohol intake, physical inactivity and smoking are specific risk factors associated with hypertension (Depart ment of Health, 2003:1).O f these risk factors, diet, physical activity, alcohol consumption and smoking are risks re lated to the person's lifestyle.Obesity and diabetes mellitus are secondary risk factors associated with the lifestyle risks with diet being a key risk factor for hypertension (Ijumba, Day & Ntuli, 2004:182).South Africa has experienced major changes in food consumption with traditional plant-based foods be ing replaced with a diet characterised by high fat, high sugar and energy dense with low fibre food.This diet is strongly associated with the develop ment o f chronic cardiovascular disease.If people's physical stature can be taken as a proxy for the quality o f their diet in terms o f cardiovascular risk, many South Africans are at risk.Ap proximately three o f every ten men (29%) and six o f every ten women (56%) in South Africa are overweight (Reddy, 2004:175).Due to the lifestyle related risk factors for hypertension, the control o f hypertension cannot rely alone on pharmacological management.
The control o f hypertension comprises both pharmacological and non-pharmacological management to prevent com plications (D epartm ent o f Health, 2003:1).The management of hyperten sion has a significant lifestyle adjust ment component, which could be a bar rier to normal blood pressure for an ex tended period.Weight gain, high salt intake, tobacco use, high alcohol in take and increased psychosocial stress can lead to poor management o f hy pertension (Bales & Ritchie, 2004:406;Steyn, 2005:83).
According to Peltzer (2002:182), a healthy lifestyle is one in which indi viduals are aware of risks to their health and can make informed choices for maintenance.These choices include stopping smoking, consuming only three alcoholic drinks per day, weight reduction and regular exercise (Smith, 1999:3).In addition, a diet with low so dium, low fat and plenty o f fresh fruit and vegetables is required.Risk aware ness is an important factor linked with knowledge and health belief.Health behaviours are associated with the ac tual practice o f the health beliefs (Peltzer, 2002:188).Health promotion strategies can be formulated and im plemented if the health beliefs and knowledge are known.Knowledge about nutrition and the risk factors as sociated with different types o f nutri tion is crucial to health promotion.With out knowledge, patients usually dis continue their nutritional management o f hypertension, making it difficult to control and manage the disease, the result being an increase in hyperten sion related complications with a con current increase in premature mortality and socio-econom ic consequences (Peltzer, 2002:188).

Research Question
In 2003, the Department o f Nursing Science at Tshwane University o f Tech nology conducted a community study in Ga-Rankuwa.The study revealed that more women (46.1%) than men (45.8%) were hypertensive and obesity was prevalent in women (69.8%) as well as in men (40.9%) (Wright & Ramukumba, 2008:72).Comparing these figures to the South African figures for 2004 where only 29% men and 56% women w ere found to be obese (R eddy, 2004:175-179), clearly indicated that an in-depth investigation in the commu nity was needed.
The formulated research question for the study was therefore, what is the knowledge regarding nutrition and hy pertension management practices of hypertensive adults attending primary health clinics in Ga-Rankuwa.

Objective of the study
The objective o f the study was to de termine the nutrition-related knowledge and hypertension management prac tices o f hypertensive adults attending primary health clinics in Ga-Rankuwa.

Theoretical framework
The Health Promotion Model (Pender, Murdaugh & Parsons, 2002:60), focus ing on promoting personal health and wellbeing, is utilised as the theoretical foundation o f the study.It consists of seven cognitive-perceptual factors and five modifying factors that predict and explain health behaviours.The cognitive-perceptual factors are the importance o f health, perceived control o f health, definition o f health, perceived heath status, perceived selfefficacy, perceived benefits and per ceived barriers.The modifying factors are the demographic and biological characteristics, interpersonal influence, situational influences and behavioural factors.

Setting
The study setting was Ga-Rankuwa.According to Statistics South Africa (2001), the total population o f Ga-Rankuwa was approximately 83900 with the total number o f households 21100.The majority in terms of socio-cultural groups was Setswana speaking peo ple (74%).More than half o f the com munity (56.8%) had an educational level o f below Grade 10 with only 32.7% of the population employed.

