THE EFFECT OF HEALTH EDUCATION ON KNOWLEDGE AND ATTITUDE ON MEDICATION REGIMEN ADHERENCE AMONG HYPERTENSION CLIENTS AT SAWANGAN VILLAGE AIRMADIDI SUB DISTRICT

FAKULTAS ILMU KEPERAWATAN UNIVERSITAS KLABAT

PLAGIARSM STATEMENT

Plagiarsm (unacknowledgment borrowing and

quotation) is an examination offence and carries heavy

penalties. The following tittle:

The effect of Health Education on Knowledge

and Attitude on Medication Regimen Adherence Among

Hypertension clients at Sawangan Village, Airmadidi

sub district

I declare that, apart from properly referenced

quotations, this baby thesis is my own work and

contains no plagiarsm; it has not been submitted

previously for any other assessed unit on this or other

degree courses.


Jedeth Jenefa Mamora Djoko Sutopo, MAN Researcher Research Advisor

DEDICATED TO:

My Beloved Parents


AKNOWLEDGEMENT

I would like to thank you and convey my

appreciation and gratitude to the following persons

who, in various ways have helped me completed this

piece of work.

Djoko Sutopo, MAN, my adviser, for all the

critical comments, constructive and invaluable


suggestions, guidance in helping me shape this work

into what it is;

S.J. Laoh, PhD, a panel member for his ensuring

and unselfish advises;

Ir. Amelia Tanalase, M.Si, a panel member for

enriching this study with her expertise in statistics;

Nova Langingi, MSN, a panel member for her support

to improve this writing and shaped it to a better

result;

Jennie J. Lintjewas, SKep., Head Nurse

Coordinator of Sawangan Health Community Center for

allowing this study to be conducted at Sawangan

Community; as well her support during data gathering

period;

’Kepala Jaga’ I-IX and health cadres of Sawangan

area, for all the support during data gathering period;

UNKLAB Nursing Faculties and Librarians, for your

support;


Lely Sualang, MA and Jenny Zebedeus, MBA, friends

for your untireless encouragement;

Nursing 2nd Batch, classmates for your friendship

and good teamwork.

TABLE OF CONTENT

TABLE OF CONTENT ............................... i-ii

I. THE PROBLEM AND ITS BACKGROUND .............. 1

Introduction .............................. 1

Problem Statement............................ 5

Significant of the Study .................. 5

Scope and Limitations on Research ......... 5

Definition of terms used in the study .... 8

II. REVIEW OF LITERATURE ....................... 8

Health education .......................... 8

Knowledge .................................. 13

Attitude .................................. 18

Hypertension .............................. 21

Primary Health Care ....................... 37

District ................................... 38

Theory Framework .......................... 38


Conceptual Framework ...................... 42

Statement of Hypotheses ................... 43


III. RESEARCH METHOLOGY........................... 45

Design .................................... 45

Subjects Participant in the study ......... 49

Subject sampling and allocation ........... 49

Limitation on Research .................... 50

Location .................................. 51

Data Collection ........................... 51

Ethical Considerations .................... 54

Collection of data Pre and Post ............ 56

Flow of data collection ................... 58

IV. PRESENTATION, INTERPRETATION AND ANALYSIS OF DATA

Description of the Participants’Socio-

demographic Profile...............................

The Outcomes Measure.................

V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS………..

Summary..............................

Conclusions..........................

Recommendations......................

References


Appendices


ABSTRACT

The primary purpose of this empirical study was toevaluate the effect of health education toward knowledge, attitude and medication regiment adherence amongst clients with hypertensive disease.

The study utilized quasi experimental pre-test andpost-test design.

There was an effect to the knowledge and attitude before and after health education. The effect of knowledge and attitude to self-report medication adherence behavior were both significant. There was no effect of health education on knowledge when adjusted with gender, age and education level likewise with attitude when adjusted with age and education level except gender was influenced by the treatment.

Key words: health education, knowledge, attitude, medication adherence,

Hypertension


Chapter I

THE PROBLEM AND ITS BACKGROUND

Introduction

Hypertension is an imperative global public-health

challenge since of its high incidence and concomitant

risks of cardiovascular and kidney disease (Whelton

and He, 1997; Whelton, 1994, in Kearney, Whelton,

Reynolds et al, 2005). It has been identified as the

leading risk factor for mortality, and is ranked third

as a cause of disability-adjusted life-years in

Kearney, Whelton, Reynolds et al, (2005) as cited by

Ezzati, Lopez, Rodgers, Vander Hoom and Murray (2002).

The prevalence of hypertension in various regions of


the world has been widely reported (Ueshime, Zhang &

Choudbury, 2000; Singh, Suh, Singh et al, 2000;

Hernandez-Hernandez, Armas-Padilla, Armas-Hernandez &

Velasco, 2000; Halberstein, 1999; Gupta, 1999; Wolf-

Maier, Cooper, Banegas et al, 2003 in Kearney,

Whelton, Reynolds et al, 2005). According to World

Health Organization Europe survey, hypertension

remains a major health problem in most countries due

to its impact on the population attributable to

mortality and morbidity due to insufficient

hypertension prevention and control at the community

level (Murray and Lopez, 2005). The mortality rate is

accounted for more than 5.8% of total deaths; 1.9% of

years of life lost and 1.4% disability adjusted life

years all over the world; it affects about 20% of

adult world wide (Heneghan, 2007) and by 2025 it is

projected that 29% of the world’s population (over

1.56 billion adults) will have hypertension.

Hypertension is categorized under chronic disease


since it is a lifelong disease (Lewanczuk, 2008) and

other examples of chronic disease that need a long

treatment are diabetes mellitus type 2, renal disease,

Asthma, Chronic Obstruction Pulmonary Disease (COPD),

and HIV/AIDS. A study of the burden of chronic

diseases in twenty-three low-and middle-income

countries posits that chronic disease is responsible

for 50 percent of the disease burden in 2005 and

estimates an economic loss of almost $84 billion (U.S.

dollars) between 2006 and 2015 if nothing is done to

address the burden (Mathers and Loncar, 2006).

According to Endang Rahayu Sedyaningsih the

disease prevalence of hypertension in Indonesia had an

average of 31 percent (which means from ten individuals

there will about three individuals diagnosed as having

of hypertension disease) and accounted for over six

percent of deaths in all ages of the population

(National Basic Health Research Ministrys 2007 as cited

by Endang, at the National Jakarta Post). The research


result also pointing out that the curve line of

hypertension incidence in Indonesia is expected to

elevate as the age advances. (Endang, S., as cited in

the Jakarta post magazine).

Since the researcher interest study is at one of

the North Sulawesi regency level which is North

Minahasa thus, the most recent annual data statistic

as per ten most leading diseases found among it was

hypertension (DHO, 2009); precisely the disease rank

second from the ten top leading diseases with a total

sum of 16, 024 patients.

There are numerous and varies reason as for the

hypertension high rate contributions; related

literatures highlighted on life-style (Gascon et al,

2004) but, mark highest on low regimen adherence

(Morisky, Bowler, and Finlay; Gascon et al; Klein,

Walker and Macleod). The World Health Organization

(WHO) referred to non-adherence as “a worldwide

problem of striking magnitude” and improving adherence


to medication has become a priority for health care

researchers and policy makers in Hayne, Akloo, Sahota,

Mcdonald &Yao report (as cited in Clifford, Garfield,

Eliiason & Barner, 2010). Researchers suggest that

30-50% of patients do not take their medication for

chronic conditions as prescribed (Home, Barner,

Weiman, Elliot, Morgan and Cribb, in Clifford, et al.,

2010). The cost of non-adherence to patients is a

missed opportunity for treatment gain and, if their

condition worsens, a possible decline in their quality

of life. Costs also arise from the perpective of the

health care system in England; the cost of unused or

unwanted medications exceeds GBP 100 million annually

(Cantrell, Eaddy, Regan and Sokol in Clifford et al

2010). Furthermore, the increased likelihood of

hospitalizations and

complications as a result of non-adherence can also

increase costs. According to Gascon et al (2004) lack

of comprehensive explanation about hypertension


disease contribute to the low adherence as well as to

the attitude. Survey on Knowledge, Attitude and

Practice (KAP) on hypertension was conducted at

Seychelles by Aubert, et al (1998) confirm that

knowledge on hypertension was good among the

hypertension clients however; the proportion in

regards to attitude and practice in terms of adopting

healthier life-style was smaller among the

hypertension clients; and none of the survey variables

draw on regimen adherence. Numbers of studies had

been done in order to find out factors contribution to

the low medical adherence among hypertension clients

in other coutries (Al-Mehza, Al-Muhailije, Khalfan,

Al-Yahya, .(2009); Gascon, Sanchez-Ortuno, Montserrat,

Lior, Skidmore, Saturno (2004); Osteberg and Blaschke

(2005); Bin Abdullah (2007) however none of it has

attempt to analyze the effect of health education

intervention which, include knowledge and attitude to

the medical regimen adherence of clients with


hypertension disease in Indonesia particularly at one

of the sub district of regency North Minahasa,

provincial North Sulawesi. To such reason, the

research study was conducted.


Research Problem Statement

1. To determine the outcomes of the health

education intervention on the knowledge of

clients with high blood pressure

2. To determine the outcomes of the knowledge of

clients with high blood pressure on medical

adherence behavior

3. To determine the difference in the outcomes of

health education nursing intervention in the

knowledge of clients with high blood pressure

before and after intervention based on the

following factor influencer:

a. Gender

b. Age

c. Education background

4. To determine the outcomes of the health

education intervention on the attitude of

clients with high blood pressure


5. To determine the outcomes of the attitude of

clients with high blood pressure on medical

adherence behavior

6. To determine the difference in the outcomes of

health education nursing intervention in

attitude of clients with high blood pressure

before and after intervention based on the

following factor influencer:

a. Gender

b. Age

c. Education background

Goal of the study:

To Community

The research study will benefit public about the

relation between knowledge, attitude and medical

adherence on hypertension disease as well as to


enlightening clients’ wth hypertension disease in order

to comply with the physician prescription through

health education intervention.

To the Education Institution

The research study will hopefully give a

significant contribution to the education institution,

especially the Nursing Fakulties as it stands on the

behalf Nursing College students about the effect of

health education on knowledge, attitude and medical

adherence amongst hypertension clients.

To the Researcher and Knowledge Development

The research study will confidently give a

significant contribution to the researcher in terms of

gain experience in conducting the study as well as to

the gain knowledge itself. The study will hopefully


give a significant contribution to the knowledge

development in nursing subject in terms of increase

adherence to the antihypertensive medication amongst

hypertension clients.

Scope and limitation of the study

Only clients with essential or primary

hypertension disease (without co-morbid disease) were

choosen to receive intervention. Respondents’ age

were limited to ≥18 years and have taken at least

three times blood pressure examinations. Clients was

labeled as uncontrol hypertensive if the mean of the

three measures of systolic blood pressure (SBP) is

≥140 mmHg and/or diastolic blood pressure (DBP) is ≥90

mmHg other limitation is the time given between the

pretest and posttest as to observe the study effect


was two weeks due to financial and time constraint of

the researcher.

The study findings were limited in

generalizability because the study was conducted in

one village, in a selected geographic location with

limited number of subjects. The intent of this study

is to find causality between the natures of medication

adherence with selected intrapersonal factors using a

medium of health education; thus, the study will not

provide a complete understanding of the nature of

medication adherence. The data is a structured

questionnaire which design to withdraw responds which

basically will be subjective in nature; thus to this,

the researcher unable to guarantee the respondent’s

truthfulness. The respondents will be clients having

a hypertension disease within the working area of

North Minahasa; able to communicate and willing to

fill up the questionnaire. If the client unable to

participate then the family will be asked the


question, while for client who refuse shall not be

used as a valid respondents.

Definitions of Operational Terms

Health education Intervention

Health education intervention is a teaching

component to a selected people with the define disease

in a housing setting and by an appointment. The aim of

the intervention is to give information and thus, the

participant may increase in knowledge about the disease

issues; and may have a new and positive outlook of the

disease as well. Both of the researcher and the

participant are expected to be active in giving

responds and raising questions.

