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i “EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE OF HYPERTENSIVE PATIENTS REGARDING DASH DIET AT SELECTED KUMBALAGUDU PHC AREA, BANGALORE.” By Mr. ARUN BABU Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. In partial fulfillment of requirement for the degree of Master of Science in Nursing In Community Health Nursing Under the Guidance of Mrs. KATHYAYINI.N.B. M.Sc. (N), Assistant Professor, Department of Community Health Nursing. Kempegowda College of Nursing K.R.Road, V.V.Puram, Bangalore-560 004 2013

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Page 1: Kempegowda College of Nursing - 52.172.27.147:8080

 

“EFFECTIVENESS OF STRUCTURED TEACHING

PROGRAMME ON KNOWLEDGE OF HYPERTENSIVE

PATIENTS REGARDING DASH DIET AT SELECTED

KUMBALAGUDU PHC AREA, BANGALORE.”

By

Mr. ARUN BABU

Dissertation Submitted to the Rajiv Gandhi University of Health

Sciences, Bangalore, Karnataka.

In partial fulfillment of requirement for the degree of

Master of Science in Nursing

In

Community Health Nursing

Under the Guidance of

Mrs. KATHYAYINI.N.B. M.Sc. (N),

Assistant Professor,

Department of Community Health Nursing.

Kempegowda College of Nursing

K.R.Road, V.V.Puram, Bangalore-560 004  

2013

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DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “Effectiveness of structured

teaching programme on knowledge of hypertensive patients regarding DASH

diet at selected Kumbalagudu PHC area, Bangalore.”is a bonafide and genuine

research carried out by me under the guidance of Mrs.Kathyayini.N.B, M.Sc.

Nursing, Asst Professor, Department of Community Health Nursing, Kempegowda

College of Nursing, Bangalore-560 004.

Place: Bangalore. Signature of the Candidate

Date: 11-2- 2013 (Mr. Arun Babu)

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CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled is “Effectiveness of structured

teaching programme on knowledge of hypertensive patients regarding DASH

diet at selected Kumbalagudu PHC area, Bangalore.”is a bonafide research done

by Mr. Arun Babu in partial fulfillment of the requirement for the degree of

Master of Science in Community Health Nursing.

Place: Bangalore. Signature of the Guide

Date: 11-2-2013 Mrs.Kathyayini.N.B. M.Sc. (N).

Asst. Professor,

Deparment of Community Health Nursing,

Kempegowda College of Nursing,

Bangalore-560004.

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ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF

THE INSTITUTION

This is to certify that the dissertation entitled “Effectiveness of structured

teaching programme on knowledge of hypertensive patients regarding DASH

diet at selected Kumbalagudu PHC area, Bangalore” is a bonafide research done

by Mr. Arun Babu under the guidance of Mrs.Kathyayini.N.B. M.Sc(N).

Asst Professor, Department of Community Health Nursing, Kempegowda College

of Nursing, Bangalore-560 004.

Seal & Signature of the HOD Seal & Signature of the Principal

Mrs.V.T.LAKSHMAMMA. M.Sc(N) Mrs.V.T. LAKSHMAMMA

Professor and HOD, Principal, Head of the department,

Department of Community Health Nursing, Community Health Nursing,

Kempegowda College of Nursing, Kempegowda College of Nursing,

Bangalore-560 004. Bangalore-560 004.

Place: Bangalore. Place: Bangalore.

Date: 11-2- 2013. Date: 11-2- 2013

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COPYRIGHT

Declaration by the Candidate

I hereby declare that Rajiv Gandhi University of Health Sciences, Karnataka,

shall have the rights to preserve, use and disseminate this dissertation/thesis in print

or electronic format for academic/research purpose.

Place: Bangalore. Signature of the Candidate

Date: 11/2/2013 (Mr. Arun Babu)

© Rajiv Gandhi University of Health Sciences, Karnataka.

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ACKNOWLEDGEMENT

“Let us be grateful to the people who make us happy; they are the charming gardeners who make our souls blossom.” (Marcel Proust) 

First, I praise and thank Lord Almighty for his abundant grace and blessings

throughout the study.

I owe a deep sense of gratitude to all those who have contributed for the

successful completion of the study. It gives an immense pleasure to acknowledge

individuals who had been a source of inspiration, guidance and support from the

conception of this dissertation till completion.

I convey my sincere indebtedness to the Kempegowda College of Nursing,

Bangalore-04, for providing me an opportunity to be a student of this esteemed

institution and to conduct this study.

I extend my sincere thanks to Mrs.Lakshmamma., M.Sc. N., Principal and

HOD, Community Health Nursing, Kempegowda College of Nursing, Bangalore-4,

who let me and my search move around freely. I owe a deep sense of gratitude and

indebtedness to her.

It is my privilege to express my sincere thanks and profound gratitude towards

my esteemed teacher and guide Mrs.Kathyayini.N.B,M.Sc (N), Assistant Professor,

Department of Community Health Nursing. She is a mentor who infused me in

confidence and encouragement in my endeavour, whenever needed. It has been my

good fortune to have her as my guide. I appreciate her to tolerate my confused looks

and her innate capacity to diffuse my anxiety with her caring words. It has been an

invaluable experience working under her. We fall short of words to “Thank you

Madam”

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I thank The Medical Officer of Kumbalagudu PHC , Bangalore, for his timely aid

and co-operation during the study.

I extend my profound sense of gratitude to Dr.Gangaboraiah, Ph.D (Statistics),

Department of Community Medicine, KIMS, for his valuable suggestions and

guidance in statistical analysis.

My sincere gratitude goes to Mr.Manjunatha.H.R, lecturer and Mrs.Sunitha

lecturer, Department of Community Health Nursing for their meticulous

corrections, valuable suggestions and expert guidance.

I would like to extend my deepest gratitude to all the Experts who have

contributed in the form of constructive criticism and suggestions to formulate the tool.

I wish to place my sincere thanks to Mrs.Suma ,HOD Department of English,

College of arts and commerce,V.V.Puram Bangalore for editing the manuscript

meticulously for editing the tool.

My heartfelt thanks and appreciation to R&R Canon who toiled for the

meticulous DTP work and providing the bound volumes of the work.

My healthy ovation of gratitude to my beloved parents Mr. K.M. Puttamadhe

Gowda, Mrs.Jayalakshmamma, and my brother Mr.Kiran Babu for their

encouragement and support. A Heartfelt thanks to classmates and all my friends for

grooming me into a postgraduate nurse.

Finally, I thank all those well-wishers of mine who have directly or indirectly

contributed to the success of this work.

Place: Bangalore Signature of the Student

Date: (Mr. Arun Babu)

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ABSTRACT

Background and Objectives

This study was under taken to evaluate the effectiveness of structured teaching

programme on the knowledge of hypertensive patients regarding DASH diet in

selected Kumbalagudu PHC area, Bangalore.

Objectives of Study

i. To assess the level of knowledge of hypertensive patients regarding

DASH diet.

ii. To assess the effectiveness of structured teaching programme on

knowledge of hypertensive patients regarding DASH diet.

iii. To find association between knowledge of hypertensive patients and

selected socio demographic variables.

Method:

The study involved one group pre-test and post-test using pre-experimental

design, with non-probability sampling technique in which convenient sampling

method was used. 60 hypertensive patients in Kumbalagudu PHC area were taken as

samples (N=60) and requested to mark the structured questionnaire followed by

implementation of structured teaching programme and post-test conducted after 8

days, using the same structured questionnaire to find out the effectiveness.

Results:

The overall pre test knowledge scores of hypertensive patients on DASH diet

was found to be 33.38% and the overall post test knowledge scores was found to

77.23% and enhancement in the mean percentage knowledge score(131.36 %) was

found to be significant at 5% level of all the aspects under study. There was no

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significant association between pre test knowledge scores and selected demographic

variables.

Interpretation and Conclusion:

The overall findings of the study clearly showed that the Structured Teaching

Program was significantly effective in improving the knowledge scores of

hypertensive patients regarding DASH diet.

