MR MAHANTESH MIRJI

I YEAR M.Sc. NURSING

MEDICAL SURGICAL NURSING

2012-14

SHREE SIDDAGANGA INSTITUTE OF

NURSING SCIENCES AND RESEARCH

CENTRE B.H. ROAD TUMKUR -02

0
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. NAME OF THE MR.MAHANTESH MIRJI

CANDIDATE AND I YEAR M.Sc. NURSING

ADDRESS SHREE SIDDAGANGA INSTITUTE OF

NURSING SCIENCES AND RESEARCH

CENTRE B.H.ROAD, TUMKUR-572102.

2. NAME OF THE SHREE SIDDAGANGA INSTITUTE OF

INSTITUTION NURSING SCIENCES AND RESEARCH

CENTRE B.H.ROAD, TUMKUR-572102.

3. COURSE OF STUDY MASTER OF SCIENCE IN NURSING

AND SUBJECT MEDICAL SURGICAL NURSING

4. DATE OF ADMISSION

TO THE COURSE 10-07-2012

5. STATEMENT OF THE A STUDY TO ASSESS THE KNOWLEDGE AND
ATTITUDE REGARDING STROKE AND ITS
PROBLEM
PREVENTION AMONG HYPERTENSIVE
PATIENTS IN SELECTED HOSPITALS AT
TUMKUR WITH A VIEW TO DEVELOP AN
INFORMATION BOOKLET.

6.0 BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

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 The context in which an individual lives is of great importance for his health

status and quality of life. It is increasingly recognized that health is maintained and

improved not only through the advancement and application of health science, but also

through the efforts and intelligent lifestyle choices of the individual and society.

According to the World Health Organization, the main determinants of health include the

social and economic environment, the physical environment, and the person's individual

characteristics and behaviors. The lifestyle changes in the present world leads to the

many diseases such as hypertension, diabetes mellitus, cardiac diseases, renal diseases

and brain diseases can leads to stroke and its incidence rate is increase from 10,81,480 in

2000 to 16,67,372 in 2015.

A stroke, or cerebrovascular accident (CVA), is the rapid loss of brain functions

due to disturbance in the blood supply to the brain. This can be due to ischemia caused by

thrombosis, arterial embolism, or a hemorrhage. As a result, the affected area of the brain

cannot function, which might result in an inability to move one or more limbs on one side

of the body, inability to understand or formulate speech, or an inability one side of the

visual field.1

Stroke is the third most common cause of death in the world after heart diseases

and cancers. Annually, 15 million people worldwide suffer from a stroke. Out of these, 5

million attain optimal recovery, 5 million die, and 5 million suffer from a long lasting

disability, placing a huge burden on families and communities. Those who develop a

stroke are more in Sub-Saharan Africa than in developed countries. Tanzania, a Sub-

Saharan African country found in East Africa, faces challenges relating to the

outcomes of stroke, similar to other Sub-Saharan countries. According to the

2
Ministry of Health of Tanzania, the burden share of conditions requiring long-term

rehabilitation, including cardiovascular disorders, cancer, and anemia, account for 25% of

the disease burden. Out of these, cardiovascular disorders alone account for

11.9%Morbidity and Mortality associated with Stroke. Morbidity and Mortality rate in

India during 2007 is 90-222 per 100,000 population aged <40 years and in the year 2012

India 0.1 to 0.3 per 100 population aged <45 years and in the year 2012 0.1 to 0.3 per

100 population aged < 45 years. 2

The risk factors for stroke are out of our control, several can be kept in line

through proper nutrition and medical care. Risk factors for stroke include the following

over age 55, African American, Hispanic or Asian/Pacific Islander, family history of

stroke, High blood pressure, High cholesterol, Smoking cigarettes, obesity and

overweight, cardiovascular disease, previous stroke or transient ischemic attack (TIA),

High levels of homocysteine (an amino acid in blood), Birth control use or other hormone

therapy, cocaine use etc

Much of stroke prevention is based on living a healthy lifestyle. This includes:

knowing and controlling blood pressure, finding out if you have atrial fibrillation,non

smoking, lowering cholesterol, sodium, and fat intake,following a healthy diet. If you eat

plenty of tomatoes, your risk of developing stroke could be reduced significantly.