Knowledege, Attitude and medical adherence


Knowledge in here is the information in regards to

the disease in nature, causes, classification and

prevention. In this context, the participant may gain

information as to the disease they have and now how to

anticipate.

Attitude is the perception or how a person sees or

value. In here the outlook of the participant is

influence by the disease information given and thus, it

will intrernalized to each of the participant and sees

it as positive.

Non adherence define in this study as being absent

or not showing up on appointment time for follow up and

not taking treatment medication <80% of the prescribed

anti-hypertensive drugs.

Vital Sign Intervention


Vital Sign intervention is the sign of life which

is recorded by the health officer in order to analize

the basic body function as this may give a clue to a

certain organs working condition which is translated in

numbers.

Sistolic is the number obtained while the heart

muscle contracted through a blood pressure instrument

using sphygmomanometer and stethoscope.

Diastolic is the number obtain while the heart

relaxing through a blood pressure instrument using

sphygmomanometer and stethoscope.

Hypertensive Client is a client resides in a

community while having the hypertension disease.

Confounding Variable Intervention


There are number of factors which influence

someone health statuses such as behavior or practice

and values. Mediation which may influence the

knowledge, attitude and medical adherence:

Gender is a physical and spiritual aspect which

differentiates two human beings as a female and a male

or a woman and a man. This cover all sex types (man and

woman) and these differences will be used to know if

there is a difference in knowledge, attitude and

medical adherences.

Age is the phase of individual development which

measures the length of life from birth until present.

This is to refer the respondent with below or equal 50

to over 60 years; where age differences will be used to

identify knowledge, attitude and medical adherences.


Education Attainment is a continuation education

process from a high adjustment and intelligent

development, emotional and humanity. In this context

it refer to the level attainment of each respondent

from no school, Elementary, Junior High School, Senior

High School, College and Graduate Studies which will be

used to identify differences to the knowledge, attitude

and medical adherence experienced.

Chapter II

REVIEW OF LITERATURE

This chapter analyzes theoretical framework of

health education, knowledge, attitude and adherence to

regimens medication, including supporting variables of

hypertension disease both pathologically and medically

explain. Nevertheless Beker’s Health Believe Model as

the researcher chosen foundation to the theoretical

framework will be concisely described and enclosed the

chapter with summary.


Health Education

Health education is a common term used in health

related areas mostly at community setting. The

researcher will utilized community as the target

participants; thus, the following subjects will

describe range of definition, goal, scope, methods,

models and media of health education based on community

Definition of Health Education

The following definitions are derived from various

related literatures. Health education according to

Griffiths, “health education attempts to close the gap

between what is known about optimum health practice and

that which is actually practiced.” (Griffith, 1972).

According to Simonds health education is “bringing

about behavior changes in individual, groups, and


larger populations from behaviors that are presumed to

be detrimental to health, to behavior that is conducive

to present future health.” (Simonds, 1976). Green et al

look at health education as “any combination of

learning experiences designed to facilitate voluntary

adaptations of behavior conducive to health (Green,

Kreuter, Partridge, and Deeds, 1980). At the

prespective of Project Preparation and Practice of

health Educators health education is a “process of

assisting individuals, acting separately or

collectively, to make informed decisions about matters

affecting their personal health and that of others”

(National Task Force on the Preparation and Practice of

Health Educators, 1985).

Scope of Health Education

Scope of health education described by Griffith

(1972) stated as “health education is concerned not


only with individuals and their families, but also with

the institutions and social conditions that impede or

facilitate individuals toward achieving optimum

health”. Green and Keuter’s PRECEDE/PROCEED Model

(2005), addresses the multiple forces that affect

health. Most recently, experts have explicitly

recommended that interventions on social and behavioral

factors related to health should link multiple livels

of influence, including the individual, interpersonal,

institutional, community, and policy levels (Smedley

and Syme, 2000). In this context, the meaning of

health education and health behavior is interchangeable

and intertwined.

Methods of health education

Cited from Notoatmodjo in Rejeki, Mandane,

Pasulle, Tamalawe, and Rondonuwu (2010) health

education methods are classified into three parts:


Individual, group and public or mass. The former

approach is utilizing coach system which, coaching

someone who got interested to learn a new behavior.

Basic acceptance of new behavior to every person has a

various reasons. Notoatmodjo suggested health workers

to know exactly the system in order to assist

individual needs to use educational methods. Kinds of

coaching system include guidance, counseling,

counseling (guidance and counseling sessions) and

interviews are being used currently. The latter

approach is focusing to the size or number of

individual in a target group. Notoatmodjo suggested

that if the participants have more than 15 individuals

than the effective educational methods for such size is

either lecture or seminar. Meanwhile for number

participants less than 15 individuals the effective

educational methods are brainstorming, snowballs or

play and simulation. The last approach is a means of

mass communication; the target group does not focusing


individual’s age, gender, educational level and

socioeconomic statutes but, how general public be

imbued.

Models of health education

There are various health education models in

attempt to explain by modifying or enhancing health

behavior. In this research paper, the researcher

deliberately chose to explain in the light of community

approach – the PRECEDE model (part of PRECED/PROCEED

model) and health belief model. The former model is

utilizing problem solving approach that begins with

identifying social, behavioral and environmental

factors that affects quality of life which by means to

determine the health measures to be taken. The latter

model appropriate for personal approach which assuming

every person are protecting themselves by threat

avoidance (Pender, 1996).


Media of health education

Harjanto in Rejeki, et al (2010) defines health

education media as tools of communication and teaching,

particularly in raltion to issues of teaching and

learning process. Meanwhile, according to Mubarak et

al (2007) as something that is delivering the message

and able to stimulate the thoughts, feelings and

interest of the audience; thus, overall able to

stimulate the learning process in itself. Edgar Dale

in Sumijatun et al (2005) divides the props into the

eleven forms, which also describes the intensity of

each tool in a cone. Of the cone is seen that in the

educational process, the original object has the

highest intensity to project the perspective

educational materials or teaching.


Figure 2.1 Edgar Dale Cone

There are benefits drawn from utilizing educational

media as Sumijatun, et al in Rejeki, et al (2010)

suggested such as:

1. Generate interest in educational goals.

2. Achieve more. Assist in overcoming language

barriers.

3. Stimulate the target of health education to

forward a message received on others.


4. Facilitate the delivery of language education

or information.

5. Encourage the person’s desire to know.

6. Implement the knowledge gained.


Knowledge

Knowledge is the result of human effort process to

recognize and this is the result of the familiarity,

consciousness, awareness, understanding and cleverness.

Where it must be true otherwise, it is a contradiction.

Work out occurred after the person commits to a

particular object sensing. Sensing occurs through the

human senses, namely the senses of sight, hearing,

smell, taste, and touch. Most human knowledge is

obtained through the eyes and ears (Burhanuddin in

Rejeki, et al 2010; Notoatmodjo in Rejeki, et al 2010).

It is and important responsibility of nurses to

provide knowledge to patients, patient’s family and

community about the importance of prevention, adjusting

to a new healthy lifestyle and the importance of

medical compliance to clients with chronic diseases

which is life threatening if not prevented and treated

(WHO, 2005).


Knowledge Level

Knowledge is varying from one individual to

another individual According to Notoatmodjo (2003); and

the differences divided into several levels, such as:

1) Know (Know). Interpret material that has

been studied previously, namely recall

(recall) something specific from the entire

material has been learned or stimulus that

has been accepted.

2) Understanding (comprehension). Is the

ability to explain properly the known

objects, and correctly interpret the material

3) Application (application). Defined as the

ability of using materials that have been

learned in actual situations or conditions

(real).


4) Analysis (analysis). That is an ability to

describe material and translate objects into

components within an organizational

structure.

5) Synthesis (synthesis). Showed the ability to

place or connect parts into a new form.

6) Evaluation (evaluation). Relate the ability

to conduct assessment of material or object.

Health Knowledge Level Indicators

According Notoatmodjo (2003), health knowledge

level of indicators is divided into:

1) Knowledge of illness and disease cover the

causes, signs and symptoms, treatment, mode of

transmission and prevention of disease.

2) Knowledge of health care and healthy

lifestyle; covers the benefits of foods and nutritious

food; the importance of sports; danger of smoking,


alcohol and drugs; the importance of adequate rest,

relaxation and recreation.

3) Knowledge of environmental health is an area

covers the benefits of clean water, healthy way of

waste disposal, pollution, lighting and lighting

benefits of a healthy home.

Factors Affecting Knowledge

1. Educational Background

Samal, Greisengger, Auf, Lang, and Lalouscheck

(2007) studied on five hundred ninety-one consecutive

patients with stroke and with medical history of

hypertension. They were interviewed about knowledge

concerning hypertension within a multicenter hospital-

based stroke registry.

Greisengger found out 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 140mmHg or less as the maximum tolerated

systolic blood pressure, and 53% had their blood

pressure only controlled monthly or less often.

Greisengger and colleagues conclude educational level

was significantly associated with knowledge of

increased risk, possible consequences of hypertension,

and knowledge about nonmedication treatment options.

Qureshi, Hatcher, Chaturvedi, and Jafar (2007) on their

study to find out the effect of general practitioner

education to adherence hypertensive drugs uses 200

patients, and 178 (89%) successfully completed six

weeks of follow-up. The result study showed adherence

was higher among patients who had higher levels of

education (P<0.001). Viera, Cohen, Mitchell, and

Sloane (2008) sought to assess primary care patients’

current knowledge about various aspects of high blood

pressure (BP). It was mailed questionnaire approach to


700 hypertensive patients enrolled in a practice-based

research network cohort from 24 practices in North

Carolina. The result showed independent associations

with lower hypertension knowledge was having less than

high school education (odds ratio, 2.43; 95%CI, 1.34-

4.41).

2. Age

Descriptive study conducted by Cingil, Delen, and

Aksuoglu (2009) was performed in hypertensive patients

to determine their level of knowledge on, and attitudes

to drug use. The study was carried out in 194 patients

(144 women, 50 men) who had been on antihypertensive

treatment for at least a year. The mean duration of

hypertension was 6.3+/-5.7 years. Data were collected

using a questionnaire on sociodemographic

characteristics and level of knowledge on, and

attitudes to drug use. Of the participants, 70.1% were

at the age of 50 years or beyond. Fifty-six patients


(28.9%) were found to have a poor compliance with drug

use.

Noncompliance showed a significant association with age

being 43.1% and 22.8% in the age groups of =/<49 years

and =/>50 years. Compliance was significantly

correlated with the delivery of information to the

patients on the dose, the right time, and the

properties of the drugs prescribed. Multivariate

logistic regression analysis showed that age =/<49

years and lack of knowledge on the right time of drug

intake were independent risk factors contributing to

irregular drug use. The incidences of nonadherence

were 2.916-fold (95% CI 1.415-6.009) and 8.964-fold

(95% CI 2.164-37.127) higher in the age group of =/<49

years, and in those who did not know the right of drug

intake, respectively.

3. Gender


Study done by Cingil, et al (2009) was performed

in hypertensive patients to determine their level of

knowledge on, and attitude to drug use. The study was

carried out in 194 patients (144 women, 50 men) who had

been on antihypertensive treatment for at least a year.

The mean duration of hypertension was 6.3+-5.7 years.

Data were collected using a questionnaire on

sociodemographic characteristics and level of knowledge

on, and attitudes to drug use. .Noncompliance showed a

significant association with gender, being 34.7% and

12% women and men, respectively.


Attitude

Attitude is a reaction or response from someone

who is still closed to a stimulus or object

(Notoatmodjo, 2003). There also are interpreted as

evaluative statements either desirable or undesirable

about the object, person, or event (Robbins, 2003).

Attitude Levels

Attitude consists of several levels (Notoatmodjo,

2003): Receiving (Receiving). Mean that person or

subject to and pay attention to the stimulus provided.

Responding (responding). Give an answer when asked,

doing, and complete the given task is an indication of

the attitude.

Appreciate (valuing). Inviting others involved to

discuss and work on a problem.