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LIST OF ABBREVIATIONS

1. STP Structured Teaching Programme

2. H Hypothesis

3. SD Standard deviation

4. P Probability

5. Df Degree of freedom

6. N Number of respondents

7. Α Alpha

8. FEP Fisher’s Exact Probability

9. S Significant

10. NS Not significant

11. DASH Dietary Approaches to Stop Hypertension

12. WHO World Health Organization

13. ISH International Society of Hypertension

14. CVD Cardio Vascular Disease

15. CUPS Chennai Urban Population Study

16. JNC Joint National Committee

17. NHLBI National Heart, Lung & Blood Institute

18. SLAN Survey of Lifestyle, Attitudes and Nutrition.

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TABLE OF CONTENTS

Sl. No.

Particulars

Page No.

1.

Introduction

1-6

2.

Objectives

7-12

3.

Review of Literature

13-32

4. Methodology

33-44

5. Results

45-66

6. Discussion

67-72

7. Conclusion

73-76

8. Summary

77-81

9. Bibliography

82-86

10. Annexure

87-175

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LIST OF TABLES

Sl. No.

Title of the Table Page No.

1 Description of the research design. 34

2 Distribution of Respondents by Age. 46

3 Distribution of Respondents by Sex. 48

4 Distribution of Respondents by Dietary pattern. 49

5 Distribution of Respondents by Educational status. 50

6 Distribution of Respondents by occupation. 52

7 Distribution of Respondents by Income. 54

8 Distribution of Respondents by Source of information. 55

9 Distribution of Respondents by Duration of hypertension. 56

10. Aspects wise pre - test mean knowledge scores. 57

11 Aspect wise post -test mean knowledge scores. 58

12 Aspect wise enhancement of knowledge score on DASH diet. 59

13 Distribution of respondents according to knowledge level on DASH diet.

61

14 Aspect wise analysis of pre-test and post test knowledge scores. 63

15 Association between selected demographic variables and over all pre test knowledge scores.

64-66

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LIST OF FIGURES

Sl. No.

Title of the Figure Page No.

1 Conceptual Framework based on general system model by Ludwig von Bertalanffy.

12

2 Schematic Representation of the Research Design. 44

3 Distribution of Respondents by Age. 47

4 Distribution of Respondents by Sex. 48

5 Distribution of Respondents by Dietary pattern 49

6 Distribution of Respondents by Education. 51

7 Distribution of Respondents by Occupation. 53

8 Distribution of Respondents by Monthly income. 54

9 Distribution of Respondents by Source of information. 55

10. Distribution of Respondents by Duration of Hypertension 56

11 Aspect wise enhancement of knowledge scores on DASH diet. 60

12 Distribution of respondents according to knowledge level on DASH diet.

62

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LIST OF ANNEXURE

SL. NO

ANNEXURE INDEX

CONTENTS

PAGE NO.

1. Annexure-A Copy of letter seeking permission to conduct the study 87

2. Annexure-B Copy of the letter seeking expert’s opinion for the content validity of the tool and Structured teaching Programme.

88-90

3. Annexure-C Content validity certificate 91

4. Annexure-C (1)

Criteria rating scale for validating structured knowledge questionnaire 92-95

5. Annexure- D List of experts consulted for content validity of the tool and Structured teaching programme. 96-97

6. Annexure-E Copy of consent form 98

7. Annexure-F Structured questionnaire (English) 99-106

8. Annexure-F(1) Key answers for the structured knowledge questionnaire 107

9. Annexure-F(2) Blue print for the structured knowledge questionnaire 108

11. Annexure-G Structured teaching programme (English) 109-135

12. Annexure-H Structured questionnaire (Kannada) 136-143

13. Annexure-I Structured teaching programme (Kannada) 144-175

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1. INTRODUCTION

“Diet cures more than the Doctor.”

(Maxim)

Health is the level of functional or metabolic efficiency of a living being.

In general it is a condition of a person's mind and body, usually meaning to be free

from illness, injury or pain.1To maintain good health, health and nutrition are the two

things that go hand in hand. Nutrition is the basic requirement for all the organisms

and cells to stay alive and to support life. A healthy diet contains a balance of food

groups and all the nutrients necessary to promote good health. Hippocrates suggested,

“Let food be your medicine.” Proper nutrition leads to a healthier body. From the

conception, the construction of the body structure in the womb starts with the food

taken by the mother. On birth, breast feeding and then other forms of foods contribute

to the growth of the child. Healthy eating is the practice of making choices about what

and/or how much one eats with the intention of improving or maintaining good health.

Many common health problems can be prevented or alleviated with a diet. Common

health problems related to unhealthy diet are cardiovascular diseases, kidney related

diseases etc.2

Blood pressure is the pressure that the blood exerts against the blood vessel

walls as the heart pumps. Blood pressure rises with each heartbeat and falls when the

heart relaxes between beats but there is always a certain amount of pressure in the

arteries. That blood pressure comes from two physical forces. The heart creates one

force as it pumps blood into the arteries and through the circulatory system. The other

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force comes from the arteries resisting the blood flow. A normal blood pressure

reading for an adult is: 120 / 80 mm of Hg.3

Hypertension is the condition of having high blood pressure, systolic pressure

above 140 mm Hg and diastolic above 90 mm Hg consistently for more than six

months. Blood pressure changes from minute to minute and is affected not only by

activity and rest, but also by temperature, diet, emotional state posture and

medications.2 High blood pressure adds to the workload of the heart and arteries. The

heart must pump harder and the arteries must carry blood that is moving under greater

pressure. If the blood pressure is too high, the heart has to work harder to pump which

would lead to organ damage and several illnesses such as heart attack, stroke, heart

failure, aneurysm, renal failure, vision loss.3

A critical step in preventing and treating high blood pressure is healthy

lifestyle. Lifestyle modification that effectively lower blood pressure are losing weight

if patients are over- weight or obese. Losing as few as 10 pounds( 4.5 kilograms) can

lower blood pressure.4

For people who are obese or high cholesterol levels, changes in diet (to a diet

rich in fruits, vegetables, and low- fat dairy products with reduced saturated and total

fat content) are important for reducing the risk of heart and blood pressure.5

   The best and recommended hypertension diet plan is DASH. DASH is a

scientifically arrived high blood pressure diet which stands for Dietary Approaches to

Stop Hypertension (DASH). It is a diet that was developed by the United States

National Heart, Lung and Blood Institute (NHLBI). DASH is an effective health eating

plans which work to directly control hypertension; it also helps in weight loss. Obesity

can definitely lead someone to hypertension. Like sodium intake, obesity is directly

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correlated with hypertension. Losing weight even in small measure can have dramatic

effects in lowering your blood pressure. Maintaining a healthy weight is an important

part of a healthy lifestyle. Foods that lower blood pressure are embedded in this eating

plan which is low in saturated fat, cholesterol and total fat. Fruits and vegetables that

lower blood pressure are included in DASH including fat-free or low-fat milk and milk

products. This diet for hypertension also includes fish, poultry and nuts as well as

whole grain products.6 Taking calcium, potassium, and magnesium supplements

instead of eating these foods does not have the same effect.7

A landmark study called DASH (Dietary Approaches to Stop Hypertension)

looked at the effects of an overall eating plan in adults with normal to high blood

pressure. Researchers found that in just eight weeks, people following the DASH diet

saw their blood pressure decrease. A subsequent study called DASH two looked at the

effect of following the DASH diet and restricting salt intake to 1500 mg per day.