Tomatoes are rich in lycopene, a powerful antioxidant. In a study published in Neurology,

October 2012, researchers found that people with high blood concentrations of lycopene

had a 59% lower risk of stroke compared to those with the lowest concentrations,

drinking alcohol only in moderation, treating diabetes properly, exercising regularly.

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Moderate aerobic fitness can reduce stroke risk, a study found., managing stress, not

using drug, drinking three cups of tea per day reduces the risk of stroke A study found

that taking preventive medications such as anti-platelet and anticoagulant drugs to

prevent stroke.

Most population-based studies indicate that a considerable proportion of

hypertensive subjects are undertreated and that undertreatment is more prevalent among

hypertensive men than hypertensive women. The study aim was to investigate the

consequences of undertreatment of hypertension for women and men in terms of stroke

occurrence. Approximately 45 000 men and women aged 20 years were examined in 2

population-based studies in the Netherlands. A cohort of 2616 hypertensive subjects

(pharmacologically treated hypertensives and untreated hypertensives were participated.

The findings shown that compared with treated and controlled hypertensives, the relative

risks of stroke for treated and uncontrolled hypertensives and for untreated

hypertensives who needed treatment were 1.30 and 1.76, respectively. These relative

risks and the prevalence of (undertreated) hypertension in the total population of 45 000

subjects were used to estimate the number of strokes in the Netherlands attributable to

undertreatment. Among hypertensive men and women aged 20 years in the Netherlands,

the proportions of strokes attributable to treated but uncontrolled blood pressure were

3.1% and 4.1%, respectively. For untreated hypertensive men and women who should

have been treated, these proportions were 22.8% and 25.4%, respectively.3

Data from the third National Health and Nutrition Examination Survey -III

suggest that only approximately half of those taking antihypertensive drugs achieve blood

pressure levels at or below the treatment goal of 140/90 mm Hg. Studies in the United

4
Kingdom and the Netherlands have demonstrated that the quality of control of

hypertension is strongly related to the occurrence of stroke in the population. Using data

from a population-based case-control study, the researcher estimated the proportion of

incident strokes occurring among treated hypertensive patients that may be attributable to

uncontrolled BP in the United States.4

The education on hypertension and improving adherence to current guidelines

might prevent a considerable proportion of the incident strokes among hypertensives. The

potential impact of achieving control of blood pressure in patients already being treated

on the reduction of strokes requires further investigation.

6.2 NEED FOR THE STUDY

High blood pressure is one of the most common causes of stroke because it puts

unnecessary strain on blood vessel walls, causing them to thicken and deteriorate.

Traditional risk factors of ischemic stroke in young adults include smoking, diabetes

mellitus and hypertension. Studies from Asia showed ischemic and hemorrhagic strokes

had the same risk factors, especially a history of hypertension. Other risk factors included

a low high density lipoprotein level, the presence of three or more components of

metabolic syndrome. In Bangkok, Thailand in 2007, morbidity of essential hypertension

was 6.4% for inpatients for all age groups.5

The incidence of stroke among adults was less than 2% in some developing

countries in 1990. Where there has been an increase in incidence of stroke in developing