Accountable (responsible). Responsible for everything

that has been created and selected with all the risks,

is the attitude of most high.


Health Attitude Indicator

Several indicators of health attitudes by

Notoatmodjo (2003):

Attitudes toward pain and disease. How can anyone

judge or argue about; symptoms or signs of disease, the

cause of the transmission, prevention of diseases and

so forth.

Attitudes and ways how to maintain healthy living. How

anyone can judge and argue about how to maintain

healthy living and behaving.

Attitudes towards environmental health. How a person

expresses himself or makes judgments on the environment

and its effects on health.

Attitude is always related to an object, and is

accompanied by positive feelings when it was valued in

his view, or negative when considered worthless or too

costly. This then underlie and lead to a number of

actions that relate to each other. Even so, one can


only have attitudes toward things that are learned. So

there should be information on someone or something.

If based on that information resulting positive or

negative feelings toward the object and cause a

tendency to behave in particular, there is the attitude

(Slamento, 2003).

Factors Affecting Attitude

1. Educational Background

Gacson, et al., (2004) regardless of educational

background, there is no differences to the attitude

however, Kubir, et al., (2004) found out on the other

way around that education has more positive attitude

compare to the no education.

2. Age


Wibowo (2009) in his research found that the

result in different age groups there was no difference

in attitude.

3. Gender

Hoa (2003) in Vietnam and Wang (2008) in China

found no relationship between attitudes and gender,

where women have a more positive attitude in dealing

with tuberculosis disease.

Adherence to Hypertension Treatments

Clinical trials (efficacy studies) have

demonstrated that blood pressure possible to be

controlled in 70% to 80% of patients when there is a

close follow up and forced drug titration (Black et

al., 2001; Carter et al., 1994; Carter & Zillich, 2004;

Griam et al., 2001; Hanson et al., 2998).

Oliveria and coworkers found that patient factors

(adherence, patient acceptance, regimen complexity)


were uncommon (90%) barriers cited by physicians or

patients (Oliveria, et al., 2002). One study conducted

in patients referred to a specializes hypertension

center found that most common reason for resistant

blood pressure were drug- related, including sub

optimal regimens 61%, patient nonadherence 13%,

secondary hypertension 7% and others 18% (Garg, Folker,

Izhar, Elliot & Black, 2002)


Hypertension

Hypertension defined by McCance and Huether, 2006

in Peate and Muralitharan (2009) as a sustained

elevation in systemic arterial blood pressure; the

elevation maybe either systolic or diastolic pressure

or in both pressures. A normal upper limit for an

adult is 130-139/85-89 mmHg (Alexander et al., 2006)

and any readings consistent with the above are

considered as hypertension. Slightly differ with the

view of the Joint National Committee (2005) which

defined hypertension beginning at 140/90 mmHg for

adults aged 18 or older. On 2005, the Seventh Report

of the Joint National Committee on Prevention,

Detection, Evaluation and Treatment of High Blood

Pressure had made significant changes in classifying

blood pressure in adults aged 18 or older. The new

classification for normal adult blood pressure is less

than 120 mmHg systolic and less than 80mmHg diastolic.


The classification is based on the average of ≥2 seated

blood pressure measurements, properly measured with

well-maintained equipment, at each of ≥2 visits to the

officer or clinic (Joint National Committee, 2005).

Chobanian, et al., 2003 in Huether and McCance, (2008)

described the new classification of blood pressure

stages as presented in Table 1.

Individual are diagnosed as having hypertension

when the average of two or more diastolic blood

pressure measurement made on three consecutive visit is

90mm Hg or higher or when the average systolic pressure

measurements made on three consecutive visits is

greater than 140 mm Hg (Huether and Kathryn, 2000;

Pickering, et al., 2005) however the latter author

clearly add the “seated blood pressure measurement” has

to be under-taken to the procedure prior to the

diagnose. Normal blood pressure is associated with the

lowest cardiovascular risk, whereas those who fall into

prehypertension category are at 90% risk for developing


hypertension unless lifestyle modification is

instituted (Chobanian, et al., 2003 in Huether and

McCance, 2008). All stages are associated with

increased risk for target organ disease events, such as

myocardial infarciton, kidney disease, and stroke;

hence both stage I and II hypertension need effective

long-term therapy (Chobanian, et al., 2003 in Huether

and McCance, 2008). Mensah, et al., 2005 in Huether

and McCance (2008) conducted research study at USA

about “States disparities in cardiovascular health” and

found out that age and blacks compare to the whites had

increased prevalence in essential hypertension.

McCance and Huether (2008) succinctly added to the

classification that individuals may have combined

systolic and diastolic hypertension or isolated

systolic hypertension, which in most cases a

hypertension (also called as essential or idiopathic

hypertension). Primary or "essential" hypertension has

no known cause, however genetic and certain lifestyle


factors such as body weight and salt intake are

involved. Ninety five percent of persons diagnosed with

hypertension fall into this category. The diagnosis is

made when no other cause is found. Secondary

hypertension is caused by some other medical diagnosis

or problem, such as kidney disease, Cushing's syndrome,

pregnancy, oral contraceptive use, chronic alcohol

abuse or the use of certain medications (O’Connell,

1999).

The mechanism blood pressure in a body is part of

the systemic arterial pressure which, is a by product

of cardiac output (CO) and total peripheral vascular

resistance (PVR). Cardiac output is determined by the

stoke volume and heart rate (CO=SV X HR). Control of

peripheral vascular resistance, vessel constriction or

dilation is maintained by the automatic nervous system

and circulating hormones (Ignatavicus and Workman,

2006).


Table 2.1 Classification of blood pressure foradults age 18 years and older

Category Systolic (mmHg)

Diastolic (mmHg)

Normal* Less than 120And

Less than 80

Prehypertension 120-139Or

80-89

Hypertension

Stage 1 140-159 Or

90-99

Stage 2 160 or higher Or

100 or higher

*Unusually low readings should be evaluated for clinical significance.

(From the Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, 2005).


Epidemiology perspective

National health surveys in various countries have

shown a high prevalence of poor control of hypertension

(WHO, 1999). These studies have reported that

prevalence of hypertension is 22% in Canada, of which

16% is controlled; 26.3% in Egypt, of which 8% is

controlled; and 13.6% in China, of which 3% is

controlled. Specific prevalence and incidence data of

Indonesia so far scarce to find due to classification

system of non communicable disease such as hypertension

is a part of Artery Coronary diseases. However, from

the annual review public health on ‘Hypertension:

Trends in Prevalence, Incidence and Control’ conducted

by Hajjar et al (2006), he and colleagues investigation

on data based population noted that prevalence of the

disease increasing worldwide. “It was estimated 972

million people suffered with hypertension. The

incidence rate of hypertension range between 3% to 18%


depending on age, gender, ethnicity and body size of

the population studied” (Hajjar et al, 2006).

Hypertension is a worldwide epidemic; in many

countries, 50% of the population older than 60 years

has hypertension. The 20% prevalence is for

hypertension defined as blood pressure in excess of

140/90 mm Hg. The prevalence dramatically increases in

patients older than 60 years.

According to Muralitharan and Peate (2009) data at

the National Health and Nutrition Examination Survey

(NHANES), record at least 65 million adult Americans,

or nearly one-third of the US adult population, have

hypertension, defined as a systolic blood pressure 140

mm Hg, diastolic blood pressure 90 mm Hg, and /or

current use of antihypertensive medication. Another

one-quarter of US adults have blood pressure in the

“prehyperteansion” range, a systolic blood pressure of

120 to 139 mm Hg or diastolic blood pressure of 80 to

89 mm Hg, ie, a level above normal yet below the


hypertensive range. The prevalence of hypertension

rises progressively with age, such that more than half

of all Americans aged 65 years or older have

hypertension. Other sources from the evidence based

done by Brashers (2006) pointed that hypertension is a

risk factor for coronary artery disease, congestive

heart failure, stroke and renal failure. Further noted

the optimal blood pressure is 115/75 mm Hg (Dreiscbach,

2010) and at each 20-mm Hg increase in systolic

pressure or 10-mm Hg increase in diastolic pressure

above normal increases cardiovascular risk twofold

(Brashers, 2006; Dreisbach, 2010)


Factors associated with primary hypertension

A specific cause for primary hypertension has not

been identified, and a combination of genetic and

environmental factors is thought to be responsible for

its development. Genetic predisposition to hypertension

is thought to be polygenic. The inherited defects are

associated with renal sodium excretion, insulin and

insulin sensitivity, activity of the rennin-

angiotensin-aldosterone system, cell membrane sodium or

calcium transport, and sympathetic response to

neurogenic hormones (Cowley, 1997 in Hueter and Mc

Cance, 2003). A mutation in the adducing gene has been

linked to changes in renal tubular sodium transport and

hypertension. Adducin is a membrane skeleton protein

that plays an important role in the determination of

cellular morphology and motility in the regulation of

membrane ion transport; mutation of the gene that codes

adducing cause an increase in tubular renal


reabsorption of sodium; the person with this mutation

more likely will exhibit salt sensitivity and more

likely to respond to diuretic treatment (Bianchi and

Tripodi, 2003). Factors associated with primary

hypertension include: family history of hypertension;

advancing age; gender (more common in men than women

before age 55 years, more common in women after age

55); black race; high dietary sodium intake (more

than60 mEq.day); glucose intolerance; cigarette

smoking; obesity; heavy alcohol consumption; and low

dietary intake of potassium, calcium, and magnesium

(Huether and Mc Cance, 2008; Muralitharan and Peate,

2009)


Clinical Manifestations

According to Bullock and Henze, 2000 in

Muralitharan and Peate (2009) for most patients are

unaware that they have hypertension and thus go

untreated. They ignore symptoms such as headache,

dizziness, nosebleed and fatigue. Frequently through

blood pressure screening or found out from other

disease that the person(s) finally discovered. Other

signs and symptoms that happened to some patients

reported to have blurred vision and tinnitus, however

thse signs do occur late since the disease has already

in the advance stage. This is more precisely explain

by Huenther and Mc Cance (2008) that during the initial

stages or “latent stage” (Price and Wilson, 2003) of

hypertension, there are no clinical manifestations

exhibits except for an elevated blood pressure neither

there are signs and symptoms that prompt patients to

seek medical care; and often found out too late or


resulting in deaths; hence hypertension is commonly

called as a ‘silent killer’.

Pathophysiology of Primary Hypertension

Primary hypertension is the result of cardiac

output and peripheral resistance are the two

determinants of arterial pressure (Richard, 2007)

cardiac output is determined by stroke volume and heart

rate; stroke volume is related to myocardial

contractility and to the size of the vascular

compartment. Peripheral resistance is determined by

functional and anatomic changes in small arteries and

arterioles.

Fig. 1.1., factors affecting arterial blood pressure.


Drug Therapy

According to Ignatavicius and Workman (2006), drug

medication is per individual basis meaning the

medications is administer based on person’s culture,


age, coexistent disease, severity of blood pressure

elevation, cost of medication and follow up

consultation.

Report from the Seventh Joint National Committee

on Preventation, Detection, Evaluation and Treatment of

High Blood Pressure 2003 guidelines and ot/her studies

stated that most clients with hypertension need two or

more medications to adequately control the goal of

blood pressure of less than 140/90 mm Hg; or 130/80 mm

Hg for clients with diabetes or renal disease. (Joint

National Committee, 2003; Feldman, et al., 2009;

Gradman, 2009). Taken for example of the low cost

thiazide-type of diuretics; clients who suffer

essential or primary hypertension may choose this drug

as a single agent or in combination with other classes

drugs.

The JNC recommends starting any antihypertensive

drug at the lowest possible dose and gradually

increasing it until blood pressure sinks to a normal


level. If the drug doesn’t lower pressure or if it

causes troublesome side effects, it should be replaced

with a different medication (JNC, 2003). The usual

course of treatment for stage 1 hypertension is to

begin with one drug and add a second if your blood

pressure does not decrease to desired levels (usually

less than 140/90 mm Hg; less than 130/80 mm Hg for

those with diabetes or chronic kidney disease). The

treatment for stage 2 hypertension often begins with a

two-drug combination. A third may be added if the

blood pressure doesn’t drop to an acceptable level.