Under the DASH two diet, people with hypertension had their blood pressure decrease

as much or more than any anti-hypertensive medication had been able to lower it.8

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NEED FOR THE STUDY:

In present day scenario the magnitude of non communicable diseases (NCDs),

mainly cardiovascular diseases, cancers, diabetes and chronic respiratory diseases,

represents a leading threat to human health and development. These four diseases are

the world's biggest killers, causing an estimated 35 million deaths each year - 60% of

all deaths globally - with 80% in low- and middle income countries.9

Hypertension has become a major cause of morbidity and mortality worldwide

and it is now ranked third as a cause of disability-adjusted life years. The World Health

Report states that elevated blood pressure alone contributes to about 50% of

cardiovascular diseases (CVD) worldwide. Furthermore, the risk for CVD starts even

at upper limits of normal levels of blood pressure. Therefore it would be desirable to

achieve optimal or normal BP (below 130/80 mmHg) in the young and middle-aged.10

About 15 % - 37% of the adult population worldwide is affected with

hypertension. Pooling of epidemiological studies shows that hypertension is present in

25% urban and 10% rural subjects in India. On estimation, there are 31.5 million

hypertensive in the rural and 34 million in the urban population.11

According to the recent review on the global burden of hypertension, the

estimated prevalence of hypertension(in people aged 20 years and older) in India in

2000 was 20.6% among males and 20.9% among females and is projected to increase

to 22.9% and 23.6% respectively by 2025.12

Hypertension has both modifiable and non-modifiable risk factors, where in

diet is one among them through which hypertension can be effectively managed and

complications can be prevented.13

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Complications of hypertension are vascular damage, coronary artery disease,

left ventricular hypertrophy; cerebral vascular involvement may produce stroke

Cerebral infarcts accounts for 80% of the strokes and transient ischemic attacks in

hypertensive persons.14

Life style modification strategies are recommended in the Joint National

Committee (JNC) 7 guidelines for the treatment and prevention of hypertension and

cardiovascular disease. The primary strategies discussed are proper nutrition through

the Dietary Approaches to Stop Hypertension (DASH) eating plan and sodium

restriction, weight reduction, increased physical activity and moderation of alcohol

consumption. Patients with hypertension have been shown to decrease their resting

blood pressure considerably by adopting one or more of these strategies.15

The DASH diet (Dietary Approaches to Stop Hypertension) is a diet promoted

by the National Heart, Lung, and Blood Institute (part of the National institute of

health (NIH), a United States government organization) to control hypertension. In

addition to its effect on blood pressure, it is considered a well-balanced approach to

eating for the general public. It is now recommended by the U.S. Department of

Agriculture (USDA) as an ideal eating plan for all Americans.16

The recent studies show that a diet rich in fruits, vegetables, whole grains, and

low fat dairy products and low in fat, refined carbohydrates, and sodium can lower

blood pressure either alone or in combination with other lifestyle changes. These

studies have greatly expanded our knowledge of non-pharmacologic interventions to

prevent and manage hypertension. They also underscore the need for diet and lifestyle

counseling in the primary care setting.17

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Regarding optimal management of Indian hypertensive population according to

CUPS – Chennai Urban Population Study, prevalence of hypertension in men (22.8%)

and in women (19.7%) is still a dream by pharmacological measurement, because rule

of halves for hypertension states that half the people with high blood pressure are not

known, half of those known are not treated, and half of those treated are not controlled.

Thus, by this rule one out of eight patients is optimally treated by pharmacological

measurement. If lifestyle modifications are adopted as a primary prevention strategy in

Indian population, then many of the uncontrolled hypertension patients can be

optimally managed.18

From the above statistics it indicates that hypertension is a burning issue; need

to bring awareness among hypertensive patients. People even after diagnosed as

hypertensive, don’t pay attention upon their diet, which can result in more

complication and severity of disease. Hence, studies suggest that educating patients

regarding DASH diet is important and essential.

The investigator has come across with many cases of hypertension in rural

communities, Bangalore and observed lack of knowledge regarding DASH diet. The

various studies already conducted also suggest and support for further research on

DASH diet in prevention of hypertension. By keeping the above points in view, the

investigator rightly felt to impart knowledge on DASH diet for hypertensive patients

for effective management and prevention of complications of hypertension.

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2. OBJECTIVES

This chapter deals with the statement of the problem, objectives of the study,

hypothesis, operational definitions and conceptual framework, which provide a frame

of reference.

STATEMENT OF THE PROBLEM

“Effectiveness of structured teaching programme on knowledge of hypertensive

patients regarding DASH diet at selected Kumbalagudu PHC area, Bangalore.”

OBJECTIVES OF THE STUDY

(i) To assess the level of knowledge of hypertensive patients regarding

DASH diet before the administration of structured teaching programme.

(ii) To assess the effectiveness of structured teaching programme on

knowledge of hypertensive patients regarding DASH diet.

(iii) To find the association between knowledge of hypertensive patients and

selected socio demographic variables.

HYPOTHESIS

H1: There is a significant difference between pre-test and post-test knowledge

scores of hypertensive patients regarding DASH diet.

H2: There is a significant association between knowledge scores of hypertensive

patients regarding DASH diet and selected ¸socio-demographic variables.

VARIABLES

Variable refers to a characteristic or attribute of a person or object that varies with in

the population understudy.

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In this study two types of variables are considered, they are dependent variables and

independent variable.

Dependent variable:

The presumed effect is referred to as the dependent variable.

In this study, knowledge of hypertensive patients is the dependent variable.

Independent variable:

The presumed cause is referred to as the independent variable.

In this study structured teaching programme is the independent variable.

OPERATIONAL DEFINITIONS:

Effectiveness: It refers to gain in knowledge on DASH diet among hypertensive

patients determined by significant difference between pre-test and post-test knowledge

scores.

Structured teaching programme: It refers to systematically organized instructional

design developed to provide information for hypertensive patients regarding DASH

diet.

Knowledge: It refers to the response given by hypertensive patients regarding DASH

diet.

Hypertensive patients: It refers to people who have been diagnosed with high blood

pressure.

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DASH diet: Dietary approaches to stop hypertension (DASH) diet refers to diet rich in

fruits, vegetables, whole grains and low-fat dairy foods which includes meat, fish, and

poultry and are limited in sugar-sweetened foods and beverages.

DELIMITATIONS OF STUDY: The study is delimited to hypertensive patients in

Kumbalagudu PHC area.

CONCEPTUAL FRAMEWORK

The conceptual framework plays several interrelated roles in the progress of

science. Their overall purpose is to make scientific findings meaningful and generalize

them. A conceptual framework deals with abstractions that are assembled by virtue of

relevance to a common phenomenon. This study is intended to assess the effectiveness

of structured teaching programme on knowledge regarding dietary approaches to stop

hypertension (DASH) among hypertensive patients in a selected Kumbalagudu PHC

area, Bangalore. The conceptual framework of the present study is based on General

System`s Theory which was introduced by Ludwig Von Bertalanffy (1968) with input,

process, output and feedback.

According to System`s Theory, a system is a group of elements that interact

with one another in order to achieve the goal. An individual is a system because he/she

receives input from the environment. This input when processed provides an output.

This system is cyclical in nature and continues to be so, as long as the input, process,

output and feedback keep interacting. If there are changes in any of the parts, there will

be changes in all the parts. Feedback from within the systems or from the environment

provides information, which helps the system to determine whether it meets its goal. In

the present study these concepts can be explained as follows.

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Input:

The input consists of information, material or energy that enters the system.

Hypertensive patient is a system and has inputs within the system itself and acquired

from the environment. The inputs include learner’s background like age, sex, dietary

pattern, education, occupation, income, source of information and duration of

hypertension which may influence the knowledge of hypertensive patients regarding

DASH die. It refers to the action needed to accomplish the derived task to achieve the

desired output that is Effectiveness of structured teaching programme on knowledge

regarding dietary approaches to stop hypertension (DASH) among hypertensive

patients in a Kumbalgudu PHC area, Bangalore.

Process or through put:

1. Assessment of level of knowledge among hypertensive patients regarding dietary approaches to stop hypertension (DASH) using a structured questionnaires.

2. Administration of STP on knowledge regarding DASH diet.

3. Assessment of post-test level of knowledge by using same structured questionnaires.

Output:

Output is the behavioural response. Output response becomes feed back to the

system and environment. In the present study, output is the gain in knowledge scores.

This is achieved through a comparison between mean pre-test and post-test knowledge

scores of the subjects.

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Feedback:

It is the process that provides information about the system’s output and its

redirection to input. Accordingly the higher knowledge score obtained by the

hypertensive patients indicates the effectiveness of structured teaching programme in

enhancing the knowledge of hypertensive patients regarding dietary approaches to stop

hypertension (DASH).

According to Ludwig Von Bertalanffy the system acts as a whole. Dysfunction

of a part causes system disturbances rather than loss of a single function. Whole

system can be resolved into an aggregation of feedback circuits such as input,

throughput and output. The feedback circuits help in the maintenance and

improvement of an intact system.

In this study, effectiveness of structured teaching programme is tested by inter

related elements such as input, throughput and output. From the feedback efficiency of

the input, such as structured teaching programme regarding DASH diet, will be

assessed. The process of teaching as throughput will be assessed in terms of its

effectiveness.