5
countries, the incidence of stroke among adults has also increased. Strokes occur in 5% of

western European adults, 8% of Americans, and 13% of Saudi Arabians. In Thailand,

stroke is fourth leading cause of death at 28.96 per 100,000 in 2009. In 2008, the death

rate from stroke in 15 to 59 years old was 16.3 per 100,000 in males, and 7.8 per 100,000

in females,India of stroke for the year 19981999 was 36/100,000 (age- adjusted annual

incidence rate 105 . Women outnumbered men regardingstroke prevalence in all age

groups except in the 50- to 69. 6

A study was conducted on number of incident strokes attributable to under

treatment of hypertension. The incidence rates of stroke after stratification for age, sex,

and categories of hypertension treated and controlled, treated but uncontrolled, untreated

but should be treated as derived from the 2 population studies. In both genders the

incidence rates increased with age. Furthermore, rates were highest in the untreated

hypertensives who should be treated. The respective age-adjusted prevalence of

hypertensives per 100 population, treated and controlled hypertension, treated but

uncontrolled hypertension, and untreated hypertension that should be treated were 11.2,

28.2, 15.5, and 39.7 for men, whereas for women these prevalences were 12.9, 39.4,

18.8, and 32.1 respectively. Age and sex-specific prevalences were used to calculate the

number of subjects in each of the categories of hypertension for the whole Dutch

population.7

A study was conducted on knowledge of stroke among hypertensive patients in

selected hospitals. The mean age of the sample was 50.77 years. Most of the participants

were females 61.3%. The findings indicated that a large percentage of the participants

52.1% define stroke as paralysis of the whole body and 19.4% as due to local beliefs.

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Further the findings revealed that 47.7% were not able to differentiate between stroke and

heart attack. The overall level of knowledge of stroke among the participants which

included their general knowledge of stroke, knowledge of the risk factors, signs, and

symptoms of stroke was low. The participants age, education level and employment were

found to be positively associated with participants level of knowledge of stroke.8

In Sub-Saharan African countries, there is extensive lack of knowledge pertaining

to stroke within the population in general, and among the medical staff, especially

on how to rehabilitate people affected by a stroke. In the Tanga region most of the

people live in the village since they are heavily dependent on farming. A large proportion

of them are poor local peasants and they are therefore not exposed to health educational

campaigns happening in cities. Additionally most of these people firstly consult

traditional healers who would not provide correct knowledge about stroke. Poor

knowledge leads to low compliance in making use of prevention programmes, thus,

patients are less likely to attend stroke management programmes. The main complication

of stroke is mood disorder, brain abscesses, paralysis or loss of muscle movement,

difficulty talking or swallowing, changes in behavior and self-care, memory loss or

thinking difficulties, emotional problems.9

These findings point to the need for the implementation of appropriate health

education and health promotion programmes providing information about stroke in target

populations. Therefore, health professionals will have to be more involved in not only

treating the patients symptoms, but also educating patients, caregivers as well as the

general public on the consequences of stroke.

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 The researcher during his clinical practice found that most of the patients are

diagnosed with stroke had the past history of hypertension. The reason behind is the

patients were not knowing about the complication of hypertension and how to prevent the

complication. Keeping it in mind the researcher decided to assess the knowledge and

attitude of hypertensive patients regarding stroke and its prevention. Based on the

knowledge and attitude of hypertensive patients the information booklet will be prepared

to improve the knowledge and attitude of the patient.

6.3 REVIEW OF LITERATURE

A cohort study was conducted on estimating the probability of stroke in Korean

hypertensive patients visiting tertiary hospitals, to find the probability of the stroke

among hypertensive patients. A total of 1,402 hypertensive patients treated by cardiology

departments at 37 general hospitals nationwide were enrolled. The results shown that the

proportion of patients who have uncontrolled hypertension despite use of anti

hypertensives was 37.2% women, 37.3% men. The average probability of stroke in

hypertensive patients was 24.17% women, 24.39% men, approximately 2.4 times higher

than of the risk of stroke observed in the Korean Cancer Prevention Study cohort.10

A prospective cohort study was conducted on presence of baseline pre

hypertension and risk of incident stroke to qualitatively and quantitatively assess the

association of pre hypertension with incident stroke through a meta-analysis of

prospective cohort studies. Pre hypertension was associated with risk of stroke. Seven

