The Effect of Culture-Based Education in Improving Knowledge of Hypertension Patients in Makassarese Community in Indonesia [PDF]

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Enferm Clin. 2020;30(S2):55---59



www.elsevier.es/enfermeriaclinica



The effect of culture-based education in improving knowledge of hypertension patients in Makassarese community in Indonesia夽 Andi Pramesti Ningsih, Nurhaya Nurdin ∗ , Arnis Puspitha, Silvia Malasari, Kusrini Kadar Faculty of Nursing, Hasanuddin University, Indonesia Received 29 May 2019; accepted 15 July 2019



KEYWORDS Hypertension; Culture-based education; Knowledge; Health literacy



Abstract Objective: This research aimed to determine the effect of culture-based education in improving knowledge of hypertension patients in the Makassarese Community, Indonesia. Method: This study used a quasi-experiment with two groups pretest---posttest control group design. The sample was 36 respondents, which were divided into two groups, which were given culture-based education and control group is given ordinary education. Each group was given a pretest and posttest. Result: This study shows that there was an increasing knowledge of the intervention group after receiving cultural-based education. The research results showed t-value 1.92 with significant p-value >0.005 with the mean values in the intervention group 27.78 and 11.67 in the control group. Conclusion: Education of culture-based hypertension affects increasing knowledge of people with hypertension in the community. Therefore, it is expected that culture-based education can be used as a health education program to increase the knowledge of hypertension patients effectively. © 2019 Elsevier Espa˜ na, S.L.U. All rights reserved.



Introduction 夽 Peer-review under responsibility of the scientific committee of the International Conference on Women and Societal Perspective on Quality of Life (WOSQUAL-2019). Full-text and the content of it is under responsibility of authors of the article. ∗ Corresponding author. E-mail address: [email protected] (N. Nurdin).



https://doi.org/10.1016/j.enfcli.2019.09.003 1130-8621/© 2019 Elsevier Espa˜ na, S.L.U. All rights reserved.



Non-Communicable Diseases (NCDs) including hypertension have emerged as a huge global health problem in low- and middle-income countries,1 particularly visible in Southeast Asia where limited resources have been used to address this rising epidemic, including Indonesia. World Health Organization (WHO) reported that cardiovascular disease, as the



56 number one killer in the world is caused over 17 million deaths represent 13% of global deaths2 including disease, congenital heart disease, and hypertension.3 Patients with hypertension in Indonesia are estimated at 15 million, but only about 4% can control hypertension.1,4 To effectively control hypertension, sufficient knowledge and awareness of the clients of the risks of hypertension are needed and important.5 Based on the results of the Basic Health Research (2013), where the prevalence of hypertension was higher in the group with low education and those who do not work.4 Disease Control and Environmental Health (P2PL) Makassar City Health Department in 2015 revealed that hypertension ranks third major cause of death in the amount of 370 population.6 Some studies in China and Indonesia show the level of knowledge people with hypertension is still low regarding their illness and how to manage their condition,7---10 especially about complication and treatment of hypertension. There are many factors that contribute to low levels of this knowledge, one of which is health education programs and cultural backgrounds.11 This suggests that the health education program requires proper management in prevention, especially in a community. The provision of health education to patients should focus on cultural aspects that exist in society,11 including the language used. Results of research in 2014 in Africa showed that culture-based health education interventions could improve patient compliance with uncontrolled hypertension to lifestyle changes that support the treatment needs of patients with hypertension.12 Thus, health education programs are needed, and health care professionals must be able to incorporate local cultural elements such as using local language providing health education about hypertension,11---13 to make patients understand the content of health education.14 It is important for health care professional to master cultural competency in providing health care provision for people in community.15 Cultural competence can be defined as ‘‘the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients’’ and it closes the gap, enables better communications, and ultimately unites people in spite of their differences.16 As mentioned above, knowledge of patient regarding their condition can be improved by proper health education17 by including cultural aspect when preparing to deliver health education. Although there have been many studies done in Indonesia related to the effect of health education, unfortunately, it is difficult to locate published articles related to this area of study in Indonesia. However, from the researcher’s personal experience as a community health nurse, health education is provided as it is, without any preparation and any consideration of important aspect, including health literacy and cultural background of the patient. They deliver health education in Bahasa (Indonesian Language), but in fact, some of those patients cannot understand Bahasa well. Thus, the researcher was interested to see the effect of cultural-based health education to increase knowledge of people with hypertension in the community.