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(- - - - - - - Not included in the study)

Figure 1: Conceptual framework based on General System Theory by Von Bertalanffy (1968)

INPUT 

Demographic and clinical variables such as, 

• Age 

• Sex 

• Dietary pattern 

• Education 

• Occupation 

• Income  

• Source of information 

• Duration of hypertension 

 

                      THROUGH PUT 

• Assessment of knowledge regarding DASH by using structured questionnaires.  

• Administration of STP regarding DASH on the same day soon after the pre‐test and encouraging learning by samples. Post test using the same structured questionnaires on 8th day after the administration of STP.  

                      OUT PUT 

Analysis and interpretation of knowledge regarding DASH into 3 categories, 

Adequate  Moderately adequate  Inadequate 

Feed back

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3. REVIEW OF LITERATURE

This chapter deals with the review of related literature.

The literature reviewed has been presented under the following categories:

1. Literature related to prevalence and risk factors of hypertension

2. Literature related to treatment and lifestyle modifications

3. Literature related to diet and blood pressure

4. Literature related to DASH diet

5. Literature related to knowledge and effectiveness of Structured Teaching

programme

1. Literature related to prevalence and risk factors of hypertension

A study was conducted on prevalence,awareness,control, and associations of

arterial hypertension in a Rural Central India Population with sample size of 4,711

subjects (ages 30+ years) undergoing an ophthalmic and medical examination. Results

shows that arterial hypertension was found in 1,041 (22.1%) subjects. Its prevalence was

associated with higher age (P < 0.001), higher body mass index (P < 0.001), body height

(P = 0.001), higher blood hemoglobin levels (P < 0.001), and elevated blood urea

concentration (P = 0.008). It was not significantly associated with gender, level of

education, family income, kind of daily physical activities, type of diet, and serum

concentrations of cholesterol and creatinine among the hypertensive study participants (n

= 1,041), 208 (20.0%) subjects were aware of their disease. A current antihypertensive

treatment was reported by 84 subjects of the 1,041 arterial hypertensive subjects (8.1 ±

0.9%). Out of the treated subjects, 24 (29%) had abnormally high diastolic blood pressure

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measurements and 44 (52%) participants had abnormally high systolic blood pressure

measurements. It concludes that rural Central Indian population of ages 30+ years, the

prevalence of arterial hypertension was 22.1 ± 0.6% with an awareness rate of 20% and a

treatment rate of 8%. The low awareness and treatment rate may demand increasing public

health efforts.19

A study was conducted to detect prevalence of essential hypertension and to

identify various risk factors in Mysore, India. Blood pressure was recorded in 503

apparently normal students in group as per standard guidelines. Detailed clinical

examination was done in all cases. 6.16% of adolescents had high blood pressure at the

end of fourth screening. Both systolic and diastolic hypertensions were documented.

Increased body mass index and reduced consumption of vegetables and fruits were found

to be statistically significant risk factors for hypertension. The study concluded that there

is a high prevalence of essential hypertension amongst adolescents with modifiable risk

factors for hypertension.20

A Meta analysis study was conducted on hypertension epidemiology in, Jaipur,

India. The study reveals the following facts. Indian urban population studies in the mid-

1950s used older WHO guidelines for diagnosis (BP > or =160 and/or 95 mmHg) and

reported hypertension prevalence of 1.2-4.0%. Subsequent studies report steadily

increasing prevalence from 5% in 1960s to 12-15% in 1990s. Hypertension prevalence is

lower in the rural Indian population, although there has been a steady increase over time

here as well. Recent studies using revised criteria (BP > or =140 and/or 90 mmHg) have

shown a high prevalence of hypertension among urban adults: men 30%, women 33% in

Jaipur (1995), men 44%, women 45% in Mumbai (1999), men 31%, women 36% in

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Thiruvananthapuram (2000), 14% in Chennai (2001), and men 36%, women 37% in

Jaipur (2002). Among the rural populations, hypertension prevalence is men 24%, women

17% in Rajasthan (1994). Hypertension diagnosed by multiple examinations has been

reported in 27% male and 28% female executives in Mumbai (2000) and 4.5% rural

subjects in Haryana (1999). There is a strong correlation between changing lifestyle

factors and increase in hypertension in India.21

A Prospective cohort study conducted to know the prevalence of masked

hypertension on 302 hypertensive patients was followed in 75 Hypertension Units at

Spain. Masked hypertension was defined when mean daytime BP ≥ 135/85 mmHg. Mean

age was 56.2 years and 56% were male. Prevalence of masked hypertension was 48%. The

most prevalent accompanying risk factors were abdominal obesity (39.7%), smoking

(24.2%), family with premature cardiovascular disease (22.5%), and diabetes (11.6%).

Prevalence of left ventricular hypertrophy was 23.8%, and 22.2% of patients had

established cardiovascular disease, and 6.3% had renal disease. Masked hypertension was

related to the absence of established cardiovascular disease and to the proximity of the

clinic BP levels to the control thresholds. The researcher concludes that, the prevalence of

masked hypertension was approximately 50% in treated hypertensive patients.22

A cross sectional survey was conducted on 979 study participants in Sidama Zone,

to assess the prevalence and determinants of hypertension in rural and urban areas. Out of

979 participating subjects 485 were from urban and 494 were from rural. The prevalence

of hypertension was 9.9% with 10.1% in urban and 9.7% in rural areas ranging from 4.2%

in those below 30 years to 29.4% in those above 60 years. Bivariate analysis showed

hypertension was highly occurring more in those above 30 years old, those with the family

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history of hypertension, and a BMI > or =25 kg/m2. Multivariate analysis showed similar

correlation of increased possibility of hypertension with being over 30 years, having a

family history of hypertension, a BMI > or =25 kg/m2 and excess meat consumption. The

study concluded that hypertension has equal public health importance in urban and rural

settings of southern Ethiopia. Hypertension is common among those over the age of 30

years, overweight, those who consume excess meat and those with family history of

hypertension.23

A cross sectional epidemiological study was conducted on 1,806 hypertensive

patients, men (n=904) and women (n=902), age range 25-64 years in India to determine

age-specific prevalence of hypertension and blood pressure (BP) levels in relation to diet

and lifestyle factors among North Indians. Diagnosis of hypertension was based on new

World Health Organization/International Society of Hypertension (WHO/ISH) criteria.

The prevalence of hypertension according to WHO/ISH criteria was 23.7% and by old

WHO criteria 13.3%.In the WHO/ISH hypertensive group, isolated diastolic hypertension

was present in 47.3% males and 40.6% females. In both sexes, the prevalence rates and

BP level increased with older age. The study concluded that association of higher socio

economic status, higher body mass index and central obesity in North Indian adults with

higher fat intake, lower physical activity.Higher prevalence and level of hypertension

indicate that these populations may benefit by decreasing the dietary fat intake and

increasing physical activity.24

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2. Literature related to treatment and lifestyle modifications

A Prospective cohort study was conducted on 83,882 adult women aged 27 to 44

years who did not have hypertension, cardiovascular disease, diabetes, or cancer, and who

had normal blood pressure (120 mm Hg / 80 mm Hg), with follow-up for incident

hypertension for 14 years through 2005 in USA to assess the Diet and lifestyle risk factors

associated with incident hypertension in women. Six modifiable lifestyle and dietary

factors for hypertension were identified. The six low-risk factors for hypertension were a

body mass index (BMI) of less than 25, vigorous exercise, Dietary Approaches to Stop

Hypertension (DASH), modest alcohol intake, use of non narcotic analgesics less than

once per week, and intake of supplemental folic acid. The association between

combinations of low-risk factors and the risk of developing hypertension was analyzed.

The study revealed that all six modifiable risk factors were independently associated with

the risk of developing hypertension. For women who had all six low-risk factors (0.3% ),

the hazard ratio for incident hypertension was 95% [CI], 0.10-0.51.For five low-risk

factors (0.8%), (95% CI) for four low-risk factors (1.6%), and (95% CI) for three low-risk

factors (3.1% of the population).Body mass index alone was the most powerful predictor

of hypertension,(95%CI) The researcher concludes that, low-risk dietary and lifestyle

factors were associated with a significantly lower incidence of self-reported hypertension.