8
studies further distinguished a low pre hypertensive population systolic blood pressure is

120129 mm Hg and diastolic blood pressure is 8084 mm Hg or a high pre hypertensive

population is 130139 mm Hg and diastolic blood pressure is 8589 mm Hg. Among

persons with lower-range pre hypertension, stroke risk was not significantly increased

rate is 1.22, 0.951.57. However, for persons with higher values within the pre

hypertensive range, stroke risk was substantially increased rate is 1.79, 95%. The study

concluded that Pre hypertension is associated with a higher risk of incident stroke. This

risk is largely driven by higher values within the pre hypertensive range and is especially

relevant in nonelderly persons.11

A prospective study was conducted to assess the risk factors of stroke among

Congolese black hypertensive diabetics. Out of 492 followed-up patients 279 women,

213 men, 57+or -10 years, 41.9% were old of age > or = 60 years, and 16.5%

experienced acute stroke. In univariate analysis, a significant association between age >or

= 60 years, cigarette smoking, excessive alcohol intake, diabetes duration > or = 2 years,

pulse pressure > or = 60 mmHg. However, multivariate analysis identified only acute

bacterial pneumonia, diabetic retinopathy, diabetic neuropathy, chronic renal failure and

pulse pressure > or = 60 mmHg as the independent risk factors of stroke onset among

these black Congolese hypertensive diabetics. The study concluded that the rate of stroke

onset is high among these hypertensive diabetics.12

A prospective population based cohort study was conducted on

the relation between knowledge about hypertension and education in

hospitalized patients with stroke in Vienna. Five hundred ninety-one

9
consecutive patients with stroke with a medical history of hypertension

were interviewed about knowledge concerning hypertension within a

multicenter hospital-based stroke registry. The results shown that

seventy-seven percent of the patients stated to have known about

hypertension being a risk factor for stroke, but only 30% felt at

increased risk of stroke. Less than half 47% could identify 140 mm Hg

or less as the maximum tolerated systolic blood pressure, and 53% had

their blood pressure only controlled monthly or less often.

Approximately half of patients were acquainted with the non-

pharmacologic treatment options of physical activity 49%, reduction of

salt intake 54%, and reduction of caloric intake 48%, whereas

relaxation techniques were only known to 17%. The study concluded

that Knowledge in our population was insufficient and partly associated

with educational level. Furthermore, we found a gap between

knowledge of the increased risk for stroke in patients with hypertension

and awareness of their own risk.13

A questionnaire study was conducted on Knowledge of stroke risk

factors among primary care patients with previous stroke or TIA, to

10
study primary health care patients with stroke regarding their

knowledge about risk factors for having a new event of stroke. A

questionnaire was distributed to 240 patients with stroke diagnoses,

and 182 patients 76% responded. The results shown that

Hypertension, hyperlipidemia and smoking were identified as risk

factors by nearly 90% of patients, and atrial fibrillation and diabetes by

less than 50%.Knowledge about hypertension, hyperlipidemia and

smoking as risk factors was good, and patients who suffered from atrial

fibrillation or carotid stenosis seemed to be well informed about these

conditions as risk factors. Better teaching strategies for stroke patients

should be developed, with special attention focused on diabetic

patients.14

A cross sectional study was conducted on Perceived and actual stroke risk

among men with hypertension. The authors performed a cross-sectional analysis of 296

men with hypertension who were enrolled in the Veterans Study to Improve the Control

of Hypertension. The median 10-year FSR was 16%, but the median perceived risk score

was 5 ranges, 1 lowest to 10 highest. There was no significant correlation between

patients' perceived risk of stroke and their calculated FSR. Patients who underestimated

their stroke risk were significantly less likely to be worried about their blood pressure

than patients with accurate risk perception 12.4%. The lack of correlation between

hypertensive patients' perceived stroke risk and FSR supports the need for better patient

education on the risks associated with hypertension.15

11
 An exploratory study was conducted on Arterial hypertension patients: attitudes,

beliefs, perceptions, thoughts and practices, to know arterial hypertension patients

through their attitudes, beliefs, perceptions, thoughts, and practices related to the disease .