Design
The study used a cross-sectional de scriptive design, which is a non-experimental design examining data from a specific group, at one point in time (LoBiondo-Wood & Haber, 2006:244).

Population, sample and size
The population investigated were hy pertensive adults, 18 years of age and older, residing in the Ga-Rankuwa area and attending primary health clinics in Ga-Rankuwa for hypertension manage ment.According to Bums and Grove (2005:47), the population is described as all the elements that comply with specific criteria for inclusion in a given universe.Patients from all three primary health clinics were conveniently in cluded in the study with a specific week being arranged with the clinic's man agement to gather data.Adhering to the statistician's advice at Tshwane University o f Technology, at least 30 participants per clinic had to be in cluded and the sample size was 101 (n=101).

Data gathering
Two data gathering methods used in this study were self report and physi ological measurement.A validated questionnaire was used to gather data relating to hypertension knowledge, habit and lifestyle changes, quality of life and care, life threats and clinical detail with personal medical history.Several physical measurements, blood pressure, weight and height, hip and waist circumference and physical ac tivity were taken.Participants were in formed by clinic managers of the proc ess and procedures of the study and informed consent was obtained before participation.Trained field workers conducted the structured interviews with participants to prevent selection bias due to low literacy level.
To ensure validity and reliability o f the data the following measures were im plemented: • Each participant's blood pres sure was measured using a cali brated baumanometer and stethoscope.

•
The height measurements were taken using a stadiometer and an electronic digital scale meas ured weight.The participant's body mass index (BMI) was cal culated using the standard for mula o f weight in kg/height in m2 • Hip and waist measurement, in male respondents, were taken in the upright position, with the circumference being measured to the nearest 0.5 centimetre.For males, the circumference was measured at the level of the um bilicus at expiration and for fe males at the narrowest point be tween the rib cage and the iliac crest.

Data analysis
Descriptive statistics were used in the analysis, to allow the researcher to de scribe and summarise data (LoBiondo-Wood & Haber, 2006:358).The SPSS programme (version 14) was used to analyse the data.As the data was not generated from a random sample, two non-parametric statistical tests were performed, a Chi-square test and the Pearson product moment correlation coefficient.

Validity and reliability
Several measures were taken to ensure data validity and reliability.
• The hypertension diagnosis was confirmed from the pa tient's file before they were in vited to participate in the study.

Ethical considerations
Approval to conduct the study was obtained from the Ethics Committee of Tshwane University o f Technology (# 2006/07/007); the Health Department of North West Province and the manage ment o f the three primary health clin ics.The participants signed informed consent before participating in the study.All hypertensive adults enter ing the day clinic for management of hypertension in the data-gathering pe riod were invited to participate and were included in the study.The data gather ing was completed in a separate room to guarantee privacy and anonymity, with confidentiality being ensured by num bering the q u estio n n aires sequentially.

Personal medical history
The most prevalent risk factors in the sample were high blood cholesterol (34.7%) and diabetes mellitus (19.8%).
From family history, the prevalence of obesity, hypertension and diabetes ranged from 30.7% to 34.7%.
Complementary alternative medications used for hypertension were investi gated; Cape Aloe was most frequently used (11.9%),followed by guava leaves (10.9%).To assess compliance with their hypertension treatment, 31.7% admitted that they occasionally forgot to take their medication and when asked if they drank their medication the morn ing before attending the clinic, 18.8% reported in the negative.

Habit and lifestyle changes
Participants' perceptions regarding their own weight were explored and of the group who were overweight (BMI >" 25-29.9kg/m2), only 22% perceived themselves to be so.The participants were also asked whether they thought being overweight had an influence on their level o f hypertension and the maj ority (93.1 %) agreed.
Diet was investigated extensively in terms o f both salt usage and healthy food choices.Only 4% o f the partici pants reported eating very salty food, with 85% indicating lightly salted food.
The knowledge o f the amount o f salt to be added daily to the food o f hyper tensive persons was also investigated.
A small group (20.8%) reported no salt should be added, with the majority (75.2%) indicating half a teaspoon of salt.
To test the participants' knowledge of food choices for overweight, hyperten sive people, they were given a list of healthy and unhealthy food choices (Table 2).
The participants' knowledge o f healthy food choices (

Life threats
Two questions examined the partici pants' perceptions regarding their vul nerability due to hypertensive status.The first question dealt with the possi ble risks the participants are exposed to if they do not adhere to treatments as planned.

