RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. Name of the candidate and Address: Mr. Denny K. Abraham
1st year MSc. [Nursing]
Mallige Institute of Nursing.
Bangalore -13
2. Name of the Institution : Mallige Institute of Nursing
Bangalore -13
3. Course of Study and Subject : 1st Year MSc Nursing
Medical Surgical Nursing
Branch 1.
4. Date of Admission to Course : 28 / 07 /2008
5. TITLE OF THE TOPIC : “A study to evaluate the
effectiveness of structured
teaching programme on
prevention of coronary artery
disease among clients
with hypertension at selected
hospitals, Bangalore”
6. BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
“Within each one of us lies the power of our consent to health and sickness, to riches & poverty, to freedom and to slavery. It is we who control these, and not another” –Richard Bach
Hypertension or high blood pressure is generally defined as persistent elevation of Blood pressure above 140/90 mm of Hg. It is a major contributor to the mortality and morbidity. Hypertension is the single most important predictor of cardiovascular risk. It is also related to increased severity of the atheroscelosis, stroke, nephropathy, peripheral vascular disease, aortic aneurysms & congestive heart failure.When a Coronary Artery is narrowed or blocked. The area of the heart muscle supplied by that artery becomes ischemic and injured and infarction may result. Also can lead failure of the heart. 1
Atherosclerosis and Coronary Artery Disease (CAD) are now the commonest sequelae of hypertension and all clinical manifestation of CAD occur in excess in person with elevated blood pressure. Risk increases in relation to the extent of blood pressure elevation whether this is in the systolic or diastolic components at any age and in either sex.2
Hypertension is a major risk factor for coronary artery disease. Among the numerous risk factors associated with coronary artery disease, hypertension plays a major role given its high frequency and its physiopathogenesis.Thus roughly 15% of the general adult population manifest hypertension and 25% patients with coronary artery disease have hypertension. CAD is the first cause of morbidity and mortality in hypertensive patients.3
Hypertension is estimated to cause 4.5% of current global disease burden and is as prevalent in many developing countries .Blood Pressure induced cardiovascular risk rises continuously across the whole blood pressure range .Cardiovascular Disease is responsible for one third of global disease burden.4
A study was done in 2002 at Assam to know the prevalence of hypertension. It concluded that the prevalence of hypertension was 61% among Men and Women aged thirty and above.5 Another study conducted in the urban areas of Chennai during 2003 reported a higher prevalence of hypertension (54%) among low income group and 40% prevalence among high income group.6
A study was done in Mysore, Karnataka regarding the prevalence of hypertension among adolescence. This study was a cross sectional school based survey conducted from June 2006 to August 2006.550 apparently normal school students in early and midadolescence (10years to 16 years) was selected by stratified random sampling. Results of the study showed that there is a high prevalence of essential hypertension amongst adolescents with modifiable risk factors for hypertension. 7
An article in a national newspaper ‘The Hindu’ states that the incidence of heart disease has doubled in the past 20 years. And the main cause for this changes is the lifestyle change brought by economic progress of people in India and also that Indians are genetically more prone for Coronary Artery Disease. 8
Another article by the BBC News warned that India will account for 60% of heart disease cases worldwide within two years and South Asians has the highest level of acute Coronary Syndromes in the world. As Indian economy is growing there is a possibility of further increase in Cardiovascular Disease.9
A study done by Mazy and Sun NL department of hypertension, People’s hospital of Peking University, Beijing, China with an objective of studying the relationship between the parameters of artery elasticity and Coronary Artery Stenosis in normotensive and hypertensive patients with coronary artery disease concluded that prevalence rate of severe Coronary Artery Disease was higher in hypertensive than in normotensive (64% vs.27%) 10
Another study was done by Pepine CJ in United States to know relation between systemic hypertension and Coronary Artery Disease. It was found that half of these patients had Hypertension. The study also stated that hypertension is a major risk factor for Coronary artery disease and that the incidence of both conditions increases with age.11
A study was done by the Medical department of the Heinrich Heine University of Düsseldorf to evaluate effectives of Structured Teaching programme on Hypertension in general practice .The study was done by Prospective Control Trial Method with a follow u-up period of 18 months .The sample was selected from 10 Primary Health Care Centers.20 patients were selected from each primary health care centers. Patients in 5 primary health care centers were subjected to teaching programme and remaining 5 primary health care centers continued without the teaching progarmme.9% of the patients in the control group and 33% of patients in the intervention group had documented reductions of body weight. Blood Pressure too decreased in the intervention group compared to the control group. The study concluded that introduction of a Structured Teaching Programme in general practice may lead to significant improvements of hypertension care12
Coronary Artery Disease which includes Heart Failure, Myocardial Infarction and Angina pectoris accounts for one of the largest reasons for admissions of clients to Cardiac unit. With increasing incidence of hypertension year after year and hypertension being the number one cause for Coronary Artery Disease there is a challenging necessity to educate the clients with hypertension on how Coronary Artery Disease can be prevented.