An exploratory study was carried out in 32 hypertensive patients seen at 2 health care

units in the municipal district of Ribeiro Preto, The findings of the study shown that

about half the patients 41% were not able to define hypertension. They believed the main

symptoms were headaches and neck pain 18% and the possible consequences of the

disease were stroke and heart attack 39%.The study concluded that psychosocial aspects

and health beliefs seem to affect directly with patients' knowledge on hypertensive

disease and their health practices. Given that all patients had already received some kind

of information about arterial hypertension before the beginning of the study, it would be

important to propose new forms of educating these patients.16

A population-based case-control study was conducted on Prevalence, treatment,

control, and awareness of high blood pressure and the risk of stroke in Northwest

England, to assess the prevalence of the high blood pressure and risks for stroke. A total

of 267 stroke cases and 534 controls were included. Sixty-one percent of cases and 43%

of controls had BP >= 160/95 mm Hg on >= 2 occasions within 3 months or received

antihypertensive. High proportions of cases 82% and controls 85% were on treatment.

There was a continuous relationship between the risk of stroke and levels of BP control.

Of 73 cases and 135 controls who were hypertensive and responded to the postal

questionnaire, 56 and 83%, respectively, were aware of hypertension (P<0.01). The

prevalence of hypertension was high among stroke patients. In those treated, <30% of

12
patients had their BP adequately controlled to <140/90 mm of Hg. Patient awareness of

previous hypertension or high BP was very poor and attention needs to be paid to patient

education.17

A Prospective cohort study was conducted on stroke-related knowledge and health

behaviors among post stroke patients in inpatient rehabilitation, to measure stroke

knowledge and pre stroke personal health behaviors of stroke patients undergoing

inpatient rehabilitation and their caregivers. A total of 130 stroke patients and 85

caregivers interviewed after ischemic stroke. The results shown that large deficiencies in

patient and caregiver stroke knowledge were found. Fifty-two percent of patients could

not name any stroke risk factors, 52% were unable to name a stroke warning sign, and

35% were unable to identify appropriate actions to take in a stroke emergency. The study

concluded that Stroke patients participating in inpatient rehabilitation and their caregivers

have large gaps in stroke knowledge and have suboptimal personal health behaviors,

thereby putting patients at high risk for recurrent stroke. Our finding highlights the need

to develop stroke-education programs for rehabilitating patients that are effective in

closing these gaps in knowledge and personal health behaviors.18

A quasi-experimental study was conducted to determine the effectiveness of a

community-based stroke prevention programme in improving knowledge about stroke;

improving self-health-monitoring practice; maintaining behavioral changes when

adopting a healthy lifestyle for stroke prevention. One hundred and ninety subjects were

recruited, of whom 147 completed the study. Data were obtained at three time points:

baseline (T0); one week after (T1) and three months after (T2) the intervention. The

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intervention programme consisted of eight weekly two-hour sessions, with the aims of

improving the participants awareness of their own health signals and of actively

involving them in self-care management of their own health for secondary stroke

prevention through informational booklet. The results shown that Significant positive

changes were found among participants of the intervention group in the knowledge on

stroke warning signs (P < 0001); treatment seeking response in case of a stroke

(P < 0001); medication compliance (P < 0001); self blood pressure monitoring

(P < 0001) as well as lifestyle modification of dietary habits (reduction in salted food

intake, P = 0004). Effective educational intervention by professional nurses helped

clients integrate their learned knowledge into their real-life practice.19

6.4 STATEMENT OF THE PROBLEM

A study to assess the knowledge and attitude regarding stroke and its prevention

among hypertensive patients in selected hospitals at Tumkur with a view to develop

an information booklet.