With all stages of hypertension, and even pre-

hypertension, lifestyle changes are also an important

component of treatment (Fuchs, 2010; Rusko, 2010).

There are several classifications of medications

available to control hypertension

Diuretics


Diuretics, commonly called “water pills,” are the

oldest and least expensive class of drugs used to treat

hypertension. They help the kidneys eliminate sodium

and water from the body. This process decreases blood

volume, so the heart has less to pump with each beat,

which in turn lowers blood pressure. Loop diuretics,

which act on the part of the kidney tubules called the

loop of Henle, block sodium and chloride from being

reabsorbed from the tubule into the bloodstream.

Thiazide diuretics act on another portion of the kidney

tubules to stop sodium from reentering circulation

(Pri-Med Patient education center, 2009)

One drawback of diuretics is they deplete

potassium, thus, the comsumer may need potassium

supplements. Doctors sometimes prescribe another type

of diuretic, called potassium-sparing diuretics, to

counteract potassium depletion. However, these drugs

can cause dangerously high levels of potassium in some

patients.


Diuretics are especially effective for salt-

sensitive patients with hypertension and older patients

with isolated systolic hypertension. Aside from

hypertension, diuretics are often prescribed for fluid

retention (edema) caused by heart failure, kidney

disorders, liver disease, or premenstrual bloating.

According to the May 2003 JNC report, diuretics

are very effective and underused. JNC recommends that

thiazide diuretics be the initial drug used for most

people with hypertension, and suggests that these

medications to control their blood pressure.

Pri-Med Patient Education Center suggests common

side effects of these drugs include frequent urination,

lightheadedness, fatigue, diarrhea or constipation, and

muscle cramps. Men may occasionally experience

erectile dysfunction. Diuretics can cause gout, a

painful form of arthristis caused by the buildup of


uric acid in the body, because they elevate blood

levels of this substance.

Anti-adrenergics

The pri-med patient education center suggests

Anti-adrenergics lower blood pressure by limiting the

action of the homones epinephrine and norepinephrine,

thereby relaxing the blood vessels and reducing the

speed and force of the heart’s contractions. They

include peripheral nerve acting agents, peripheral

adrenergic receptor blockers, and centrally acting

agents.

Peripheral acting agents

These anti-adrenergics (now used far less often

because of frequent side effects) deplete the autonomic

nerves of norepinephrine, a substance that causes


vessels to contract and raises blood pressure. Such

drugs are usually prescribed along with other

antihypertensives since they are more effective this

way. Reserpine (Serpalan) can cause depression,

nightmares, nasal stffiness, and indigestion, while

guanethidine (Ismelin) is more apt to bring on a drop

in blood pressure upon standing up (orthostatic

hypertension) (Pri-Med Patient Education Center, 2009)

Peripheral adrenergic receptor blockers.

These drugs work by preventing neurotransmitters

from attaching to cells and stimulating the heart and

blood vessels. They are divided into two major groups:

beta blockers and alpha blockers. Beta blockers, which

have been used since the 1960s, lock on to cell

structures called beta receptors – the same receptors

that certain neurotransmitters (primarily epinephrine)

normally attach themselves to in order to stimulate the

heart. Thus, by preventing the neurotransmitters from


activating heart cells, beta blockers cause the heart

rate to slow and blood pressure to fall. Beta blockers

come in two varieties: cardioselective and

nonselective. Cardioselective beta blockers attach

primarily to beta-1 receptors in the heart.

Nonselective beta blockers attach to beta-1 receptors

and beta-2 receptors, which are found in the lungs,

blood vessels, and other tissues. Either type of beta

blocker can worsen asthma or other chornic lung

disorders, but the nonselective agents are potentially

more dangerous for people with respiratory problems.

Beta blockers can also worsen heart failure in some

patients, while improving it in others. They can mask

the warning signs of hypoglycemia (low blood sugar) in

patients with diabetes. The most common side effects

of beta blockers are fatigue, depression, erectile

dysfunction, shortness of breath, insomnia, and reduced

tolerance for exercise.


Alpha blockers are similar in action to beta

blockers, but they work on alpha receptors --- the

sites where neurotransmitters that cause vessel

constriction (primarily norepinephrine) attach

themselves. Drugs called alpha-1 blockers block alpha

receptors in the heart and blood vessels. They may be

especially useful for hypertensive patients with high

cholesterol. In addition to reducing blood pressure,

alpha-1 blockers also reduce “bad” LDL cholesterol

levels and increase “good” HDL cholesterol. They may

improve insulin sensitivity in patients with glucose

intolerance and hyperglycemia (high blood sugar). They

are also prescribed for men with benign prostatic

hyperplasia, a noncancerous enlargement of the prostate

gland, because these drugs relax smooth muscles

surrounding the prostate, relieving the constriction of

the urethra and easing urine flow.

Side effects of alpha blockers include orthostatic

hypotension, heart palpitations, dizziness, nasal


congestion, headaches, and dry mouth. These drugs can

also cause erectile dysfunction, although not as

frequently as some other blood pressure medications.

Some patients require both alpha and beta blockers to

control their blood pressure. The drugs labetalol

(Normodyne) and carvedilol (Coreg) have properties of

both.

Centrally acting agents

These agents block the neurotransmitters that

activate the sympathetic nervous system to increase

blood pressure. They include clonidine (Cataperes),

guanabenz (Wytensin), guanfacine (Tenex), and

methyldopa (Aldomet). Like peripheral nerve acting

agents, they are generally used in combination with

other blood pressure medicines. Common side effects

include abnormally low blood pressure when standing up,


dry mouth, depression, erectile dysfunction, and

sedation (Pri Med Patient Ediucation Center, 2009)

Direct-acting vasodilators

Direct-acting vasodilators relax the arterial

blood vessels. They act quickly and are often used in

emergencies. However, they can cause fluid retention

and tachycardia (fast heart rate), so doctors usually

prescribe them in combination with another blood

pressure medication that slows heart rate, such as a

cardioselective beta blocker. Hydralazine and

minoxidil, the direct-acting vasodilators most commonly

used to treat hypertension, can cause headaches,

weakness, flushing, and nausea. In addition, minoxidil

can cause hair growth, fluid retention, and

hyperglycemia (increased blood sugar).

Calcium-channel blockers


Calcium-channel blockers slow the movement of

calcium into the smooth-muscle cells of the heart and

blood vessels. This reduces the strength of heart

muscle contractions and dilation of blood vessels,

lowering blood pressure. Because calcium-channel

blockers also slow nerve impulses in the heart, they

are often prescribed for arrhythmias (irrregular

heartbeat). Common side effects of calcium-channel

blockers are headache, edema, hearburn, bradycardia

(slow heart rate), and constipation. (Pri Med Patient

Education Center, 2009)

ACE inhibitors

This class of drugs, inroduced in 1981, has proved

widely effective in treating hypertension. These

agents prevent kidneys from retaining sodium and water

by deactivating angiotensin-converting enzyme (ACE),

which converts inactive angiotensin I to the active

angiotensin II. Angiotensin II raises blood pressure


by triggering sodium and water retention and

constricting the arteries.

ACE inhibitors reduce blood pressure in most

patients and produce fewer side effects than many other

antihypertensive drugs. In addition, ACE inhibitors

protect the kidneys of people with diabetes and kidney

dysfunction and the hearts of people with congestive

heaert failure.

The most common side effects of these medications

are a reduced sense of taste and a dry cough. Rarely,

a patient can have difficulty breathing because of a

swelling of the lips, tongue, and throat. ACE

inhibitors can also cause potassium retention;

therefore, people with poor kidney function must use

them cautiously. Because these drugs can cause

spontaneous abortion, women who are pregnant or trying

to get pregnant should not take them.

Angiotensin II receptor blockers


This class of medication, approved for treating

hypertension since 1995, blocks angiotensin II from

constricting the blood vessels and stimulating salt and

water retention. Because angiotensin receptor blockers

are highly effective and well tolerated by most people

who take them, these medications have become quite

popular. They do not produce any of the traditional

side effects of other antihypertensive medications, and

they are less likely to cause like ACE inhibitors do.

In addition, like ACE inhibitors, they benefit patients

with diabetes, congestive heart failure, or both.

Health Center

Community Health Centres (PHC) is the functional

organization where people receive health services and

counseling about health. Organizes health efforts that

are comprehensive, integrated, equitable, with costs

which are borne by the government and soociety; to

achieve optimal health status for the public by not


ignoring the quality of service to individuals. The

institution is largely under the management of District

Health Office / Town (Great Dictionary of Indonesian

Languange, 2008).

Regency

District level autonomous region II led by a

regent and an office of a regent. A regency area is in

equal level with a city, which means, has an autonomous

region; has an authorization to regulate and manage the

affairs of the regency government. In here, the

regency affair is not accountable to the governor

(Great Dictionary of Indonesian Languange, 2008).

Synthesis

Studies by Feldman, Bacher, Campbell, Drover and

Chockalingam (1998) found out adherence to

pharmacologic therapy of hypertension is as low as 50%


to 70% and has an important implications both for blood

pressure control and cardiovascular complication. On

the other hand, in the similar study done by Osterberg

& Blasche (2005) entitled ” Adherence to

Medication”concluded poor adherence to medication

regimens is common, contributing to substantial

worsening of disease, death and increased health care

costs.

Health education intervention was underscrored for

the area of hypertension (Ascroft & Desai , 1978 and

Hassel, 1976 in Livingston 1985). In Hassel (1976) it

was identified that from 4, 322 participants adults

only 40 percent identified as hypertensive and aware of

it and of this, only 13 percent were on medication.

The need of health education was also tapped with

studies conducted by Yang, Yan and Bong (2002). In

their studies on ”Drug Compliance of Patients with

Hypertension and Countermeasures” one of the factors

that affect drug compliance is the lack of knowledge


about current prevalence for drug treatment of

hypertension and uncompliance to the doctor’s

prescription.

A prospective study was done by Khalil & Elzubier

(1997) on ”Drug compliance among hypertensive patients

in Tabuk, Saudia Arabia”. In this study pill-count

method was used to measure the study sample’s

compliance rate. The result showed 47 percent of the

study sample were uncomplied. The reason for

noncompliance includes the asymptomatic nature of

hypertension, a shortage of drugs, side effects,

forgetfulness and lack of health education.

There are many studies on the use of health

education and drug compliance, however the use of

variables knowledge, attitude and medical compliance

indicators have yet to be explored. This study

investigate the variable of health education

intervention and knowledge, attitude and medical

adherence indicators as dependent variables.


Theoritical Framework

Research study by Widyastuti in Rejeki, et al

(2010) on the effect of health education with lecture

and discussion methods concluded that there is

significant influence of health education to the

knowledge and attitudes of patients’ osteoarthtritis.

Likewise study conducted by Suryanti in Rejeki, et al

(2010) reported that health education with lecture and

discussion methods able to change the motivation of the

respondents in the experimental group

In Newman’s systems model, nursing is a “unique”

profession (Newman in Fitzpatrick, 2005, p. 196)

concern with “all variables affecting a client’s

possible or actual response to stressors”. Through

purposely interventions, nursing can help individuals,

families, and a group to “retain, attain, and maintain


a maximum level of optimal system wellness” (Newman in

Fitzpatrick, 2005, p. 197).

Hypertensive clients who has to take medication

continuously under the tertiary intervention and role

of nurse in this stage is to ‘help client to maintain

the current level of wellness” (Fitzpatrick, 2005, p.

197) in other words ‘the nurse serves as an active

participant by supporting the client’s defenses and

thereby assisting him or her to effectively respond to

the stressor (Fitzpatrick, 2005, p. 197). Watson sees

nursing as “collective caring-healing role and its

mission in society as attending to, and helping to

sustain, humanity and wholeness” (Watson in George,

2008, p. 406). Both theories hath similar perspective

in seeing nurse as an active, caring role in society.

Different perspective found from the model of health

belief. The model “addresses the individual’s

perceptions of the threat posed by a health problem

(susceptibility, severity), the benefits of avoiding


the threat, and factors influencing the decision to

act (barriers, cues to action, and self-efficacy).”