Adopting low-risk dietary and lifestyle factors has the potential to prevent a large

proportion of new-onset hypertension occurring among young women.25

A cross-sectional analysis of the Survey of Lifestyle, Attitudes and Nutrition

(SLÁN) was conducted in Ireland. They investigated socio\demographic and lifestyle

predictors of poor-quality diet in a population. The SLÁN survey is a two-stage clustered

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sample of 10,364 individuals aged 18 years. The study Results was Adjusting for age

and gender, a number of socio demographic, lifestyle and health-related variables were

associated with poor-quality diet: although the association with social support was

attenuated and that with food poverty was borderline significant (OR = 1·2, 95 % CI 1·03,

1·45).Concluded that Dietary quality was associated with social class, educational

attainment, food poverty and related core determinants of health.26

A cross-sectional and descriptive assessment was done on adherence of

hypertensive individuals to treatment and lifestyle change recommendations in Turkey.

The face-to-face interview method was used to collect data among 150 patients who were

followed by the outpatient clinics for at least one year. 94 (63%) were female, mean

duration of drug use was 6.5+/- 6.5 years and the mean number of drugs used was 1.6+/-

0.8. The adherence to recommendations of medication, diet, exercise, home-blood

measurement and smoking were 72%, 65%, 31%, 63% and 83%, respectively. 11% of

patients were adherent to one recommendation, 23% - to two, 29% - to three, 24% - to

four and 13% - to five. According to the regression analysis, factors effective on each type

of adherence were found to be different from others. The presence of three or more types

of adherence was related to income level (OR= 0.297; <0.001) and presence of any other

chronic disease (OR=2.329; p=0.002). It shows that the rates of adherence to medicine and

life-style changes were generally found to be low in hypertension and concludes that there

is a need to create awareness about the effectiveness of medicine and lifestyle changes in

managing hypertensive clients.27

A study was done on Effects of comprehensive lifestyle modification on diet,

weight, physical fitness, and blood pressure control: 18-month results of a randomized

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trial at multicentre in Portland,USA. Where 810 adult volunteers with prehypertension or

stage 1 hypertension was enrolled as multicomponent behavioral intervention that

implemented the established recommendations plus the Dietary Approaches to Stop

Hypertension (DASH) diet ("established plus DASH"); and advice only To compare the

18-month effects of 2 multicomponent behavioral interventions versus advice only on

hypertension status, lifestyle changes, and blood pressure..The main 6-month results from

the PREMIER trial showed that comprehensive behavioral intervention programs improve

lifestyle behaviours and lower blood pressure. Relative to the advice only group, the odds

ratios for hypertension at 18 months were 0.83 (95% CI, 0.67 to 1.04) for the established

group and 0.77 (CI, 0.62 to 0.97) for the established plus DASH group. Reductions in

absolute blood pressure at 18 months were greater for participants in the established and

the established plus DASH groups than for the advice only group.28

A study was conducted in Alta, Canada to provide updated, evidence based

recommendations for health care professionals on lifestyle changes to prevent and control

hypertension in otherwise healthy adults. For people who already have hypertension, the

options for controlling the condition are lifestyle modification, antihypertensive

medications or a combination of these options. The results were the health outcomes

considered were changes in blood pressure and in morbidity and mortality rates. It is

recommended that health care professionals must determine the body mass index and

alcohol consumption of all adult patients and assess sodium consumption and stress

level.29

The contemporary approach to the epidemic of elevated BP and its complications

involves pharmacologic treatment of hypertensive individuals and “lifestyle

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modification,” which is beneficial for both nonhypertensive and hypertensive persons in

Maryland. A substantial body of evidence strongly supports the concept that lifestyle

modification can have powerful effects on BP. Increased physical activity, a reduced salt

intake, weight loss, moderation of alcohol intake, increased potassium intake, and an

overall healthy dietary pattern, termed the Dietary Approaches to Stop Hypertension

(DASH) diet, effectively lower BP. The DASH diet emphasizes fruits, vegetables, and

low-fat dairy products and is reduced in fat and cholesterol. Other dietary factors, such as

a greater intake of protein or monounsaturated fatty acids, may also reduce BP but

available evidence is inconsistent. The current challenge to health care providers,

researchers, government officials, and the general public is developing and implementing

effective clinical and public health strategies that lead to sustained lifestyle modification.30

A study conducted on 661 hypertensive patients to investigate relationship

between blood pressure control status and lifestyle in Japan. It reveals that average BP

was 129 ± 10/71 ± 11 mmHg and overall rate of achieving goal BP was 60.1%. Achieving

rate of each target BP category was 83.3% in the elderly patients (<140/90 mmHg), 56.7%

in the young/middle patients (<130/85 mmHg) and 45.5% in the patients with diabetes

mellitus/chronic kidney disease/myocardial infarction (<130/80 mmHg). Adherence to

each item of lifestyle modification was as follows: Patients who answered to be conscious

about salt restriction was 80.9%, those with increased intake of fruits/vegetables was

79.0%, reduced intake of cholesterol/saturated fatty acids was 67.9%, presence of obesity

was 37.7%, daily exercise for ≥30 min was 31.9%, habitual alcohol intake was 38.0%,

habitual smoking was 9.8%. Only 22.5% of the patients had no lifestyle items to be

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modified. On the other hand, 19.6% of patients had more than 3 items to be modified.

Subjects with more than 3 lifestyle items to be modified are more frequently found in

young, male, and obese groups. In conclusion about 60% of the patients achieved goal BP

by the intensive combination therapy. It shows that the lifestyle modification seems to be

important especially for the young, male and obese patients.31

3. Literature related to diet and blood pressure

Randomized trials were done to investigate the long term effect of salt restriction

and blood pressure (BP) control status among Japanese hypertensive outpatients. Three

trials in normotensives (n=2,326), five in untreated hypertensives (n=387) and three in

treated hypertensive (n=801) were included, with follow up from six months to seven

years. Systolic and diastolic blood pressures were reduced at 13 to 60 months in those

given low sodium advice as compared with controls. (Systolic by 1.1 mm Hg, 95%,

diastolic by 0.6 mm hg, 95%) People on anti-hypertensive medications were able to stop

their medication more often on a reduced sodium diet as compared with controls, while

maintaining similar blood pressure control. Evidence from a large and small trial showed

that a low sodium diet helps in maintenance of lower blood pressure following withdrawal

of anti hypertensives.32

A Prospective cohort study was conducted on 5,532 hypertensive patients to

evaluate the association between diet and mortality in the Third National Health and

Nutrition Examination Survey in New York. Among these, 532 participants, 391 (7.1%)

consumed a DASH-like diet. During an average of 8.2 person-years of follow-up, there

were 1,537 all-cause deaths; this included 312 cancer deaths and 788 cardiovascular

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deaths, of which 447 were due to ischemic heart disease and 142 were due to stroke. After

adjusting for multiple confounders while accounting for the complex survey design by

utilizing survey weights, strata, and clusters in Cox proportional hazards models, a

DASH-like diet was associated with lower mortality from all causes hazard ratio (HR)