Method This research used a quantitative method using quasiexperiment design with two groups pre and post control



A.P. Ningsih et al. group to evaluate the effect of culture-based health education to the level of knowledge of patients with hypertension. There were as many as 36 respondents involving in this study chosen by using purposive sampling techniques that have met the inclusion criteria including patients with hypertension aged 40---59 years and using the native language, willing to participate and involving in all activities in this study. The 36 respondents were divided into two groups, 18 respondents in the intervention group that receive health education using culturally based in this case Makassarese culture and 18 respondents in the control group receiving usual health education provided in the community center provided in Bahasa language. Interventions in this study using a cultural approach and using modified precede-proceed method into 3 phases (original method using 8 phases). The 3 phases used in this study were data collection phase which was pretest knowledge for both groups, 2nd phase was the implementation of 3 learning sessions (basic knowledge of hypertension, diet, and physical activity, stress management, and social support) then the 3rd phase was the post-test for both groups. Each session in the provision of education conducted for 30 min using media poster. The questionnaire that was used in this study was Culturally Adapted Hypertension Education (CAHE) invented by Beune et al.12 and was translated into Bahasa (Indonesian language) by a nursing lecturer whom expert in health education topic and back-translated into English by another lecturer with similar expertise. Validity test result (between 0.324 and 0.857) and Cronbach’s alpha (0.849) showed that this instrument valid and reliable for this study. Ethic approval was sought from the Faculty of Medicine Ethic Committee Universitas Hasanuddin (Ethic No. 1095/H4.8/5/31/PP36-KOMETIK/2017). Before this study began, respondents were given to inform consent explaining about what this study aim and what is the role of researcher and respondents. Data were analyzed using SPSS 20.0 statistical test using a paired t-test and independent t-test.



Result Questionnaires were distributed to all groups and contained demographic data information and clinical status of the respondents. Table 1 show details data about demographic data and clinical status of respondents. The table shows a majority of respondents are female in both groups with half of the respondents only have lower education in the intervention group (50%) while in control group more than half were graduated from senior high school (61.1%). More respondents working at home as a housewife in both groups and intervention group more than half (55.6%) of respondents do not have a family history with CVD while in control group 72.2% respondents have a family history with CVD. Mean age in intervention and control groups are 54.6 and 52.7, respectively. Blood pressure means in both groups are 150/80 for the intervention group and 160/100 for the control group. Table 2 shows the result of level knowledge differences before and after the intervention. From the table above, it can be seen that although respondents in both groups experienced the effect of health education on their knowledge (p-value 0.005.



Discussion This study shows that there is no significant difference in the level of knowledge in both groups might have been



influenced by several factors that existed in respondents. One of them is the education level of respondents who were in the control group, where the majority of them had a high school education level. The level of education is a factor of considerable influence in obtaining information that can support health. Demographic data showed that the education of the respondents in the intervention group was lower than in the control group education. This may affect the level of acceptance of the respondent by the theory that the higher the level of education, the higher the person’s ability to receive the information provided.7 Reception of information in the provision of knowledge is also influenced by the age and experience of the respondents. Older people show a level of maturity and strength; thus, they will be more mature in thinking.18 However, increasing age resulted in the decline of cognitive functions, and that age will prolong the time to recall information that has been obtained.18 Health education has been proven can improve patient knowledge about their condition.17 This study also prove that after receiving health education knowledge of hypertension patients was increased. Thus, providing health



58 education should need more preparation, choose the best strategy to that the topic can be delivered well, and the patient can absorb the information easily.19 Primary health care services sometimes do not have enough time to provide a long-sophisticated health education program for patients.20 In some health clinics in developed countries such as in the US, clinicians are sometimes struggling to fit multiple agenda items into the 15-min visit, hence cannot meet every need of their patients with chronic conditions. Half of the patients leave primary care visits, not understanding what their doctor told them. The results showed that health education strategy to use culture strategy is needed. This cultural approach will increase the confidence and awareness of the health information provided.11 Approach using culture is considered more able to increase public knowledge, especially in areas with cultural value is still quite high. Needs of patients with health personnel competency in understanding aspects of the prevailing culture in the community are very important in determining the action to be taken.13 Development of health services by the cultural aspects of each patient’s condition is an important issue.21 Therefore, the health workers as much as possible in partnership with social scientists, anthropologists, and researchers develop and evaluate health education programs. This is because of cultural competence is a standard for the delivery of information to patients who come from different cultural backgrounds.



Conclusion Based on the discussion that has been described above, health staff must understand the culture in the community to provide an easy-understandable explanation. Providing health education that using the local language of the community will help the hypertension patient understand easily about the topic that is taught. This will certainly facilitate the public in identifying the medical term that is often used by health staff when explaining or providing health education. This cultural approach is not an easy thing so that building up networks of public health experts and policymakers, increasing the understanding of non-health sectors of their role in NCDs prevention, including hypertension, is very important. Also, health staff should be encouraged to always upgrading their knowledge and skills about health literacy and health education. Providing them with training to understand cultural competency is necessary.



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Conflict of interest 14.



The authors declare no conflict of interest.



Acknowledgment Thank you for all the participants and research assistant who were very helpful in this study.



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