(Rimer and Glanz, 2005). The model touches the

intrapersonal level of an individual in order to seek

an understanding of individual’s behavior. The model

is relevant to the current study since the study is

using knowledge and attitude as several component of

individual’s adherence.


Conceptual Framework

Knowledge

Medicationregimen

AdherenceHealth

Education

Confoundingvariables:

a. Genderb. Agec. Educational

Attitude


Hypothesis Statements:

Ho1.a: there is no effect of health education to

knowledge amongst hypertensive clients.

Ho1.b: there is no effect of health education to

attitude amomgst hypertensive clients.

Ho2.a: there is no effect of knowledge to medication

adherence amongst hypertensive clients.

Ho2.b: there is no effect of attitude to medication

adherence amongst hypertensive clients.

Ho3.a: there is no effect of health education toward

knowledge based on pre and post test scores when the

following variables are considered:

a. Gender

b. Age

c. Educational background

Ho3.b: there is no effect of health education toward

attitude based on pre and post test scores when the

following variables are considered:

a. Gender


b. Age

c. Educational background


Chapter III

METHODOLOGY

This chapter describes the method, the research

design, setting, instrumentation and the data

gathering procedure

The Research design

The research deliberately uses quasi experimental

study as the design of her underlying framework study.

In this study design the research’s purpose is to

examine causality between the experimental treatment

(the independent variable) and the dependent

variables. It is a partial experimental design where

“at least one of the following components of true

experimental design is lacking (random sampling,

control groups and manipulation of the treatment).”

(Burns and Groove, 1993, P. 305); the researcher has

chosen to control the threats to the validity of the


study by controlling the treatment; the reliability

and validity measurement of the dependent variables

deliberately choose the nonequivalent control group

design specifically the one group pretest-posttest

design in controlling the threats .The nonequivalent

control group design by the researcher due to the

control group is not selected by random means (Burns

and Groove, 1993). The advantage of using the one

group pretest-posttest design is that both treatment

and dependent variables are in researcher control.

Pretest scores of treatment group is expected to serve

as a control group though the disadvantages is that it

may altered or threat the validity by “maturation

processes, administration of the pretest, changes

instrumentation and statistical regression.” (Burns

and Groove, 1993, P. 307). The researcher is also

using nonprobability sample design which is purposive

sampling process. The research design is constructed

as follow:


O1 X O2

O1 = pre test

O2 = post test

X= health education intervention

Treatment of the data

The selected clients answer questions on the

questionnaires which were used as the pretest to the

treatment. Information which, includes the modifying

variables such as: age, gender classification and

education attainment.

Data was analyzed using SPPS software. Ratio

scale in measuring and scaling the dependent variables

was utilized in order to find the effect of health

education on knowledge and attitude on medication

adherence of clients with hypertensive.


Ho1.a and Ho1.b, to know the effect of health

education to knowledge and attitudes amongst clients

with hypertensive using the formula:

T pair:

t=dsd√n

sd=∑ d2−¿¿¿¿

Description:

d= differences

d= mean differences

sd= standard deviation

n = sample size / population

T pair test, decision making is based on the value

that is, if p value <.05 then Ho is rejected

Ho2.a and Ho2.b, to know the effect of knowledge

and attitude to medication adherence amongst clients

with hypertensive using the following formula:

Model Regression: γ=βo+β1x


γ=dependentvariable

βo=¿ Constant

x=Independentvariable

t test formula: t = β1−Os √SSx

s=√ SSEn−2

SSE=SSy−β1SSxy

S= standard deviation

SSE= Sum of Square Error

SSx=Sum of square variable x (independent variable)

SSy=Sum of Square variable y (dependent variable)

SSxy=Sum of Square of multiplicative variable x and y

Regression Coeficients test decision making is

based on the value that is, if p value <.05 then Ho is

rejected.


Ho3.a and Ho3b in order to know the effect of

health education to knowledge and attitude based on

pre and post test scores when the confounding

variables such as age, gender and education attainment

are considered, two statistics tools are used.

Confounding variable of age and educational level

utilizes ANOVA; as for gender variable, Independent

sample T test is used.

The formula of ANOVA and Independent sample T

test written as follow:

ANOVA: F=MSbMSe

Independent sample T test: t=X1−X2SX1−X2

Participants in the study subjects

As the population to be used in this study is

medication compliance of hypertensive are in the

clients working area of North Minahasa, precisely at


district of Airmadidi Bawah and will for time to time

seek treatment assessment until November 2010.

Population and Sampling

There are one hundred thirty four (134) out-

patients with hypertensive cases found in HCC

Sawangan, Airmadidi, 2009. Sixty (60) subjects

consisted of adult male female age’s ≥ 18 years used

as the sample.

Sampling and Subject Allocation

Samples in this study is the whole object being

researched or considered to represent the entire

population with inclusion criteria are the general

characteristics of the subjects from a population

target that can be reached and studied, and exclusion

criteria is to eliminate or remove a subject that does

not meet the criteria for inclusion of a study for

various reasons (Nursalam, 2008).


The inclusion criteria in this study:

a. Respondents age 18 years and above

b. Respondents who are presently using

antihypertensive medication

c. Respondents who are diagnosed as essential

hypertensive disease

d. Respondents who seek treatment at Airmadidi

Bawah health center of North Minahasa regency.

e. Respondents who reside in the working area of

North Minahasa regency clinic.

Exclusion criteria in this study consisted of:

a. Respondents who are diagnosed as having

secondary hypertensive disease

b. Respondents in the unconscious state of mind

c. Respondents who refused to participates

Location

The existence of the respondents to be studied is

hypertensive patients who are located at the area of


north Minahasa regency Sawangan health community

center.

Data Collection

The 60 subjects were selected by a register nurse

from the health center.. The subjects were tested

before health education given. A lesson review was

given again on the following day in order to enhance

subjects’ understanding. A follow up test was given

after 14 days of the first test. Each subject

received questionnaire, as well as verbal instruction

on how to complete the instrument; the content of pre

test and post will be the same. The collection of

data obtained from primary data, is data obtained

directly through observation and interviews with the

respondents using a questionnaire. In the

questionnaire questions for the knowledge and

attitude, medication adherence, are separated and each

correct answer and one score.


1) Answer to question on the knowledge part

rated as one (1) if answer correctly; and rated as

zero (0) if the answer false. Set of Knowledge

questionnaire is adopted based on Abdullah (2008) in

tittle ‘Hypertension Knowledge and Adherence Study in

a Specialist Outpatient Medical Clinic in Miri

Hospital, Sarawak, Malaysia – A Pilot Study.

(Appendices C). Scores obtained from each question are

added and then divided by the number of questions;

then, the results were processed using SPPS software.

2) Answer to question on the attitude is adopted based

on questionnaire used by Abdullah (2008) in tittle

‘Hypertension Knowledge and Adherence Study In A

Specialist Outpatient Medical Clinic In Miri Hospital,

Sarawak, Malaysia – A Pilot Study in a form of Likert

scale which the value of strongly agree = 5, agree=4,

hesitated=2, disagree=2, strongly disagree=1

(appendices C). Values obtained from each column are

summed up and made up the average value-flat; the


results are processed using SPPS software. Test

validity and reliability were perfomed. Test of

validity utilizing Pearson r was significant (0.01) in

ten- items average. Test of reliability was also

performed with a Cronbach’s alpha of .84 as a result.

This reliability coefficient was much higher than the

score of .70 which commonly considered acceptable for

research purposes (Field, 2005; Franken & Wallen, 2003

in Rondonuwu, 2006). Eight-item of questionnaires on

medication adherence which adopted from eight-item

Morisky Medication Adherence Scale will be used to

monitor patients’ adherence to the prescribe

medication (appendices C). It is a closed question

and categorizes each correct answer as one (1) and

false answer as nil (0).

Each respondent will receive a demographic form

(appendices C) and a consent form including the

investigator’s name, the purpose of the study and the

rights of the subjects regarding participation.


All of the adopted tools were translated into

Indonesian language by the researcher. The tools were

being evaluated by three experts in this area, and

were tested unto fifteen lay people having

hypertension disease and changes were made after the

review. A statistic tools to test the validity and

reliability of attitude questionnaire was performed

with Pearson-r and alpha value (appendices B).

Ethical Considerations in Research

A recommendation letter from the Klabat

University was submitted to the health centers in

North Minahasa regency.

1. Informed consent form given to client with

hypertension disease at the working area of North

Minahasa regency. Informed consent is equipped

with the investigator’s name and purpose of the

study and subject right in participation.

2. Anonymity


In order to maintain confidentiality, the

investigator will utilize special code to each

answered questionnaire.

3. Confidentiality

Respondents are guaranteed for information

confidentially, and only certain data will report

as a result of investigation.

Data Analysis

T paired test decision making is based on the

value that is, if p-value <.05 then Ho1 rejected,

meaning that there is an effect of health education to

the level of knowledge and attitude of hypertensive

client. Conversely, if p-value >.05 the Ho1 accepted,

meaning there is no effect of health education with

knowledge and attitude of hypertensive clients.

Likewise with Regression coefficients, decision making

is based on the value that is, if p-value .05 the ho2

rejected, meaning there is an effect of knowledge to


medical adherence of hypertensive clients before.

Meanwhile, when the value p-value >.05 is concluded

accept Ho2, meaning that no effect of knowledge to

medical adherence of hypertensive clients. ANOVA and

Independent sample T test decision making are used on

the value that is, if p-value <.05 then Ho3 is

rejected, meaning that there is an effect of health

education to the knowledge and attitude based on pre

and post test scores when the confounding variables

are being considerered.. Conversely, if p-value >.05

the Ho3 is accepted, meaning there is no effect of

health education toward knowledge and attitude based

on pre and post test scores when the confounding

variables are being considered.

Data Collection Procedures on Pre and Post

Data collection procedure (Pre):

1. Gather preliminary data in Puskesmas


2. Reported in the Village office for data collection

in the working area health center

3. Visiting the respondents in each house

respectively

4. Opening salutation

5. Explaining the purpose and goals

6. Give informed concent, as a sign the patient

agrees to be the respondent

7. Explaining how to fill out questionnaires.

Treatment

1. Provide health education about hypertension

disease

2. Make arrangements for another meeting

3. Thank you

4. Back to visit the respondents in their homes

5. Opening salutation

6. Repeating the material that has been given

Data collection procedures (Post)

1. Respondents completed the same questionnaire


Chronology of Data Collection Planning

Table, Time calendar

Letter approval from thedean of nursing

Letter approval from thehead of

Airmadidi BawahCommunity Health

Third meeting:Review of lesson 30

minutes

Data collection; tabulation;data process;Data report

Second meeting:Distribute questionnaire;

conduct healthEducation 30-45 minutes;

Fourth meeting:Distribute questionnaire;collection of questionnaire

First meeting:Investigator self introduction,

clarity the purpose andadvantage of the study; gain

Approval of research proposal


Figure 3.1 Flow of data collection planning

Table 3.1 Time calendar

No.

Keterangan

12th

month

1st month 2nd month 3rd

month

4th

month

W

1

W

2

W

3

W

1

W

2

W

3

W

4

W

1

W

2

W

3

W

4

W

1

W

2

W

3

W

4

W

1

W

2

W

3

1 Researc

h

Contrac

t

x

2 Pre

Survey

x x

3 Pilot

Study

X

4 Actual

Researc

h

x x


5 Data

Collect

ion

x x x x

6 Analysi

s

x X

7 Report

making

X x

8 Discuss

ion/

Seminar

x X

9 Report

submiss

ion

X x x

Chapter IV

PRESENTATION, INTERPRETATION & ANALYSIS OF DATA

This chapter present the data gathered from sixty

(60) clients, with hypertension disease at Sawangan

community, Airmadidi.


The main objective of the study was to determine

the outcomes of health education intervention on

knowledge, attitude and medical adherence among clients

with hypertension at Sawangan community, Airmadidi.