6.5 OBJECTIVES

To assess the knowledge regarding stroke and its prevention among

hypertensive patients.
To assess the attitude regarding stroke and its prevention among hypertensive

patients.
To find out the co-relation between the knowledge and attitude regarding

stroke and its prevention among hypertensive patients.

To determine the association between the level of knowledge with selected

socio demographic variables.

14
 To determine the association between the level of attitude with selected socio

demographic variables.
To develop an information booklet regarding stroke and its prevention.

6.6 HYPOTHESIS

H1: There will be significant correlation between the knowledge and attitude regarding

stroke and its prevention.

H2: There will be significant association between the level of knowledge with selected

socio demographic variables.

H3: There will be significant association between the level of attitude with selected socio

demographic variables.

6.7. OPERATIONAL DEFINITIONS

Knowledge: - In the present study knowledge refers to the correct response given by the

hypertensive patients regarding stroke and its prevention as it is elicited through self

administered knowledge questionnaire.

Attitude: It refers to hypertensive patients way of thinking about the stroke and its

prevention as evidenced from attitude scale.

Stroke: A stroke or cerebrovascular accident is the rapid loss of brain functions due to

disturbance in the blood supply to the brain. This can be due to ischemia caused by

thrombosis, arterial embolism, or a hemorrhage.

15
Prevention: It refers to health promotion and taking measures to keep away the

complications of hypertension such as stroke.

Hypertensive patients: In this study hypertensive patients refer to patients who are

having more than 140/90 mm of Hg blood pressure and taking treatment in out patient

department or in patient department above 30 years of age

Information Booklet: It refers to the planned self instructional material contains stroke

about definition, causes, clinical features, investigation treatment and its prevention

measures prepared by the researcher based on the results of the study.

6.8 ASSUMPTIONS

Hypertensive patients may have limited knowledge regarding stroke and its

prevention.
The hypertensive patients may have unfavorable attitude regarding stroke.
Information booklet may help to improve the knowledge and attitude regarding

stroke and its prevention.

6.9. VARIABLES IN THE STUDY

Research variable: knowledge and attitude

Socio -demographic Variable: age, gender, religion, occupation, duration of illness,

type of family, income, education, previous source of information etc

7. MATERIALS AND METHODS

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7.1 Sources of Data : Information provided by hypertensive Patients

7.2. Methods of data collection:

7.2.1. Research Design : Descriptive research design

7.1.3 Settings : Selected hospitals at Tumkur.

7.1.4. Population : Hypertensive patients

7.1.5. Sample : Hypertensive patients in selected hospitals at Tumkur.

7.1.6 Sample size : 100 Hypertensive patients

7.1.7 Inclusion criteria :

Hypertensive patients who are

Available during the period of data collection.

Willing to participate in the study.
Above 30 years of age.
who can competent to read and write kannada and/or English

7.1.8 Exclusion criteria

Hypertensive patients who are having pregnancy induced

hypertension
Hypertensive patients who are already diagnosed with stroke.

7.2 Method of data collection

7.2.1 Sampling technique : Non probability convenient sampling.

17
7.2.2 Tool : Self administered questionnaires.

It is divided into three parts:

Part I Socio-demographic data

Part II Knowledge questionnaire regarding stroke and its prevention.

Part III - Attitude scale on stroke and its prevention.

7.2.4 Method of data collection:

The data will be collected from hypertensive patients by using Self administered

knowledge questionnaire and attitude scale for knowledge and attitude assessment

respectively.

Written permission will be taken from the concern authorities.

7.3. Data Analysis and Interpretation:

Descriptive statistics

Descriptive statistical techniques such as frequency, percentage, mean,

median, mode and standard deviation.

Inferential statistics

Karl-Pearson co-relation co-efficient and Chi- square test

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7.4. Ethical clearance

Does the study require any investigation or interventions to be conducted on

patients?

No.

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