Effectiveness of education in health in the non-medication treatment of arterial hypertension

Oliveira, Thatiane Lopes; Miranda, Leonardo de Paula; Fernandes, Patrícia de Sousa; Caldeira, Antônio Prates

doi:10.1590/S0103-21002013000200012

Abstracts

OBJECTIVE: To verify the efficacy of health education on the adherence to non-pharmacological treatment in arterial hypertension. METHODS: Habits related to nutrition, physical activity and use of tobacco and alcohol were analyzed, as well as assessment of anthropometric and blood pressure levels, before and after the performance of group health education in 216 hypertensive patients. RESULTS: There was a statistically significant change in the consumption of legumes, in the adherence to physical activity, in the reduction of body mass index and abdominal circumference, and in the control of arterial pressure, after the health education groups. CONCLUSION: The proposed health education was effective in incentivizing the adherence to non-pharmacological treatment in arterial hypertension, evidenced by the relevance of the adoption of these educational strategies

Primary health care; Health education; Efficacy; Hypertension; Health promotion

OBJETIVO: Verificar a eficácia da educação em saúde na adesão ao tratamento não medicamentoso da hipertensão arterial. MÉTODOS: Foram analisados hábitos referentes à alimentação, à atividade física e ao uso de tabaco e álcool, bem como avaliação de medidas antropométricas e níveis pressóricos, antes e após a realização de grupos de educação em saúde em 216 hipertensos. RESULTADOS: Houve mudança estatisticamente significante no consumo de legumes, na adesão à prática de atividade, na redução do índice de massa corpórea e da circunferência abdominal e no controle da pressão arterial, após os grupos de educação em saúde. CONCLUSÃO: A educação em saúde proposta foi eficaz no incentivo à adesão ao tratamento não medicamentoso da hipertensão arterial, evidenciando a relevância da adoção dessas estratégias educacionais pelos profissionais de saúde.

Atenção primária à saúde; Educação em saúde; Eficácia; Hipertensão; Promoção da saúde

ORIGINAL ARTICLE

Universidade Estadual de Montes Claros, Montes Carlos, MG, Brazil

Corresponding author

ABSTRACT

OBJECTIVE: To verify the efficacy of health education on the adherence to non-pharmacological treatment in arterial hypertension.

METHODS: Habits related to nutrition, physical activity and use of tobacco and alcohol were analyzed, as well as assessment of anthropometric and blood pressure levels, before and after the performance of group health education in 216 hypertensive patients.

RESULTS: There was a statistically significant change in the consumption of legumes, in the adherence to physical activity, in the reduction of body mass index and abdominal circumference, and in the control of arterial pressure, after the health education groups.

CONCLUSION: The proposed health education was effective in incentivizing the adherence to non-pharmacological treatment in arterial hypertension, evidenced by the relevance of the adoption of these educational strategies for health professionals.

Keywords: Primary health care; Health education; Efficacy; Hypertension; Health promotion

Introduction

Systemic arterial hypertension is a grave public health problem, considered one of the principle risk factors for cardiovascular diseases, and responsible for high rates of morbidity.⁽¹⁾ Its control depends on pharmacological and nonpharmacological measures. The nonpharmacological measures are indiscriminately indicated for the hypertensive patients.⁽¹⁾ These measures include the reduction of alcohol consumption, control of obesity, a balanced diet, a regular practice of physical activity, and tobacco cessation.^(1,2)

Adherence to these lifestyle habits favors the reduction of blood pressure levels and contributes to the prevention of complications.⁽¹⁾ However, it is estimated that only a third of people monitored in health services have their arterial blood pressure maintained at desirable levels, and that insufficient treatment adherence is identified as one of the important determinants of this disease.⁽³⁾ The family health teams have, in theory, the best conditions to promote adherence to treatment of diseases such as hypertension, because they stimulate a good user/professional relationship and encourage co-responsibility for treatment. The educational activities promoted by the professionals stimulate the development of individual autonomy and enables the discussions and guidelines on how to adopt new lifestyle habits.⁽⁴⁾

The objective of this study was to verify the efficacy of proposed health education on adherence to nonpharmacological treatment of arterial hypertension in patients enrolled in family health teams.