This chapter is divided into two parts. The first

part is description of the study participants’ socio-

demographic profile such as: age, sex, education

attainment and scores of knowledge, attitude and

medication adherence to age, gender and education

attainment. Part two shows the result outcomes

measures, such as the effect of health education to

knowledge, the effect of health education to attitude

and the relation between knowledge and attitude to

medical adherence.


Part 1. Description of the Study Participants’s Socio-

Demographic Profile

Table 4.1 Demographic Characteristic of the Study

Participant

Characteristics Study Groupn %

Age < 50 12 2050-59 24 40≥ 60 24 40Total 60 100Sex Male 11 18.3Female 49 81.7Total 60 100Educational Attainment Elementary 11 18.3Junior High School 22 36.7Senior High School 22 36.7College 5 8.3Graduate Studies 0 0Total 60 100


The study participants consisted of 60 clients

with essential hypertension disease, were used both on

pre and post intervention. Table 4.1 shows the

composition of the participants’ relative to various

socio-demographic variables. The following section

summarizes the socio-demographic variables and illness

variables.

Table 4.1 shows the distribution of the

participants’ population according to their age group.

Majority of the respondents (80 %) were between the age

period of 50-59 and more or equal to 60 years old. In

terms of participant’ ages, they were mostly in the

late adult stages. Old age is usually correlated with

blood pressure because as person ages, vascular changes

occurs. A gradual thickening within the tunica media of

large and medium-sized arteries occurs with age. This

is associated with an increase in the number and

density of collagen fibres, making the artery

increasingly rigid and less compliant (Alberto et al,


2003). The vessels also display fracturing of the

elastic (elastin) components and often varying degrees

of calcification.

The respondents per group were sorted based on

gender differences. The sample consisted of males, 11

(18. 3 %) and females 49 (81. 7%). Most of the

respondents graduated from junior and senior high

school education levels 44 (73. 4 %), elementary school

11 (18. 3 %) and college 5 (8. 3 %). The level of

education would assists individuals in understanding

better the information given by the health care

providers.

Pre and post tests scores of knowledge, attitude

and medication adherence are displayed in the following


Part I Table 4.2 Scores Differences before and afterKnowledge Test

POSTKNOWLEDGE Total

3.00 5.00 7.00 8.00 9.0010.00

PREKNOWLEDGE .00 0 0 0 0 0 2 2 1.00 0 0 0 0 0 1 1 2.00 0 0 0 1 1 7 9 3.00 0 0 0 0 0 10 10 4.00 0 0 0 0 0 7 7 5.00 1 1 1 1 1 5 10 6.00 0 0 0 1 2 4 7 7.00 0 0 1 1 1 7 10 8.00 0 0 0 1 0 1 2 9.00 0 0 0 0 0 1 1 10.0

0 0 0 0 0 1 0 1

Total 1 1 2 5 6 45 60

Table 4.2 showed the differences each scores

before and after the Knowledge test. Score on Knowledge

test were range from zero (0) to ten (10). On pre

Knowledge test there was one respondent received the

lowest score of one (1). However, on the post test

Knowledge there were ten (10) respondents received the


lowest score of five (5). The highest score of ten (10)

on pre test Knowledge achieved by one (1) respondent

however, on post Knowledge test, there were 45 (forty-

five) respondents achieved scores of ten (10). The

cross tabulation calculation has showed an improvement

of respondents’ knowledges on hypertension.

Table 4.3 Scores Differences Before and After AttitudeTest

POSTATTITUDE Total 3.00 4.00 5.00

PREATTITUDE 2.00 0 4 1 5

3.00 3 20 6 29

4.00 0 20 2 22

5.00 0 2 2 4

Total 3 46 11 60

Table 4.3 displayed respondents’comparable scores

before and after Attitude test conducted. Attitude test


scores ranged from 1 (one) to 5 (five). Scores of 2

(two) were achieved by 5 (five) respondents on pre test

result. However, on the post test result 3 (three)

respondents received the lowest score of 3 (three).

Based on ranking, score of 3 (three) on pretest result

showed 29 respondents followed by score of 4 (four)

with 22 respondents and 4 (four) respondents achieved

scores of 5 (five). As it compared with the post test

result, there were 3 (three) respondents received

scores of 3 (three); 46 respondents received score of 4

(four) followed by 11 (eleven) respondents achieved

score of 5 (five). The cross tabulation calculation has

showed respondents’ moderate improvement on attitude

about hypertension disease.


Table 4.4 Scores Differences Before and AfterMedication Adherence Test

POSTACTIONTotal

1.00 2.00 3.00 4.00 5.00 6.00 7.008.00

PREACTION.00 1 0 0 0 0 0 0 0 1

1.00 1 0 2 0 0 1 2 6 12

2.00 0 0 0 1 1 0 2 3 7

3.00 0 2 0 1 0 1 1 5 10

4.00 1 0 0 0 1 1 3 5 11

5.00 0 0 0 0 3 0 2 3 8

6.00 0 0 0 0 0 0 0 7 7

7.00 0 0 0 0 0 0 1 2 3

8.00 0 0 0 0 0 0 0 1 1

Total 3 2 2 2 5 3 11 32 60

Table 4.4 showed comparable result of Medication

Adherence Test amongst the 60 (sixty) respondents. The

total scores of Medication Adherence Test are 8

(eight). As it showed in the table, on pre test the

lowest score of 0 (zero) has 1 (one) respondent as it

compared to post test result, none amongst the 60


(sixty) respondents received score of 0 (zero). The

lowest score on post test was 1 (one) and it has 3

(three) respondents; the highest score of 8 (eight) has

1 (one) respondent on pre test as it compared to post

test result, there were 32 (thirty two) respondents

having the highest scores of 8 (eight). The table has

showed varied score’s improvement amongst the 60

(sixty) respondents on pre and post test result and the

scores’ variances tend to improved on the post test

score result.

Other cross tabulation scores of confounding

variables as it compare with the dependent variables

were showed at the appendix C.

Part II. The Outcome Measures

The following presentation shows the study outcome

measures: the effect of health education to knowledge,

the effect of health education to attitude and the


relation between knowledge and attitude to medical

adherence.

The effect of health education to knowledge amongsthypertension client at Sawangan Health Community Center

The following diagram will answer the problem

statement 1 and hypothesis 1 of the research which

quest the effect of health education to knowledge among

hypertension client.

Table 4.5 shows the statistic result using paired

t test statistic tool in order to answer the problem

statement 1 and hypothesis 1.

Table 4.5 Mean Analysis Result on the effect of HealthEducation to Knowledge

Mean NStd.

DeviationStd. Error

Mean

PREKNOWLEDGE 4.5667 60 2.21219 .28559POSTKNOWLEDGE 9.4333 60 1.29362 .16701


Table 4.6 Paired Sample t Test on the Effect of Knowledge Before and After Health Education

Paired Differences

MeanStd.

Deviation

Std.ErrorMean

95% ConfidenceInterval of

the Difference t

DFSig. (2-tailed

Lower Upper PREKNOWLEDGE – POSTKNOWLEDGE

-4.8667 2.77071 .35770 -

5.5824-

4.1509-

13.606 59 .000

A paired sample t-test was conducted to evaluate

the effect of intervention on respondents’ scores on

the Knowledge Test. There was a statistically

significant increase in Knowledge scores from pre

intervention (M= 4.6, SD= 2.2) to post intervention (M=

9.4, SD= 1.3), t = -13.6, p = 0.000 in favor of the

posttest. P value 0.000 less than .05 (two-tailed). The

Mean increase in Knowledge scores was -4.86 with 95%

confidence interval ranging from -5.58 to -4.15. The

eta squared statistic (.76) indicated a large effect

size. The effect size based on guidelines proposed by


Cohen (1988) in Pallant (2007)

which, .01=small, .06=moderate, .14=large effect. It

rejects the Ho and suggests health education has an

effect to knowledge. This result was supported by Shi,

et al (2010) on their quasi-experimental study the

‘Effect of Health Education on farmer’s intention of

joining in the new rural cooperative medical system’.

Their research study had shown an increased of

knowledge level in two intervention counties by 29.0 %

and 37.8%. The study concluded health education was

effective and helpful in increasing farmer’s knowledge.

Based on data collection the respondents mostly having

chronic hypertensive disease with the duration of 1-4

years (28. 6%), within the span of time these

respondents assumed has hath long interaction in terms

of health education on hypertension and the use of

medication with health workers though the frequencies

of meeting are varied thus, the questions were

relatively familiar to the respondents. Aside of it, I


did repetition on health education and discussed the

answer of each question items with the respondents. It

was unexpected result because the duration of

intervention was relatively short (two weeks) compare

to 2 years intervention health education program able

to increase level of knowledge though it was not

affected to the health behavior (Lindberga, Stahlea &

Rvdena, 1991). Other similar study also showed no

significant differences before and after health

education session toward mother’s knowledge within a

year of intervention (Yameen, 2005).

Table 4.7 Mean Analysis Result on the Effect of Health

Education to Attitude

Mean NStd.

Deviation

Std.ErrorMean

PREATTITUDE 3.3650 60 .68984 .08906 POSTATTITUDE 4.0917 60 .32275 .04167


Paired Differences95% ConfidenceInterval of the

Difference

Mean

Std.Deviatio

nStd. Error

Lower Upper tDf

Sig.(2-

tailed)

PREATTITUDE –POSTATTITUDE

.72903 .09412 -.9150 -.538

3-7.721

59 .000

Table 4.8 Paired Sample t Test on the Effect of Attitude Before and After Health Education

A paired sample t-test was also conducted to

evaluate the effect of intervention toward respondents’

scores on Attitude Test. There was a statistically

significant increase in Attitude scores on pre test (M=

3.4, SD= 0.7) to post test (M= 4.1, SD= 0.3), t = -

7.72, p = 0.000 < .05 (two-tailed). The mean increase

in Attitude scores was .729 with a 95% confidence


interval ranging from -.915 to -.538. The eta squared

statistic (.50) indicated a large effect size it

rejects the Ho and suggest health education has an

effect to attitude.

Similar finding was reported by Tsai, et al (2005)

on their evaluation to measure the effectiveness of

smoking prevention program on the perception of and

attitudes towards smoking in adolescents found out both

knowledge and attitudes in the experimental group

improved significantly (0.18> 0. 12, p = 0.039) after

2 (two) weeks intervention. This kind of positive

attitude given by the respondents perhaps related with

the content of the questions which mostly familiar and

have been emphasis by the health workers. The

respondents were open and receptive to the ‘right’

thing as to adhere to the regimen medication,

regardless of some respondents’ perceived

antihypertensive herbal medication less likely to give

side effect.


Table 4.9 Analysis Regression test on the Efect of Knowledge to Medical Adherence

Model Summary

Model R R SquareAdjustedR Square

Std. Errorof theEstimate

1 .587(a) .345 .339 2.08338a. Predictors: (Constant), KNOWLEDGE

Coefficients (a)

Model

UnstandardizedCoefficients

Standardized

Coefficients t Sig.

BStd.Error Beta

(Constant) 1.582 .479 3.299 .001 KNOWLEDGE .495 .063 .587 7.880 .000a. Dependent Variable: ACTION

For the regression of Knowledge on Medication

adherence, r = .59 and r2= .34, therefore 34% of the

variance in knowledge can be accounted by knowing the

variance in medication adherence. There is 34% of the

information that need to make an accurate prediction.

The complement of r2 or 1- r2, reflects the propotion of


variance that is not explained by the relationship

between X and Y (means, explained by other variables),

in this case 66%. Other variables which might

contribute to the prediction of medication adherence

could be the positive perception of the respondents to

the medication adherence concept, “older than 50 years,

were insured, a positive attitude toward

antihypertensive drugs...and consumed antihypertensive

drugs for more than 5 years with p = 0.05” (Hadi &

Gooran, 2004). Using knowledge as a predictor will

result in a reasonable but not thoroughly accurate,

estimate of medication adherence. Values of r square

are more meaningful for conceptualizing the extent of

an association between variables than values of r

alone. When strength of association is of interest, r

will be properly interpreted in this case r = .59

suggesting a large strength of relationship between

knowledge scores and medication adherence scores as

well to show there was a significant, positive


correlation between knowledge and medication adherence

(ß = .59, p = .000 < .05); however, when Y is predicted

from X, r square provides a more meaningful description

of the relationship. R square will range 0.00 to 1.00.