With above mentioned data and discussions with experts in the Medical and Nursing fields, the investigator has understood and is convinced that hypertension is a dreadful, silent killer which often goes unnoticed until it is diagnosed accidentally or when the clients comes for treatment due its complications .Investigator’s conversation with hypertensive clients regarding their knowledge in prevention of Coronary Artery Disease was found poor. Hence investigator is of the strong view that hypertensive clients should be educated regarding control of hypertension and prevention of Coronary Artery Disease. Even though the investigator was unable to access studies regarding effectives of Structured Teaching Programme among hypertensive clients regarding prevention of Coronary Artery Disease, one study which proves that Structured Teaching Programme was effective in control of hypertension was obtained. Therefore the investigator finds it necessary to educate hypertensive clients regarding prevention of Coronary Artery Disease by using a Structured Teaching Programme.
6.2 REVIEW OF LITERATURE
A prevalence survey of Coronary Artery Disease was done in an urban population in Northern India .The survey involved house –to-house clinical and electrocardiographic abnormalities. The study concluded that the prevalence of Coronary Artery Disease increased with age, with socioeconomic status, sedentary nature of occupation and in Hypertension. The study also states that 62% of the men and 88% of the women had clinically silent Coronary Artery Disease 13
In an ICMR study involving 5537 individuals (3050 urban residents and 2487 rural residents) demonstrated 25% and 29% prevalence of hypertension among males and females respectively in Urban Delhi and 13% and 10% in rural Haryana.14 . This study shows that prevalence of hypertension is higher in the urban population than in the rural population.
World Health Report 2002 stated Cardiovascular Diseases (CVD) will be the largest cause of death and disability by 2020 in India. I 2020 A.D., 2.6 Million Indians are predicted to die due to Coronary Artery Disease which constitutes 54.1% of all CVD deaths. Nearly half if their deaths are likely to occur in young and middle aged individuals (30-69).Currently Indians experience CVD deaths at least a decade earlier than their counterparts in countries with established market economies.15
An article in the Dawn dated April 25,2008 stated that India has highest incidence of heart disease and by 2010 India will carry 60% of the worlds heart disease nearly four times than its share of the global population.16
Another article by BBC News presented the fact that Indians are genetically prone to Heart disease. Even though people of Indian origin smoke lesser than the whites and the blood pressure and cholesterol levels seem to be lower than the whites living in U. K. Yet it is noticed that Indians are more prone to get heart disease than the white living in U.K. The researchers attribute the finding to the lesser ability of the cells that line the Brachial Artery to expand and contract according to blood flow in people of Indian origin regardless of the levels of glucose, insulin or cholesterol in the blood.17
A study conducted to estimate the mortality of CVD concluded that 52% of CVD deaths occur below the age of 70 years in India as compared to 23% in established market economies. The contributing factor for the growing burden of CVDs are increasing prevalence of Cardiovascular risk factor especially hypertension.18
Another study done by William, Melvin and Patricia in Framingham Massachusetts on blood pressure and risk of coronary artery disease proved the relationship between blood pressure and coronary artery disease. The study was done in 5127 men and women over a period of 14yerars. The study summarized that risk of every manifestation of CHD including angina, coronary insufficiency, myocardial infarction and sudden deaths was related to the antecedent level of both systolic and diastolic blood pressure.19
A study was done to ascertain the relation of blood pressure to coronary heart risk change with ageing in Framingham. The study examined the relative importance of Diastolic (DBP), Systolic (SBP) and Pulse Pressure (PP) as predictors of Coronary Heart Disease (CHD) risk in different age groups. The study was done on 3060 men and 3479 women between 29 and 79 years of age who are free of CHD and were not on antihypertensive drug therapy at baseline. The result of the study were that with increasing age, there was a gradual shift from DBP to SBP and the to PP as predictors of CHD risk. This study also shows a strong relation between hypertension and development of CAD. 20
In a study done by the department of Nutrition and Metabolic Diseases, Heinrich- Heine University of Düsseldorf, Germany assessed the improvement if hypertensions care in patients by a structured teaching program. A significant improvement in compliance to antihypertensive therapy and hence control in blood pressure was demonstrated. The study concluded that such studies need to be carried out on a large scale. 21
6.3 OBJECTIVE OF THE STUDY
-Assess the knowledge of clients with hypertension regarding prevention of
coronary artery disease by conducting pretest.
- Evaluate the effectiveness of structured teaching program regarding
prevention of coronary artery disease among clients with hypertension by comparing mean pretest and mean post test scores.
- Determine the association between knowledge of clients with hypertension
regarding prevention of coronary artery disease with selected demographic
variables.
7. MATERIALS AND METHODS
7.1 SOURCE OF DATA
Data will be collected from clients with hypertension both admitted and visiting the outpatient departments of selected hospitals, Bangalore.
7.2 METHOD OF DATA COLLECTION
7.2.1 INCLUSION AND EXCLUSION CRITERIA
· INCLUSION CRITERIA
1. Clients with hypertension who are willing to participate
in the study.
2. Who can read and write English or Kannada language.
3. Who are available at the time of data collection.
· EXCLUSION CRITERIA
1. Who are not willing to participate in the study.
2. Clients with hypertension who are critically ill.
3. Clients who have already developed coronary artery
disease.
7.2.2 RESEARCH DESIGN :
Quasi Experimental one group Pretest Post test design.
7.2.3 SETTING
Selected hospitals in Bangalore.
7.2.4 SAMPLING TECHNIQUE
Purposive Sampling Technique.
7.2.5 SAMPLE SIZE
The sample size will be 50 Hypertensive Clients.
7.2.6 TOOLS OF RESEARCH
Tools will be prepared based on the objectives of the study.
Components of the tool will consist the following sections.
1. Structured Questionnaire to elicit baseline variables of clients.
2. Structured Questionnaire to elicit knowledge of clients in
relation to prevention of CAD in clients with hypertension.
7.2.7 COLLECTION OF DATA
Sample will be selected based on inclusion criteria through purposive sampling technique.Data collection will be done in the wards and outpatient departments of selected hospitals. After explaining the objectives of the study and after taking their permission, structured questionnaire will be administered to check their pretest knowledge. Followed by that a structured teaching programme will be conducted by the investigator. A follow up will be done by the investigator one week later and the same clients will be given a post-test to compare the level of knowledge in the pretest and post test.
7.2.8 METHOD OF DATA ANALYSIS AND
PRESENTATION
Data analysis will be done through descriptive and inferential statistics.
(a) Descriptive Statistics: The investigator will use descriptive statistical techniques like mean, median, mode, percentile and standard deviation for data analysis. The analyzed data will be presented in the form of tables, diagrams and graphs based on the findings.
(b) Inferential Statistics: Test of significance such as t-test and chi square will be used depending on the results obtained.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS
OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN BEINGS OR ANIMALS
The study requires no investigations or interventions to be conducted on patients or other human beings or animals. This study includes knowledge assessment and providing Structured Teaching Program.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM
YOUR INSTITUTION IN CASE OF 7.3 ?
Permission will be obtained from head of the Hospitals and consent
will be obtained from the individual patients taking part in the study.
8. LIST OF REFERANCE
SUPERSCRIPTNUMBER / REFERANCE
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14.
SUPERSCRIPT NUMBER / Joyce M. Black and Matassarin, Medical Surgical Nursing, Clinical Management for Continuity Care, 5th edition, 1998, Page No.1387,1238.
Kannel W.B., Influence of multiple risk factors on hazard of hypertension, Journal of Cardiovascular Pharmacology.
Jean-Phillipne Bagnuet and Jean-Micahel Mallion, Hypertension and Coronary Heart Disease, Cardiology and Hypertension, Grenoble University, France European Society of Hypertension Scientific Newsletter: Update on hypertension management, 2005:6:No.14r.
2003 World Health Organization(WHO)/International Society of Hypertension(ISH),Statement on management of hypertension,WHO,ISH Writing group,Lippincot Williams & Wilkins,2003.
Hazarika NC,Biswas D,Narain k,Kaliota HC,Mahanta J.Hypertension and its risk factors in tea garden workers of Assam, National Medical Journal India,2002,March-April 15(12):63-68.
Gupta R et al,High Prevalence of Multiple Coronary risk factors in Punjabi Bhatia Community : Jaipur Heart Watch-3,Indian Heart Journal,2004 November-December:56(6):564-52.
M.R.Savitha e tal Essential Hypertension in early and mid-adolescence, Department of Pediatrics and Community Medicine, Government Medical College,Mysore, India, Indian Journal of Pediatrics, Volume 74 –November2007,Page No.1007.
The Hindu, Online edition of India’s National Newspaper, Saturday, November04, 2006.
India Warned Over Heart Disease, BBC News, Friday 25 April 2008, UK.
Mazy, Sun NL, Association between coronary artery function in normotensive and hypertensive patients with coronary artery disease, American College of Chest Physicians, Chest 1969:56:43-52.
Pepine C.J. Systematic hypertension and coronary artery disease, American Heart Association, 2001; 103:1245.
Mulhauseratel e tal , Evaluation of Structured Treatment and Teaching Programme on Hypertension in general practice, Medical Department for Metabolic Disease & Nutrition. Hein Rich Heine university of Düsseldorf, Page No.349-355.
S.G. Sarvotham, J.N.Berry, Prevalence of Coronary Heart Disease in Urban population in Northern India, American Heart Association,1968;37:939.
ICMR Task Force Project on Collaborative study of Coronary Heart Study.
REFERANCE
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21. / National Cardiovascular Disease Database, Sticker No: SE/04/233208, IC Health, Supported By Ministry of Health and Family Welfare, Government of India and WHO, Page No.1.
Dawn the Internet edition, April 25, 2008, Friday, India has highest incidence of heart disease.
BBC News, Wednesday, 28 april,1999, “Indians Genetically Prone To Heart Disease”.
National Cardiovascular Disease Database , IC Health, Supported By Ministry of Health and Family Welfare, Government of India and WHO, Page No.1.
William B.Kannel, Melvin J.Schwartz M.D.,Patricia M.Mc.Namara,Blood Pressure and Risk of Coronary Heart Disease: Framingham Study. American Journal of Cardiology,1998 August 6;82:21H.
Stanly S.Franklin , Does the relation of Blood Pressure to Coronary Heart Disease risk change with aging ,The Framingham Heart Study, American Heart Association,2008,39:343.
Sawicki PT, Muhlhauser I, Didjurgeit U, Berger M ,Improvement of Hypertension Care by Structured Treatment and Teaching Programme.
9. Signature of Candidate :