Methods

This was an interventional, randomized, uncontrolled, prospective cohort study. The population consisted of 261 hypertensive patients enrolled in family health units in the urban area of the municipality of Januária, in the state of Minas Gerais, southeastern region of Brazil, who were older than 18 years of age. Excluded from the study were those hypertensive patients who refused to participate in educational activities. The outcome variables used were physical activity, diet, smoking, alcoholism and sociodemographic data. The sample size was estimated to detect a difference of at least 30% in the control of arterial hypertension after the educational activities, in relation to an estimated ratio of 50% of people with controlled arterial pressure before initiating the work. A confidence level of 95% and a sample power of 80% was assumed.

For purposes of data collection, home visits were conducted before the health education activities. The first visit was executed with the aim of applying the individual adult type questionnaire recommended by the National Cancer Institute - NCI,⁽⁵⁾ in order to gather information about the outcome variables.

After the home visits, the educational intervention was performed. The activities were conducted, by means of dialogued exposition, specific written material, sharing experience and evaluation, all performed in regular encounters lasting 60 minutes and with participation of 12 to 15 people. The programmatic content was: diet (Dietary Approaches to Stop Hypertension - DASH,⁽⁶⁾ physical activity (International Physical Activity Questionnaire - IPAQ),⁽⁷⁾ abdominal circumference (normal: up to 88 cm - women; 102 cm - men),⁽⁸⁾ body mass index (normal <25, overweight > 25 and <30, obese > 30),⁽⁹⁾ reduction of the consumption of alcohol and tobacco. The level of arterial pressure gauged was classified as optimum /normal /borderline, hypertension stage one and two, and hypertension stage three /isolated arterial systolic hypertension.⁽¹⁾

The variables of weight and arterial blood pressure were assessed in a standardized manner before and after each educational activity. Three months after the last activity on health education, a home visit was conducted to collect data, in order to evaluate possible changes occurred during the research process.

For descriptive analysis, the sociodemographic and clinical variables were listed.

In the analysis of categorical variables, the Chi-square of McNemar was used, in order to evaluate the paired data before and after the process of health education. Data analysis was performed using the software Statistical Package for the Social Sciences - SPSS^® 15.0 for Windows^®.

The development of the present study met the national and international standards of ethics in research involving humans.

Results

The characteristics of the study participants are provided in Table 1.

Thumbnail

There was a statistically significant change in the consumption of legumes, as measured by the proportions of appropriate use of this type of food before and after the educational intervention. There were no significant changes in relation to the consumption of fruits and vegetables (Table 2).

Thumbnail

In relation to the practice of physical activity, a statistically significant improvement was observed (Table 2). In the cessation of alcohol and tobacco, there were no positive changes observed. Regarding the anthropometric data, there was a statistically significant reduction in relation to abdominal circumference in relation to BMI (Table 2).

It was also possible to observe an improvement in blood pressure levels. The blood pressure measures encountered at the baseline were: SBP = 141.67 ± 23.94 mm/Hg and DBP = 81.94 ± 12.13 mm/Hg. At the end of the study, the observed values were 131.32 ± 21.63 mm/Hg and 81.76 ± 12.08 mm/Hg, respectively.

Discussion

The educational groups were characterized as a positive tool in incentivizing the appropriateness of certain behaviors and promoted improvement in blood pressure levels. However, the study results should be considered in light of some limitations. Examples of limitations are the short period of monitoring and the fact there was no control. It would be important to reevaluate the results over time, in order to ascertain whether the changes have been effectively incorporated into the patient's routine. It should be emphasized that the study, because it was not controlled, did not permit more evident inferences.

The health education was conceived from an initial objective, and with adequate planning and systematic methodology it gives rise to the attainment of good results. The results of this study show the importance of this strategy and the possibility for health professionals to make effective use of it in health promotion.

The predominance of females has been observed in other studies, as well as the prevalence of the age range between 60 to 79 years.^(10-12) The low educational level observed may impair behavior change by hampering the understanding of the orientations given, and therefore, it merits special attention from professionals.⁽¹³⁾

The Dietary Approaches to Stop Hypertension has had its benefits verified by other authors.⁽¹⁴⁾ Among the dietary habits discussed, consumption of legumes had a statistically significant change. Other studies have obtained a significant increase in intake of fruits and vegetables, after conducting educational activities.⁽¹⁵⁾ The modification of eating habits is not a simple task, because it is a custom present since childhood, related to ethnic origin and socioeconomic status of individuals.⁽¹⁶⁾

In relation to the practice of physical activity, there was a statistically significant improvement in the level of activities performed; several individuals who were sedentary began to practice physical exercises. The prevalence of physical activity and the impact of health education on a sedentary lifestyle are variable, according to the literature.^(17,18) The practice of physical exercise may be a behavior to which it is easier to adhere, since even activities performed during leisure time are associated with blood pressure control, but it is found that this practice is not a reality experienced by most hypertensive patients.^(19,20)

No changes were observed in the consumption of alcohol and tobacco. Different results were found by Al Qassim, where a 7% reduction in smoking among participants of a health education program was observed.⁽¹⁷⁾ Another study in Mexico observed association between these habits and the control of arterial pressure, thereby enhancing the benefits of adequate behavior.⁽²¹⁾

Changes in habits related to the use of tobacco and alcohol are difficult results to achieve in the short term, so it is essential to continue groups that reinforce the importance of these behaviors.

Research confirms that the more overweight, the higher the blood pressure levels.^(22,23) In this study we observed a statistically significant reduction in BMI values. In the abdominal circumference values, a statistically significant reduction was also obtained. A study of educational guidance, conducted with hypertensive patients, showed a reduction in abdominal circumference, body mass index and, consequently, in blood pressure levels.⁽²⁴⁾ The maintenance of these measures and of body weight is not an easy task; therefore, the conservation of healthy habits is necessary, such as the adoption of an adequate diet and the practice of regular physical activity.⁽²⁵⁾

In consonance with the changes in some lifestyle habits, we observed a statistically significant reduction in arterial pressure values, ratifying that the lifestyle of patients with arterial hypertension was related to the control of this condition.

New studies on the subject are desirable in order to identify the best intervention measures, in order to attain a greater commitment of patients and to obtain more effective results from the health promotion actions.

Conclusion

The health education proposed was effective in encouraging adherence to nonpharmacological treatment of arterial hypertension, demonstrating the relevance of adopting these educational strategies by health professionals.

Acknowledgements

The Universidade Estadual de Montes Claros - Unimontes. The Municipal Secretary of Health of the municipality of Januária.

Collaborations

Oliveira TL participated in the project design, analysis, interpretation, drafting the article, critical revision of the content and final approval of the version to be published. Miranda LP collaborated with the project design, analysis and interpretation, drafting the article and final approval. Fernandes PS participated in the analysis, interpretation and writing of the article. Caldeira AP participated in the project design, analysis, interpretation, drafting the article, critical revision and final approval of the content.

References

1. Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. [VI Brazilian Guidelines on Hypertension]. Arq Bras Cardiol. 2010;95(1 Suppl):1-51. Portuguese.
2. Santos ZM, Lima HP. Educational health technology in arterial hypertension prevention in workers: lifestyle change analysis. Texto & Contexto Enferm. 2008;17(1):90-7. Portuguese.
3. Krousel-Wood MA, Muntner P, Islam T, Morisky DE, Webber LS. Barriers to and determinants of medication adherence in hypertension management: perspective of the Cohort Study of Medication Adherence Among Older Adults (CoSMO). Med Clin North Am. 2009;93(3):753-69.
⁴
Brasil. Ministério da Saúde. Portaria n. 2488, de 21 de Outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS) [Internet]. Diário Oficial da República Federativa do Brasil, Brasília (DF); 2011 Out 24 [citado 2012 Jan 12]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html
5. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Instituto Nacional de Câncer. Coordenação de Prevenção e Vigilância. [Household survey on risk behaviors and morbidity of noncommunicable diseases and injuries]. 2003 [cited 2010 Abr 4]. Available from: http://www.inca.gov.br/inquerito/docs/faseII_tipoadulto.pdf Portuguese.
⁶
United States. Department of health and Human Services. Your guide to lowering your blood pressure with DASH. DASH eating plan. Lower your blood pressure [Internet] [cited 2010 Apr 4]. (NIH Publication, n. 06-4082). Available from: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
7. Martins LC, Guedes NG, Teixeira IX, Lopes MV, Araujo TL. Nível de atividade física em portadores de hipertensão arterial. Rev Latinoam Enferm. 2009;17(4). Portuguese.
8. Sociedade Brasileira de Cardiologia. I Diretriz Brasileira de Diagnóstico e Tratamento da Síndrome Metabólica. Arq Bras Cardiol. 2005; 84 Supl 1:1-28.
9. Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica. Diretrizes brasileiras de obesidade [Internet]. 3Ş.ed. Itapevi (SP): AC Farmacêutica; 2009 [citado 2011 Out 5]. Disponível em: http://www.abeso.org.br/pdf/diretrizes_brasileiras_obesidade_2009_2010_1.pdf
10. Lima HP, Santos ZM, Nascimento JC, Caetano JA. Hypertensive user's adherence to treatment and the interface with knowledge about the disease. Rev RENE. 2010;11(2):170-8. Portuguese.
11. Mano GM, Pierin AM. Evaluation from the hypertensive patients followed in the Family Health Program at Health School Center. Acta Paul Enferm. 2005;18(3):269-75. Portuguese.
12. Nobre F, Ribeiro AB, Mion Júnior D. Control of arterial pressure in patients undergoing anti-hypertensive treatment in Brazil - Controlar Brazil. Arq Bras Cardiol. 2010;94(5):623-30.
13. Cotta RM, Batista KC, Reis RS, Souza GA, Dias G, Castro FA, et al. Social-sanitary and lifestyle profile of hypertense and/or diabetics, users of the Family Health Program in the city of Teixeiras, Minas Gerais state. Ciênc Saúde Coletiva. 2009;14(4):1251-60. Portuguese.
14. Appel LJ, Brands MW, Daniels SR, Karanja N, Elmer PJ, Sacks FM. Dietary approaches to prevent and treat hypertension. Hypertension. 2006;47:296-308.
15. Svetkey LP, Pollak KI, Yancy WS Jr, Dolor RJ, Batch BC, Samsa G, et al. Hypertension improvement project: randomized trial of quality improvement for physicians and lifestyle modification for patients. Hypertension. 2009;54(6):1226-33.
16. Gimeno SG, Mondini L, Moraes SA, Freitas IC. Dietary patterns and correlates in adults living in Ribeirão Preto, São Paulo State, Brazil: the OBEDIARP Project. Cad Saúde Pública. 2011;27(3):533-45. Portuguese.
17. Sharaf F. Impact of health education on compliance among patients of chronic diseases in Al Qassim, Saudi Arabia. Int J Health Sci (Qassim). 2010;4(2):139-48.
18. Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Physical activity in young adults and the elderly in areas covered by primary health care units in municipalities in the South and Northeast of Brazil. Cad Saúde Pública. 2008;24(1):39-54.
19. Pitanga FJ, Lessa I. Relationship between leisure-time physical activity and blood pressure in adults. Arq Bras Cardiol. 2010;95(4):480-4. Portuguese.
20. Serafim TS, Jesus ES, Pierin AM. Influence of knowledge on healthy lifestyle in the control of hypertensive. Acta Paul Enferm 2010;23(5):658-64.
21. Reza CG, Nogueira MS. The life style of the hypertensive patient of a program of aerobic exercise: study in the Toluca City, Mexico. Esc Anna Nery Rev Enferm. 2008;12(2):265-70. Portuguese.
22. Hasselmann MH, Faerstein E, Werneck GL, Chor D, Lopes CS. Association between abdominal circumference and hypertension among women: the Pró-Saúde Study. Cad Saúde Pública. 2008;24(5):1187-1191. Portuguese.
23. Wenzel D, Souza JM, Souza SB. Prevalence of arterial hypertension in young military personnel and associated factors. Rev Saúde Pública. 2009;43(5):789-95.
24. Staten LK, Cutshaw CA, Davidson C, Reinschmidt K, Stewart R, Roe DJ. Effectiveness of the pasos adelante chronic disease prevention and control program in a US-Mexico border community, 2005-2008. Prev Chronic Dis. 2012;9:1-9.
25. Martín CR, Sánchez CC, Ortiz LG, Rodríguez JI, Sánchez YC, Marcos MA. Efficacy of an educational intervention group on changes in lifestyles in hypertensive patients in primary care: a randomized clinical trial. Rev Esp Salud Pública. 2009;83:441-52. Spanish.