Discussion of the results
The Health Promotion Model (Pender, Murdaugh & Parsons, 2002:60) indicate that individual characteristics and ex periences involve prior related behav iour and personal factors.

Perceived body mass
One such factor is the perception dis parity between a person's perceived and measured or actual weight also re ported by Reddy (2004:182).The po tential problem o f perceiving to have a normal weight is that all health educa tion regarding diet will be ignored as not being applicable.The influence of perception of having normal weight will negate the perceived benefit of dieting as this has apparently already been achieved.The commitment to the diet ing plan of action will be low (Pender, Murdaugh & Parsons, 2002:60).
To emphasise the participants' lack of awareness of their risk o f cardiovascu lar disease in terms o f their body size, the waist circumference is relevant.
According to the results, 66.3% had a waist circumference above the cut off point.The implication o f abdominal adiposity is that excess adipose tissue releases several products that exacer bate hypertension and other cardiovas cular risk diseases (Scott & Cohen, 2004:3).Clinical trials have proven that weight loss is effective in the primary prevention o f hypertension, plus reduc tion o f both diastolic and systolic pres sure (Dickey & Janick, 2001:392).
The participants' physical measure ments also indicated increased risk.The majority had a waist-to-hip circumfer ence above the cut off point, a known risk for cardiovascular disease.Even though the participants knew weight was a risk factor for hypertension and with weight reduction it can be con trolled, the knowledge did not result in a change o f behaviour.The waist alone is a good measurement for intra-ab dominal fat (Gaw & Lindsay, 2004:167).
The authors state that BMI alone does not take fat distribution into account, so it is useful to measure obesity with waist-to-hip ratio and BMI.

Knowledge of nutritional factors
The study provided evidence that the participants were uninformed regard ing a healthy diet for a hypertensive person and if knowledgeable, they did not apply the information to improve and maintain their health.The lack of transition from knowledge to a change in behaviour maintains hypertension patients' risk level.Frequently, the change would be minor but the risk re duction significant.Several authors (Hooper, Bartlett, Smith & Ebrahim, 2003;He & McGregor, 2004) report a modest reduction in sodium for at least four weeks resulted in significant re duction in blood pressure.The authors suggest a daily intake o f sodium from 3-12 g/day to achieve a long-term re duction of strokes, heart attacks and heart failure.
Another implication o f lack o f knowl edge is that the participants use un healthy foods whilst being hyperten sive.Lack of knowledge in this instance also acts as a situational influence, which will affect the participants' com mitment to a plan of action (Pender, Murdaugh & Parsons, 2002:60).Becker et al. (2004:67) also found that the knowledge o f diet and hypertension to be poor.The results o f the study indi cated that although the participants have been educated about healthy food for hypertension, they still lack infor mation as to which food is healthy and continue to consume a diet familiar to them though not recommended for hy pertensive people.

Risk factors
In terms of personal and family medical history, evidence that could influence nursing practice was generated.

Table 3 : Results of true or false questions (n~100)
, has proven to be elusive and failure is frequent.Commu nity-specific interventions, based on evidence generated from that commu nity, may be the only way to reduce the burden of hypertensive disease.Health behaviour among black and white South Africans.Roval Society for the Promotion o f Health.122:187-193.PENDER, N; MURDAUGH, C & PAR SONS, A 2002: Health Promotion in Nursing Practice.Julie Alexander: Prentice hall.REDDY, P 2004: Chronic diseases.Durban: Health System Trust.SM ITH, S 1999: An introduction to the curative aspects of primary health care.Glenstantia: GM printers.
LimitationsOne urban area, Ga-Rankuwa was cho sen for the purpose o f the study.DuePELTZER, K 2002: