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2012-14
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
DISSERTATION
6.1 INTRODUCTION
1
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
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
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
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
High levels of homocysteine (an amino acid in blood), Birth control use or other hormone
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
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,
3
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
prevent stroke.
hypertensive subjects are undertreated and that undertreatment is more prevalent among
hypertensive men than hypertensive women. The study aim was to investigate the
occurrence. Approximately 45 000 men and women aged 20 years were examined in 2
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
incident strokes occurring among treated hypertensive patients that may be attributable to
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
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
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
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
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 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
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.
6
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
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
traditional healers who would not provide correct knowledge about stroke. Poor
patients are less likely to attend stroke management programmes. The main complication
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
7
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
hypertensive patients visiting tertiary hospitals, to find the probability of the stroke
departments at 37 general hospitals nationwide were enrolled. The results shown that the
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
hypertension and risk of incident stroke to qualitatively and quantitatively assess the
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
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
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
9
consecutive patients with stroke with a medical history of hypertension
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
10
study primary health care patients with stroke regarding their
smoking as risk factors was good, and patients who suffered from atrial
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
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
11
An exploratory study was conducted on Arterial hypertension patients: attitudes,
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
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%
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
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
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
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
13
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
A study to assess the knowledge and attitude regarding stroke and its prevention
an information booklet.
6.5 OBJECTIVES
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
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
H2: There will be significant association between the level of knowledge with selected
H3: There will be significant association between the level of attitude with selected socio
demographic variables.
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
Attitude: It refers to hypertensive patients way of thinking about the stroke and its
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
15
Prevention: It refers to health promotion and taking measures to keep away the
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
Information Booklet: It refers to the planned self instructional material contains stroke
about definition, causes, clinical features, investigation treatment and its prevention
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
hypertension
Hypertensive patients who are already diagnosed with stroke.
17
7.2.2 Tool : Self administered questionnaires.
The data will be collected from hypertensive patients by using Self administered
knowledge questionnaire and attitude scale for knowledge and attitude assessment
respectively.
Descriptive statistics
Inferential statistics
18
7.4. Ethical clearance
patients?
No.
8. BIBLIOGRAPHIC REFERENCES
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1. John Joseph Tesha, Knowledge of stroke among hypertensive patients in selected
hospitals in the Tanga Region, Tanzania. October 2003, Vol 60, No. 10 Available at
October 2012)
2. Case-control study of stroke and the quality of hypertension control in northwest
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05thOctober 2012)
3. Olaf H. Klungel, Bruno H. C. Stricker, Arsenio H. P. Paes, Jacob C. Seidell, Albert
October 2012)
4. Nicholas L. Smith, Rozenn N. Lemaitre, Susan R. Heckbert, Robert C. Kaplan, David
L.et al Serum potassium and stroke risk among treated hypertensive adults.
Goodwin, et al. Essential Hypertension: Renin and Aldosterone, Heart Attack and
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2012).
Hormone Therapy Analyses Based on the Danish Nurse Study. Arch Neurol.
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10. Cheol U Choi and Chang G Park. Estimating the probability of stroke in Korean
hypertensive patients visiting tertiary hospitals using a risk profile from the
11. M. Lee, J.L. Saver, B. Chang, K.-H. Chang, Q. Hao, B. Ovbiagele, Presence of
baseline prehypertension and risk of incident stroke. Neurology October 4, 2011 vol.
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12. Longo-Mbenza B, Ngimbi RM, Ngoma DV, Fuele SM, Buassa-bu-Tsumbu B. Risk
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16. Pres DS, Magna JM, Viana LA. Arterial hypertension patients: attitudes, beliefs,
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17. Du X. Prevalence, treatment, control, and awareness of high blood pressure and the
risk of stroke in Northwest England. Prev Med. 2000 Apr;30(4):288-94. Available at.
18. Koenig KL, Whyte EM, Munin MC, O'Donnell L, Skidmore ER, Penrod LE, Lenze
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