Study which supported the positive correlation

between knowledge and medication adherence (Tsuboyoma,

et al 2005) found knowledge about hypertension showed a

positive correlation with diastolic blood pressure

(Spearman r = .298, p <.01). On the other hand, study

(Miller, et al 2001) found poor medication knowledge

after eight (8) weeks of regiment initiation was

associated with lower medication adherence (p = .3).

The value of Y= .495 X + 1.582, is obtained

through independent variable knowledge and constant as

an intercept. In other words, the prediction equation

is knowledge = .495 (medication adherence) + 1. 582,

informing that knowledge score is predicted to increase

.495 when the medication adherence score goes up by one

and is predicted to be 1. 582, when medication


adherence score is zero. To test regression significacy

based on t resulted to 7.880 having a significant value

of 0.000. Therefore it concludes due to significant

value < α regression coefficient has a significant

meaning. The Normal P-P plot and Scatterplot of

dependent variable medication adherence are displayed

at appendices C.

Table 4.10 Analyses Regression on the Effect ofAttitude to Medical Adherence

Model Summary (b)

Model R R SquareAdjustedR Square

Std. Errorof theEstimate

1 .432(a) .187 .180 2.32085 a. Predictors: (Constant), NEWPPATTITUDE

b. Dependent Variable: action

Coefficients (a)

Model UnstandardizedCoefficients

StandardizedCoefficients t Sig.

BStd.Error Beta

(Constant) -.796 1.142 -.697 .487 NEWPPATTITUDE 1.549 .297 .432 5.208 .000

a. Dependent Variable: ACTION


For the regression of Attitudes on Medication

adherence, r = .4 and r2= .18, therefore 18% of the

variance in attitude can be accounted by knowing the

variance in medication adherence. There is 18% of the

information that need to make an accurate prediction.

The complement of r2 or 1- r2, reflects the propotion of

variance that is not explained by the relationship

between X and Y (means, explained by other variables),

in this case 82%. Other variables which might

contribute to the prediction of medication adherence

could be the adequate knowledge of the respondents to

the medication adherence concept, “beliefs and positive

motivation” of the clients (Kocurek, 2009). Using

attitude as a predictor will result in a reasonable but

not thoroughly accurate, estimate of medication

adherence. Values of r square are more meaningful for

conceptualizing the extent of an association between

variables than values of r alone. When strength of


association is of interest, r will be properly

interpreted in this case r = .4 suggesting a medium

strength of relationship between attitude scores and

medication adherence scores as well it showed there was

a significant, positive correlation between attitude

and medication adherence (ß = .4, p = .000 < .05);

however, when Y is predicted from X, r square provides

a more meaningful description of the relationship. R

square will range 0.00 to 1.00.

Study which supported the positive correlation

between attitude and medication adherence (Wu, et al

2007) found self reported adherence to medication had a

siginificant correlation with attitude scores (r = .30,

p = <.05) and knowledge scores (r = .25, p = <.05).

The value of Y= 1.966 X + -2.280, is obtained

through independent variable attitude and constant as

an intercept. In other words, the prediction equation

is attitude = 1.966 (medication adherence) + -2.280,

informing that attitude score is predicted to increase


1.966 when the medication adherence score goes up by

one and is predicted to be -2.280, when medication

adherence score is zero.To test regression significacy

based on t result 6. 231 having a significant value of

0.000. Therefore it concludes due to significant value

< α regression coefficient has a significant meaning.

The Normal P-P plot and Scatterplot of dependent

variable medication adherence are displayed at

appendices C.

Table 4.11 One Way ANOVA of the Effect of HealthEducation on Knowledge on Age Variable

DescriptivesDIFKNOWLEDGE

N Mean

Std.Deviatio

nStd.Error

95% ConfidenceInterval for Mean

Minimum

Maximum

LowerBound

UpperBound

Less to50 yrs 12 4.3333 2.26969 .65520 2.8912 5.7754 1.00 8.00

50-59 yrs 24 4.2917 2.75806 .56299 3.1270 5.4563 .00 8.00

60 yrs-above 24 5.7083 2.89646 .59124 4.4853 6.9314 -2.00 10.00

Total 60 4.8667 2.77071 .35770 4.1509 5.5824 -2.00 10.00


ANOVA

DIFKNOWLEDGE

Sum ofSquares Df

MeanSquare F Sig.

BetweenGroups 28.350 2 14.175 1.903 .158

Within Groups 424.583 57 7.449Total 452.933 59

A one-way between groups analysis of variance was

conducted to explore the impact of health education on

levels of knowledge on age. Subject were divided into

three groups according to their age (Group 1: 50 yrs or

less); Group 2: 50-59 yrs; Group 3: 60 yrs and above).

There were no statistically significant differences at

the p = .05 level in Knowledge scores for the three age

groups: F = 1.9, p = .16. In other words, there was no

significantly effect of health education to knowledge

when adjusted with age.The effect size, calculated

using eta squared, was .06 (moderate size effect). The

mean score for Group 1 (M = 4.33, SD = 2.26) was

significantly different from Group 3 (M = 5.71, SD =


2.89). Group 2 (M = 4.29, SD = 2.76) differed

significantly from Group 3 however, did not differ

significantly from Group 1. Eventhough there were means

score differences among the age group the overall was

not significant. In other words, there were no

differences of health education intervention to the

age. Age less than 50 years or between 50-59 years or

more than 60 years will have a similar effect of the

intervention. Therefore, I can not assume that 60 years

or more were more knowledgeable compare to age period

of 50-59 years and vice versa. This might be due to

social and cultural factors. The effect size show a

moderate effect or moderate correlation between health

education intervention and age variables thus, it

suggest replicating of the study with larger sample to

increase the power of the test. Other studies (Solomon,

et al, 2003; Kadowaki, et al, 2005) found age did not

affect TB-related knowledge in tailoring up DOTS

(directly observed treatment short course) strategy in


to the local norms. As well there was no significantly

different in the cessation rate after age adjustment

between health education and environmental changes

groups (p = 0. 189).

Table 4.12 Independent – Sample T Test of theEffect of Health Education to Knowledge on Gender

Group Statistics

GENDER N MeanStd.

Deviation

Std.ErrorMean

DIFKNWL Male 11 5.7273 2.28433 .68875

Female 49 4.6735 2.85327 .40761

Independent Samples Test

Levene'sTest forEquality

ofVariances t-test for Equality of Means

FSig. T Df

Sig.(2-tailed)

MeanDifference

Std.ErrorDifference

95% ConfidenceInterval of

the Difference Lower UpperDIFKNOWLEDGE

Equalvarianc

esassumed

1.980

.165

1.143 58 .258 1.053

8.9220

4-.7918

52.8994

6


An independent – samples t-test was conducted to

know the effect of health education to Knowledge Scores

to gender (males and females). There were no

significant differences in scores for males (M = 5.

72, SD = 2. 28) and females, M = 4. 67, SD = 2. 85; t =

1. 14, p = .26 (two-tailed). The magnitude of the

differences in the means (mean difference = 1. 05, 95%

CI: -. 791 to 2. 736) was small (eta squared = .02).

In other words, there is a similar effect of health

education on both females and males. Other studies (Yin

et al., 2011; Selassie et al., 2003; Foster et al.,

2010) found no significant differences between genders

in terms of knowledge related subjects and learning

attitudes. It is assume as well that the quantity

sample is not equal between males and females adding

with a small size effect result, it is suggested to

replicate the study using larger sample to increase the

power of the test.


Table 4.13 One Way ANOVA Test of theEffect of Health Education to Knowledge Considering

Education level Variable

Descriptives

DIFKNOWLEDGE

N MeanStd.

DeviationStd.Error


Minimum Maximum

LowerBound

UpperBound

Elementary 11 6.0000 2.04939 .61791 4.6232 7.3768 3.00 10.00

JuniorHS 22 5.1818 3.11121 .66331 3.8024 6.5613 -2.00 10.00

SeniorHS 22 3.9545 2.45875 .52421 2.8644 5.0447 -1.00 8.00

College 5 5.0000 3.39116 1.51658 .7893 9.2107 .00 8.00

Total 60 4.8667 2.77071 .35770 4.1509 5.5824 -2.00 10.00

ANOVA

DIFKNOWLEDGE

Sum ofSquares Df

MeanSquare F Sig.

BetweenGroups 34.706 3 11.569 1.549 .212

Within Groups 418.227 56 7.468Total 452.933 59

A one way between groups analysis of variance was

conducted to explore the effect of health education on

levels of knowledge on education attainment, as it


measured by the Health Education intervention. Subjects

were divided into six groups (Group 1: no school; Group

2: elementary; Group 3: junior high school; Group 4:

senior high school; Group 5: college/university; Group

6: postgraduate studies). There was no statistically

difference at the p > .05 level in Knowledge scores for

the six education groups: F = 1.5, p = .21. Despite of

insignificant result, the actual difference in mean

scores between the groups was relatively large. Study

(Emtner, 2009) found that there were no significant

differences regarding patient education and knowledge

between group with or without further ER visits after

adjusting with education background, age and sex. The

effect size calculated using eta squared, was .08.

Meaning, there was moderate correlation between health

education interventions to education level. However, it

is suggested to replicate the study using larger sample

in order to increase the power of the test.


Table 4.14 One Way ANOVA Test of theEffect of Health Education to Attitudes Considering Age

Variable

Descriptives

DIFATTITUDE

N MeanStd.

DeviationStd.Error


Minimum

Maximum

LowerBound

UpperBound

Less to 50 yrs 12 .8333 1.11464 .32177 .1251 1.5415 -1.00 3.00

50 to 59 yrs 24 .5833 .82970 .16936 .2330 .9337 -1.00 2.00

60 yrsto above 24 .7917 .72106 .14719 .4872 1.0961 .00 2.00

Total 60 .7167 .84556 .10916 .4982 .9351 -1.00 3.00

ANOVA

DIFATTITUDE

Sum ofSquares Df Mean Square F Sig.

Between Groups .725 2 .362 .498 .610Within Groups 41.458 57 .727

Total 42.183 59

A one way between-groups analysis of variance was

conducted to evaluate the effect of health education on

levels of attitudes on age, as measured by Health

Education intervention. Subjects were divided into


three groups according to their age (Group 1: 50 yrs

and less; Group 2: 50-59 yrs; Group 3: 60 yrs and

above). There was no significant differences at the p >

.05 level in Attitude scores for the three age groups:

F (2, 57) = .49. Study (Nochajski et al., 2009) found

that there was no influence of age among gender in

showing negative attitudes toward older person. No

difference in terms of age and sex permissive attitude

toward sexual practices was also identified in

Egbochuku’s study (Egbochuku et al., 2008). Other study

conducted by Rahman et al., (2009) also found that

there were no significant association between usage of

herbal medicines during pregnancy and age. The actual

differences in mean scores between the groups were

quite small. The effect size, calculated using eta

squared (.02). In other words, the effect of health

education intervention was similar to all age groups.

It is suggested to replicate the study using larger

sample to increase the power of the test.


Table 4.15 Independent – Sample T Test of theEffect of Health Education to Attitudes Considering

Gender Variable

Group Statistics

GENDER N MeanStd.

Deviation

Std.ErrorMean

DIFATTITUDE

Males 11 1.2727 .78625 .23706Females 49 .5918 .81441 .11634

Independent Samples Test

Levene'sTest for

Equality ofVariances t-test for Equality of Means

F Sig. T Df

Sig.(2-

tailed)

MeanDifference

Std.ErrorDifference

95%ConfidenceInterval of

theDifference

Lower UpperDIFATTITUDE

Equalvarianc

esassumed

.929 .339 2.521 58 .014 .680

9.2701

3.1401

81.2216

0

An independent – samples t-test was conducted to

know the effect of health education to Attitude Scores


to gender (males and females). There were significant

differences in scores for males (M = 1. 27, SD =.79)

and females, M = .59, SD =.81; t = 2. 52, p = .014 <.05

(two-tailed) despite of magnitude of the differences in

the means (mean difference = .68, 95% CI: .140 to 1.

222) was small (eta squared = .01) which indicated a

small effect between variables. Study (Chung &

Phillips, 2002) found significant differences between

attitude toward physical education and leisure time

exercise both in gender and nationality where the males

had more positive attitudes toward physical education

than the females. Other study (Mirmiran & Azizi, 2010)

found as well that age, educational background and

gender are factors influencers to Knowledge, Attitude

and Practice (KAP) in regards to Nutrition.


Table 4.16 One Way ANOVA Test of theEffect of Health Education to Attitudes Considering

Education level Variable

Descriptives

DIFATTITUDE

N MeanStd.

DeviationStd.Error


Minimum

Maximum

LowerBound

UpperBound

Elementary

11 .9091 .83121 .25062 .3507 1.4675 .00 2.00

Junior HS 22 .8182 .85280 .18182 .4401 1.1963 -1.00 2.00

Senior HS 22 .4545 .67098 .14305 .1570 .7520 -1.00 2.00

College 5 1.0000 1.41421 .63246 -.7560 2.7560 .00 3.00Total 6

0 .7167 .84556 .10916 .4982 .9351 -1.00 3.00

ANOVA

DIFATTITUDE

Sum ofSquares Df

MeanSquare F Sig.

BetweenGroups 2.547 3 .849 1.199 .318

Within Groups 39.636 56 .708Total 42.183 59

A one way between-groups analysis of variance was

conducted to explore the effect of health education on

levels of attitudes on education attainment, as

measured by Health Education intervention. Subjects

were divided into six groups according to their


attainments (Group 1: no school; Group 2: elementary;

Group 3: junior high school; Group 4: senior high

school; Group 5: college/university; Group 6: post

graduate studies). There was no significant differences

at the p= .32 > .05 level in Attitude scores for the

six age groups: F = 1.2. Study by Rahman et al. (2009)

showed no significant association between user of

herbal medicine during pregnancy and education

background. The effect size, calculated using eta

squared, was .6 which indicate a moderate effect size

between variables. This is in other words the effect of

health education is similar to all education levels. It

is suggested to replicate the study with larger samples

in order to increase the test power.


Chapter V

SUMMARY, CONCLUSIONS & RECOMMENDATIONS

This final chapter contains a brief summary of the

study, conclusion derived from the major findings and

recommendations based on the findings and conclusions.

Summary of the Study

The purpose of this study was to investigate the

effect of health education on knowledge and attitude on

Medication regimen adherence among hypertension clients

at Sawangan Village, Airmadidi Sub District.


A quasi-experimental one group pretest and

posttest design was being

utilized in implementation of the treatment and

examining its effect using selected methods of

measuremement The target population was hypertensive

clients at Sawangan community health center; data

clients were taken from the health center registration

book. The study was taken on the first and third week

of December, 2010 on sixty (60) clients as the

respondents.

A quantitative, descriptive and inferential

research approaches were

adopted. The research study used purposive,

nonprobability sampling technique. Three parts of

instruments composes of Knowledge and self report were

validated to three medical experts (Appendix A); ten-

items of Attitude to medication adherence was reliable

(α= .84) and item’s validity significant at 0.01 (2-

tailed).


Majority of the respondents was female (81.7%),

80% aged 50-59 and more or equal to 60 years old and

more than half (73. 4%) had been graduated from junior

and senior high school levels.

Highest score of 10 on Knowledge test were able to

achieved by more than half (45) of the respondents

after intervention given.

On the part of the attitude scores, more than half

(46) of respondents achieved the total score of 4 on

the post test as to compare to highest score of 5 by 11

(eleven) respondents on the pre test.

On the part of medication adherence scores, there

were 32 (thirty-two) respondents able to achieved the

highest scores of 8 (eight) after the intervention

given; whilst on the pre test result, 1 (one)

respondent able to achieved the highest scores of 8.

There was an effect of health education to

knowledge among the hypertensive clients as well as

there was an effect of health education to attitude


occurred among the hypertensive clients. Therefore

hypothesis 1 a), is rejected and hypothesis 1 b), is

rejected.

There was an effect of knowledge to medication

adherence behavior inspite of only 34% variable

knowledge contributes to medical adherence and the rest

variable (66%) contributes by other variables. It was

siginificant at 0.000 < α. Like wise with variable

attitude contributes 18% to the medication adherence

and the rest of other variables (92%) contributes to

the medical adherence behavior. It was significant at

0.000 less than 0. 05. Both hypotheses 2a) and 2b) were

rejected.

There was no effect of health education on

knowledge on age. There were no statistically

significant differences at the p = .05 level in

Knowledge scores for the three age groups: F = 1.9, p =

.16. The effect size, calculated using eta squared, was

.06. The mean score for Group 1 (M = 4.33, SD = 2.26)


was significantly different from Group 3 (M = 5.71, SD

= 2.89). Group 2 (M = 4.29, SD = 2.76) differed

significantly from Group 3 however, did not differ

significantly from Group 1. Hence, hypotheses 3a) is

accepted


knowledge on gender. There were no significant

differences in scores for males (M = 5. 72, SD = 2.

28) and females, M = 4. 67, SD = 2. 85; t (58) = 1. 14,

p = .26 (two-tailed). The magnitude of the differences

in the means (mean difference = 1. 05, 95% CI: -. 791

to 2. 736) was small (eta squared = .02). Therefore,

hypotheses 3a) is accepted.


knowledge on education level. There was no

statistically difference at the p > .05 level in

Knowledge scores for the six education groups: F = 1.5,

p = .21. The effect size calculated using eta squared,

was .08. Hypotheses 3a) is accepted.



attitudes on age.There was no significant differences

at the p > .05 level in Attitude scores for the three

age groups: F = .49. The effect size, calculated using

eta squared, was .02. Hypotheses 3b) is accepted.

There was an effect of health education on

attitudes on gender. There were significant differences

in scores for males (M = 1. 27, SD =.79) and females,

M = .59, SD =.81; t = 2. 52, p = .014<.05 (two-tailed).

The magnitude of the differences in the means (mean

difference = .68, 95% CI: .140 to 1. 222) eta squared =

.01. Hypotheses 3b) is rejected.


attitudes on education level. There was no significant

difference at the p > .05 level in Attitude scores for

the six groups: F = 1.2. The effect size, calculated

using eta squared, was 06. Hypotheses 3b) is accepted.


Conclusions

There was an effect to the knowledge of

respondents before and after the health education

given. This could be happened amongst clients having

acute and chronic hypertension. They had received

information in regards to the disease pathophysiology

from the medical doctors and nurses. However, the part


of attitude gives an effect before and after the health

education treatment. This could explain that the

respondents have a positive attitude to the medical

adherence.

The effect of knowledge and attitude to self-

report medical adherence behavior were both

significant. Meaning the respondents was aware and

positive in taking regular medication.

The effect of health education to knowledge was

not significant upon considering to three confounding

variables: gender, age and education background. This

could explain that there is no difference between

female and male, age variation and level of education

attainment in knowledge of hypertension disease.

Likewise in part of attitude, there was no effect to

the age and education levels in exception to gender.

This explains that there is no difference preference

between ages in medical adherence like wise with the

education background. Elementary school graduate will


have a similar attitude about medical adherence with

the high school graduates and vice versa. On the other

hand gender was influenced by the treatment. Variable

males differed significantly from variable females.

These differences were assumed due to different and

vary perspective in valuing medication adherence

concept.

In the relation with the theoretical framework,

this study presented findings within the parameters of

a well articulated analytical framework, the Health

Belief Model by Pender.

The Health Belief Model is one of the most widely

used practices to understanding individual health

behaviors. It is used in this study because their

component reflects the goal of health behavior and in

this context it is apply to knowledge, attitude and

adherence to medication.

The empirical generalization of the theory was

seen in the effect between knowledge, attitude and


medication adherence. However, this was not affected or

influenced the mediating variable of age, gender and

educational background. This could be assumed due to

high perceived benefits of action which is the

compliance in taking consistently of the medicine or

could be due to interpersonal influences, norms,

supports, models and situational influences faced by

the respondents.

Recommendations

Based on the research result the following

recommendations are proposed:


To the Health Community Center

The health education given to the clients

hypertensive treatment should be standardized and

include all the topics needed to empower clients with

knowledge.

Health workers, professionals and non-professional

should be well versed in the principles of adult

learning.

Health education should be given as soon as the

client is diagnosed and should be on going so that the

clients understand their condition and treatment.

Awareness campaigns through a multi-sectoral

approach including schools, media and churches should

be utilized and involved disseminating information. If

the community is informed about hypertension as a

disease, they might provide better support and

motivation to the hypertension clients.


To the Education Institute

To the education institute, especially to the

Nursing Faculty of the Klabat University, the research

result would be useful as one of the supporting

research paper to the community training services.

The research result could be published as one of

the scientific article which will add the Nursing

department’s credibility.

To the Science Development

The research result could be possible use in the

future research studies. The researcher recommend to

replicate the study with larger sample size and/or


widening the scope of field such as to sub district

level and/or to add components of interpersonal

influences and situational influences, self efficacy,

the perception in antihypertensive herbal usage,

motivation, perception of barriers to medication

taking. Component of income level may be added to the

confounding variable as to observe the effect toward

medication adherences.

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The effect of Health Education on Knowledge

and Attitude on Medication Regimen Adherence Among

Hypertension clients at Sawangan Village, Airmadidi

sub district

Presented to Nursing Department of Nursing Faculties

UNKLAB Airmadidi

In Partial Fulfillment of the Requirement for the

Degree

Of Bachelor Science in Nursing (BSN)


By

Jedeth J. Mamora

NIM: 08710005

0 1

1

Approval Sheet for Proposal Defense

The heading of the proposal is” The effect of

Health Education on Knowledge and Attitude on

Medication Adherence Among Hypertension Clients at

Sawangan Village, Airmadidi Subdistrict”

It was submitted on ____ (date) _______ (month)

_________ (year) by:

Jedeth Mamora (NIM: 08710005)

In partial fulfillment for the degree of BSN and is

ready for panel evaluation


Djoko Sutopo, MAN

_________________

Health Advisor

List of Tables

Table

Page

Table 3.1 – Time calendar

Table 4.1 – Demographic Characteristic of the Study

Participant


Table 4.2 – Scores Differences Before and After

Knowledge Test

Table 4.3 – Scores Differences Before and After

Attitude Test

Table 4.4 – Scores Differences Before and After Medication Adherence Test

Table 4.5 – Mean Analysis result the effect of health

education to knowledge

Table 4.6 – Paired T Test on the Effect of Knowledge

before and after

Health Education

Table 4.7 – Mean Analysis Result Before and After Health Education to Attitude

Table 4.8 – Paired T Test on the Effect of Attitude Before and After Health

Education

Table 4.9 – Analysis Regression test on the Efect of Knowledge to Medical

AdherenceTable 4.10 – Analyses Regression on the Effect of Attitude to Medical Adherence

Table 4.11 – One way ANOVA of the Effect of Health Education on Knowledge

Considering Age Variable


Table 4.12 – Independent Sample T Test of the Effect ofHealth Education on

Knowledge Considering Gender Variable

Table 4.13 – One way ANOVA of the Effect of Health Education on Knowledge

Considering Education Attainment Variable

Table 4.14 – One way ANOVA of the Effect of Health Education on Attitudes

Considering Age Variable

Table 4.15 – Independent Sample T Test of the Effect ofHealth Education on

Attitudes Considering Gender Variable

Table 4.16 – One way ANOVA of the Effect of Health Education on Attitudes

Considering Education Attainment Variable

List of Figures

Figure

Page


List of Appendices

Appendix Page

THE EFFECT OF HEALTH EDUCATION ON KNOWLEDGE AND ATTITUDE ON MEDICATION REGIMEN ADHERENCE AMONG HYPERTENSION CLIENTS AT SAWANGAN VILLAGE AIRMADIDI SUB DISTRICT

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