95% and stroke HR 95% . Mortality risk from cerebrovascular accident (HR 95%),

ischemic heart disease (HR 95%) and cancer (HR 95%) did not reach statistical

significance. The study concluded that, though findings for specific causes of mortality are

mixed, consumption of a DASH-like diet is associated with lower all-cause mortality in

adults with hypertension.33

A four-year randomized controlled trial assessed whether less severe hypertensive

could discontinue antihypertensive drug therapy, using nutritional means to control blood

pressure. The study population randomly allotted to three groups: group one--discontinue

drug therapy and reduce overweight, excess salt, and alcohol; group two--discontinue drug

therapy, with no nutritional program; or group three--continue drug therapy, with no

nutritional program. In groups one and two patients resumed drug therapy if pressure rose

to hypertensive levels. Loss of at least 4.5 kg (10 + lb) was maintained by 30% of group

one, with a group mean loss of 1.8 kg (4 lb); sodium intake fell 36% and modest alcohol

intake reduction was reported. At four years, 39% in group one remained normotensive

without drug therapy, compared with 5% in group two. The study findings demonstrated

that nutritional therapy may substitute for drugs in a sizable proportion of hypertensive or,

if drugs are still needed, can lessen some unwanted biochemical effects of drug

treatment.34

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A study conducted on 307 hypertensive patients to evaluate the effects on BP of a

return to the habitual diet following a dietary intervention period in Italy. The study

reveals that patients had reported having reverted to their habitual diet after a period of at

least 6 months on a prescribed low-energy and/or low-sodium diet. Nutritional habits were

investigated by a simple semi quantitative 24-item food-frequency

questionnaire. Patients were divided into tertiles according to their systolic BP. The

groups differed in regard to their body mass index (27.6+/-4, 28.7+/-4, and 30.4+/-6

kg/m(2), respectively, for the low- to high-systolic BP groups, but were similar in regard

to the number of antihypertensive pills taken (2.1+/-0.9, 2.2+/-1.2, 2.2+/-1.3) and

metabolic parameters. Patients in the lowest tertile consumed a diet significantly lower in

the percentage of energy from saturated fats and sodium content and significantly higher

in the percentage of energy from carbohydrate, and the fiber and potassium content in

comparison to the highest tertile. The number of servings of legumes, fish and cooked

vegetables was higher and that of salami and cheese lower in the 1st tertile. Definitively

changing a habitual diet to a healthier one is a difficult task for hypertensive patients. In

conclusion those who return to a diet richer in vegetables, legumes and fish and poorer in

saturated fat and salt achieve better control of their BP, without increasing the number of

antihypertensive pills.35

A study conducted on 436 patients to determine the effects of diet on plasma lipids,

focusing on subgroups by sex, race, and baseline lipid concentrations. The intervention

consisted of 8 wk of a control diet, a diet increased in fruit and vegetables, or a diet

increased in fruit, vegetables, and low-fat dairy products and reduced in saturated fat, total

fat, and cholesterol (DASH diet), during which time subjects remained weight stable. The

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main outcome measures were fasting total cholesterol, LDL cholesterol, HDL cholesterol,

and triacylglycerol. The result shows that the control diet, the DASH diet resulted in lower

total (−0.35 mmol/L, or −13.7 mg/dL), LDL- (−0.28 mmol/L, or −10.7 mg/dL), and HDL-

(−0.09 mmol/L, or −3.7 mg/dL) cholesterol concentrations (all P < 0.0001), without

significant effects on triacylglycerol. The net reductions in total and LDL cholesterol in

men were greater than those in women by 0.27 mmol/L, or 10.3 mg/dL (P = 0.052), and

by 0.29 mmol/L, or 11.2 mg/dL (P < 0.02), respectively. Changes in lipids did not differ

significantly by race or baseline lipid concentrations, except for HDL, which decreased

more in participants with higher baseline HDL-cholesterol concentrations than in those

with lower baseline HDL-cholesterol concentrations. The fruit and vegetable diet

produced few significant lipid changes. The study researcher concludes that the DASH

diet is likely to reduce coronary heart disease risk. The possible opposing effect on

coronary heart disease risk of HDL reduction needs further study.36

4. Literature related to dietary approaches to stop hypertension

A study was done in USA on dietary approaches to stop hypertension (DASH)

clinical trial: implications for lifestyle modifications in the treatment of hypertensive

patients where 459 participants were included for an 11- week period. Those randomized

to the combination diet (n = 151) had a significant change in systolic (-5.5 mmHg; p <

0.001) and diastolic blood pressure (-3.0 mmHg; p < 0.001) after subtracting the response

to the control diet (n = 154). The fruits-and-vegetables diet (n = 154) produced a

significant but lesser decrease in blood pressure (systolic, -2.8 mmHg; p < 0.001 and

diastolic, -1.1 mmHg; p = 0.07). Hypertensive individuals and African Americans had

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particularly favorable responses with blood pressure reductions, which were significantly

greater than other subgroups. The combination diet was well-accepted and adherence to

the diet was high (>90%) for all participants. The study shows that the DASH

combination diet is an effective lifestyle modification for lowering blood pressure in

patients with high-normal or Stage 1 hypertension. 37

A longitudinal observational study was conducted in Boston University Medical

Centre, for evaluating Weight, blood pressure, and dietary benefits after 12 months of a

Web-based Nutrition Education Program (DASH for health). After 12 months, 735(26%)

of 2,834 original enrolees were still actively using the program. For subjects who were

overweight/obese (body mass index > 25; n = 151), weight change at 12 months was 4.2

lbs. For subjects with hypertension or pre hypertension at baseline (n = 62), systolic blood

pressure fell 6.8 mmHg at 12 months. Diastolic pressure fell 2.1 mmHg. Based upon self-

entered food surveys, enrolees (n = 181) at 12 months were eating significantly more

fruits, more vegetables, and fewer grain products. They found that continuous use of a

nutrition education program delivered totally via the Internet, with no person-to-person

contact with health professionals, is associated with significant weight loss, blood pressure

lowering, and dietary improvements after 12 months.38

A longitudinal observational study was conducted on 112 participants for one year

in Durham, regarding the Dietary Approaches to Stop Hypertension (DASH)-Sodium trial.

The participants were divided equally into the control group and trial group. The trial

groups significantly increase in their intakes of fruits or juices and vegetables for 12

months. Control participants had no change in DASH food group intake. Both groups

increased sodium intake. Among control participants, systolic and diastolic blood pressure

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increased 5.33 and 3.20 mm Hg, respectively. Among DASH participants, systolic and

diastolic blood pressure increased 3.12 and 0.79 mm Hg, respectively. There was a

significant effect of the final sodium level by diet on the change in systolic blood pressure

over time. The study concluded that, DASH diet participants ate more fruits/vegetables

and had sustained reductions in blood pressure despite increased sodium intake.39

A randomized study was conducted on 412 participants were randomly assigned to

eat either a control diet typical of intake in the United States or the DASH diet to assess

the effect of different levels of dietary sodium in conjunction with the Dietary Approaches

to Stop Hypertension (DASH) diet, in persons with and in those without hypertension.

The participants were within the assigned diet, participants ate foods with high,

intermediate, and low levels of sodium for 30 consecutive days each, in random order. The

study result shows that, reducing the sodium intake from the high to the intermediate level

reduced the systolic blood pressure by 2.1 mm Hg (P<0.001) during the control diet and

by 1.3 mm Hg (P=0.03) during the DASH diet. Reducing the sodium intake from the

intermediate to the low level caused additional reductions of 4.6 mm Hg during the

control diet (P<0.001) and 1.7 mm Hg during the DASH diet (P<0.01). The DASH diet

was associated with a significantly lower systolic blood pressure at each sodium level; and

the difference was greater with high sodium levels than with low ones. As compared with

the control diet with a high sodium level, the DASH diet with a low sodium level led to a

mean systolic blood pressure that was 7.1 mm Hg lower in participants without

hypertension, and 11.5 mm Hg lower in participants with hypertension. The researcher

concludes that ,the reduction of sodium intake to levels below the current recommendation

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of 100 mmol per day and the DASH diet both lower blood pressure substantially, with

greater effects in combination than singly.40

A study was conducted on 412 participants to study the effects on Blood Pressure

of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH)

Diet in England. Participants were randomly assigned to eat control diet typical of intake

in the United States or the DASH diet. Within the assigned diet, participants ate foods

with high, intermediate, and low levels of sodium for 30 consecutive days each, in random

order. Study reveals that Reducing the sodium intake from the high to the intermediate

level reduced the systolic blood pressure by 2.1 mm Hg (P<0.001) during the control diet

and by 1.3 mm Hg (P=0.03) during the DASH diet. Reducing the sodium intake from the

intermediate to the low level caused additional reductions of 4.6 mm Hg during the

control diet (P<0.001) and 1.7 mm Hg during the DASH diet (P<0.01). The effects of

sodium were observed in participants with and in those without hypertension, blacks and

those of other races, and women and men. The DASH diet was associated with a

significantly lower systolic blood pressure at each sodium level; and the difference was

greater with high sodium levels than with low ones. As compared with the control diet

with a high sodium level, the DASH diet with a low sodium level led to a mean systolic

blood pressure that was 7.1 mm Hg lower in participants without hypertension, and 11.5

mm Hg lower in participants with hypertension. It concludes that reduction of sodium

intake to levels below the current recommendation of 100 mmol per day and the DASH

diet both lower blood pressure substantially, with greater effects in combination than

singly.41

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The Dietary Approaches to Stop Hypertension (DASH) Trial was designed to

assess the relation between modification of dietary patterns and hypertension in Boston.

DASH provides evidence that existing dietary recommendations can produce concrete

health results in a relatively healthy but sedentary population in which 50% of the

participants were women and 60% were African American. The results showed a 12.1%

decreased risk of CHD in the participants consuming the DASH diet compared with a

slightly increased risk in those consuming the control diet. The decrease was achieved in

the absence of changes in weight or physical activity. Reductions in blood lipids were

greater in men than in women, whereas the lipid response to diet did not differ

significantly between African Americans and non-African Americans.42

A study conducted on 810 participants in local community of Durham to examine

the influence of the PREMIER study lifestyle interventions on dietary intakes and

adherence to the Stop Hypertension (DASH) dietary pattern and the Dietary Reference

Intakes (DRI). An 18-month multicenter, randomized controlled trial comparing two

multicomponent lifestyle intervention programs to an advice only control group design

used. The two active intervention programs were a behavioral lifestyle intervention that

implements established recommendations, and an established intervention plus the DASH

dietary pattern. Both interventions consisted of intensive group and individual counseling

sessions. The control group received a brief advice session after randomization and again

after 6 months of data collection. Dietary intakes were collected by two random 24-hour

recalls at baseline, 6 months, and 18 months. The study results that participants in both the

established intervention and established intervention plus DASH dietary pattern groups

substantially reduced energy, total fat, saturated fat, and sodium intake and these

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reductions persisted throughout the study. Established intervention plus DASH dietary

pattern group participants increased intakes of fruits, vegetables, dairy, and many vitamins

and minerals; these increases were significantly greater than that of the control and

established intervention groups. A majority of established intervention plus DASH dietary

pattern group participants achieved at least two thirds of the DRI recommendations for

most nutrients at 6 months, despite their reduction in total energy intake. Some but

relatively small recidivism occurred at 18 months. The study concludes that in both

intervention were effective in helping participants follow established recommendations to

control blood pressure. The advice-only control group also made some behavior changes,

mainly decreasing energy and sodium intake. But intervention plus DASH dietary pattern

group developed intake of specific DASH food items. Whereas the established

intervention plus DASH dietary pattern group intervention provides a useful platform to

achieve the DASH dietary pattern and current DRI recommendations.43

A study conducted on 55 hypertensive patients to assess the BP response to

the DASH diet with an antihypertensive medication, losartan, in participants with essential

hypertension. Patients were assigned to 8 weeks of controlled feeding with either a control

diet or the DASH diet in USA. The study result shows that there was no significant

change in ABP during the placebo period on the control diet (n = 28), but there was a

significant reduction in systolic ABP and no change in DBP on the DASH diet (n = 27).

Losartan significantly reduced ABP on the control diet and to a greater extent on

the DASH diet particularly in African Americans. On the DASH diet, Delta SBP on

losartan was inversely related to basal plasma renin activity. The researcher concludes that

the DASH diet enhances the ABP response to losartan in essential hypertension.44

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5. Literature related to knowledge and effectiveness of structured teaching

programme

A study was conducted on 205 elderly patients to determine the prevalence,

awareness and control of hypertension among elderly community in Penang, Malaysia. In

this population there are 74 hypertensive patients resulting in an overall prevalence of

36%, with 81% of patients being initially aware of this diagnosis. This relatively low

hypertension prevalence rate may be because residents have a fairly sheltered lifestyle

with less social stress and a daily routine that incorporates adequate exercise. Similarly,

the high hypertension awareness rate compared to reported figures in the community may

be because residents are more regularly monitored by the attending medical care-givers.

At the beginning of the study, only 34% of hypertensive patients were well controlled

with a blood pressure less than 140/90 mm Hg. This proportion rose to 53% at the end of

study period showing that closer medical attention plays an important part in achieving

better outcomes. Compliance is better at a residential home because medication is served

by their care-givers and cost is absorbed in this charitable organization. This study

suggests that hypertension awareness and control can be reasonable for the elderly in a

residential home.45

A random household survey conducted on 482 individuals (212 males and 270

females) to determine the prevalence and possible risk factors for hypertension and

pre hypertensive state in Trivandrum City of Kerala (South India). Overall prevalence of

hypertension was 47% (n = 226) with equal sex ratio; 109 (21.6%) had stage-I

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hypertension, 45 (9.34%) had stage-II hypertension and 72 were taking drug treatment.

Only 55 (11.4%) individuals had normal BP, while 201 (41.7%) were pre hypertensives.

Only 81 (16.8%) hypertensive patients were aware of their disease. Among the parameters

such as dietary habits, physical activity, educational standards, salt intake, and diabetes

mellitus,Only high salt diet (P= 0.03) and diabetes mellitus (P= 0.004) had a significant

association with hypertensive state. The study concludes that prevalence of hypertension

is high but the awareness is low in our community, and intervention is necessary to

impose control measures and to improve awareness.46

A study on knowledge and perceptions about hypertension was conducted among

neo- and settled-migrants in Delhi, India .Data pertaining to blood pressure, height,

weight; socio-demographic details and knowledge and perceptions on hypertension were

obtained from a total of 453 individuals (227 neo-migrants and 226 settled-migrants) aged

20 years and above study results reveals that around 62% of respondents had heard of

blood pressure. This awareness was comparatively more among women and settled-

migrants. Less than half of the respondents considered hypertension a serious condition,

and a considerable proportion did not perceive that hypertension leads to other diseases.

With regard to prevention and control, more than one third suggested lessening tension

and anger followed by reducing salt intake/dietary changes, and a very small proportion

mentioned that exercise would help. Regarding treatment, three fourths of the respondents

considered that hypertension can be treated, mostly by medicines and only 10%

considered lifestyle changes along with medicines. The study concluded that knowledge

about hypertension was only moderate and comprehensive knowledge was lacking, and

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recommended for the awareness programme for preventing and controlling hypertension

along with the provision of primary health care services.47

A study findings congruent with the study to assess effectiveness of planned

teaching programme on healthy lifestyle modifications to prevent hypertension. The total

mean percentage of the pre-test knowledge score was 38.13% with mean and SD 15.25 ±

3.11 and the mean post-test knowledge score was 73.56% with mean and SD 29.41± 3.62.

Significance of difference between the pre-test and post-test knowledge scores was

statistically tested using paired ‘t’ test and it was found to be very highly significant

(t=31.505, P<0.005). The pre-test knowledge scores of the adolescents in relation to

selected demographic factors were compared and tested statistically using chi-square test.

Significant association (χ2=4.6952; P<0.05) was found between the pre-test knowledge

score of the adolescents and their exposure to previous information.48

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4. METHODOLOGY

This chapter comprises of the research approach used, research design, setting of

the study used, population, sample selection, sampling technique, development and

description of the tool, pilot study, method of data collection and plan for data analysis.

The study conducted was to evaluate the effectiveness of STP on knowledge regarding

DASH diet among Hypertensive patients.

1. RESEARCH APPROACH

In the present study, quantitative approach was considered to be the most

appropriate and adopted to assess the effectiveness of structured teaching programme on

knowledge regarding DASH diet among Hypertensive patients.

2. RESEARCH DESIGN

The research design selected for the present study was Pre-experimental one group

pre test and post test design in which pre-test was conducted followed by structured

teaching programme (STP) and then conducing post-test for the same group after 8 days.

(Table 1)

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Table 1: Description of the research design

Group Pre-test Intervention Post-test

Hypertensive patients

at Kumbalgudu PHC

area, Bangalore.

Day I

Assessment of

knowledge by

conducting structured

knowledge

questionnaires

regarding DASH diet

among Hypertensive

patients.

Day I

Structured teaching

programme on DASH

diet among

Hypertensive

patients.

After 8 days of

structured teaching

programme,

knowledge of

Hypertensive

patients is assessed

by conducting

same knowledge

questionnaires.

O1 X O2

Effectiveness of STP= O2 – O1

O1: Knowledge scores regarding DASH diet among Hypertensive patients before

intervention.

O2: Knowledge scores regarding DASH diet among Hypertensive patients after

intervention.

X: Structured teaching programme on DASH diet.

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3. SETTING OF THE STUDY

The study subjects were selected from the Kumbalagudu PHC area Bangalore. The study

conducted in Kumbalagudu, Gerupalya, Hospalya and Kanminke Colony.

i. Population

Population in the study consists of Hypertensive patients at Kumbalagudu PHC area,

Bangalore.

ii. Sample Size and Sampling Technique

The sample size for the present study is 60 Hypertensive patients at Kumbalagudu

PHC area, Bangalore and samples were selected by convenient sampling technique.

iii. Criteria for Selection of Sample

a) Inclusion Criteria

• Hypertensive patients who are available and willing to participate in the study.

• Hypertensive patients who can communicate in Kannada or English.

b) Exclusion Criteria

• Hypertensive patients who are sick at the time of data collection.

• Who have attended previous educational programme on DASH diet.

• Hypertension with diabetes mellitus patients.

4. TOOL OF RESEARCH

Based on the objectives of the study, a structured questionnaire was prepared in

order to assess the knowledge of hypertensive patients on DASH diet.

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a) Selection and Development of Instrument

A structured questionnaire was prepared to assess the knowledge of hypertensive

patients regarding DASH diet.

The tool was selected based on the research problem, review of related literature

and with suggestions and guidance of experts in the field of Community Health Nursing,

Medical Surgical Nursing, General Physician, Statistician, Dietician, English language

expert, Kannada Language expert, Psychologist and sociologist. The tool was prepared on

the basis of objectives of the study. The final tool was prepared with guidance and

suggestion of the guide. These steps were followed in preparing the tool:

• A thorough review of literature to provide adequate content and information.

• Consultation and discussion with experts from Community Health Nursing,

Medical Surgical Nursing, Statistician, Dietician, English language expert,

Kannada language expert, Psychologist and Sociologist.

• Reviewing of text books.

• Discussion and consultation with the statistician.

• The final tool was prepared and translated to Kannada with guidance and

suggestion of the guide.

b) Preparation of Blue Print

The blue print of the structured questionnaires was prepared according to the

demographic characteristics, knowledge of hypertensive patients regarding DASH diet.

The blue print consists of 34 items.

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c) Description of the Tool

After a thorough review of literature related to the topic and considering the

suggestions of experts a structured questionnaire was developed.

The structured questionnaires are of two parts:

Part I: Consists of 9 demographic characteristics of respondents seeking information such

as age, gender, religion, dietary pattern, educational status, occupation, monthly family

income, source of information regarding DASH diet, duration of disease.

Part II: Consists of 34 items pertaining to knowledge regarding DASH diet.

Scoring of the Items

There were 34 items. Each item has four options with one accurate answer. The

score for correct response to each item was “one” and incorrect response was “zero”. Thus

for 34 items maximum obtainable score was 34 and minimum score was zero.

Obtained Score

Percentage = -------------------------------× 100

Total Score

To find out the association with the selected demographic variables and knowledge

scores, respondents were categorize into three groups.

Below 50% - Inadequate knowledge

51-75% - Moderate knowledge

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Above 75% - Adequate knowledge

5. TESTING OF THE TOOL

• Content Validity

Content validity of the tool was established by obtaining the suggestions from

experts. The tool was validated by 10 experts in the field of Community Health

Nursing, Medical Surgical Nursing, General Physician, Statistician, Dietician, English

language expert, Kannada Language expert, Psychologist and sociologist.

Modifications were made on the basis of recommendations and suggestion of the

experts. After consulting guide and statistician, the final tool was reframed. Tool was

found to be valid and suitable for hypertensive patients.

• Reliability

The tool after the validation was subjected to test for its reliability. The reliability

of the tool was computed by split half Karl Pearson’s correlation formula (raw score

method). The reliability co-efficient of knowledge found to be 0.93 revealing the tool is

feasible for administration for the main study. Since the reliability co-efficient for scale

r > 0.70, the tool was found to be reliable and feasible. (r=2r / 1+r) Brown�s prophecy

formula was used.

6. DEVELOPMENT OF THE STRUCTURED TEACHING PROGRAMME

The structured teaching programme was developed based on the review of the

related research, journals, books and the objectives of the study.

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The following steps were adopted to develop the structured teaching programme.

• Development of content blue print.

• Development of structured teaching programme.

• Establishment of content validity of structured teaching programme.

• Pre-testing of structured teaching programme. Content blue print

A blue print of objectives and content items pertaining to knowledge of hypertensive

patients regarding DASH diet was prepared for the construction of structured teaching

program.

Preparation of structured teaching programme

(i) Preparation of first draft of structured teaching programme:

The first draft of structured teaching programme was developed based on the

objectives, criteria checklist, literature reviewed and the opinion of experts. The main

factors that were kept in mind while preparing structured teaching programme were:

literacy level of the sample, method of teaching to be adopted, simplicity of language,

relevance of teaching aids and attention span of hypertensive patients.

(ii) Content validity of the teaching plan The initial draft of structured teaching

programme was given to experts in the field along with the tool. The suggestions were

incorporated in the structured teaching programme and tool.

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(iii) Preparation of final draft of structured teaching programme

The final draft of structured teaching programme was prepared after incorporating

suggestions of the experts; the final teaching plan was finalized after the modifications

based on the suggestions of guide.

(iv) Selecting the method of teaching

Lecture cum discussion was selected as an appropriate method of teaching for

hypertensive patients.

(v)Selection and preparation of appropriate audio-visual aids

Chalk board and the charts were considered as visual aids to increase the impact of

teaching.

(vi)Planning to implement the structured teaching programme

The time and date to implement the structured teaching programme was planned and

decided in co-ordination with the hypertensive patients.

(vii) Determining the method of evaluating the structured teaching programme

The evaluation of structured teaching programme was planned through conducting

post-test after eight days of implementation of structured teaching programme.

(viii) Description of structured teaching programme

The STP was titled Dietary Approaches to Stop Hypertension. The structured

teaching plan was structured for one session, which was prepared to enhance knowledge

of hypertensive patients on DASH diet. It consisted of the following content area:

1. Defines hypertension

2. Lists out the causes for hypertension

3. Enumerates the risk factors for hypertension

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4. Explains the signs and symptoms of hypertension

5. Describes the complications of hypertension

6. Explains the importance of lifestyle modifications for control of hypertension

7. Discuss about dietary approaches to stop hypertension(DASH) diet

8. Define DASH diet

9. Explains the principles of DASH diet

10. Explains the importance of DASH diet

11. Discuss about components of DASH diet

7. PILOT STUDY

After having obtained formal administrative approval from the medical officer in

the Kumbalagud PHC, Bangalore, participants were informed about the purpose of the

study and consent was taken from them. The pilot study was conducted from the 7-09-

2012 to 14-9-2012. Data was collected from ten samples with the help of the structured

questionnaire schedule.

The subjects selected for pilot study were excluded in the actual study. The pre-

testing of the structured questionnaire was done to check the clarity of the items, their

feasibility, reliability and practicability. It was administered to ten hypertensive patients.

The samples chosen were similar in characteristics to the population under study. It was

found that each respondent took 35-40 minutes to complete the structured questionnaire

and it was found that the items were simple and comprehend.

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The mean percentage knowledge score in post-test (73.23%) was higher than the

mean percentage knowledge score in pre-test (41.47%). The percentage enhancement

(48.98%) was found to be significant at 5 % (p<0.05) level. The findings of the pilot study

revealed that the study is feasible.

8. PROCEDURE FOR DATA COLLECTION

(a) Permission from the concerned authority

Formal permission was obtained from the medical officer in Kumbalagudu PHC

Bangalore.

(b) Period of data collection

The data was collected from 2/11/2012 to 30/11/2012 for a period of 4 weeks at

Kumbalagudu PHC area (Kumbalagudu, Gerupalya, Kanminke) Bangalore.

(c) Pre-test (O1)

The structured questionnaire was used to collect the data by conducting structured

interview schedule from the hypertensive patients at Kumbalagudu PHC area, Bangalore.

After obtaining permission from the authority and consent from the subjects, the

investigator collected data from 60 hypertensive patients at their houses that took 35-40

minutes for each patient to complete the structured questionnaires.

(d)Implementation of Structured Teaching Programme (X)

Followed by pre-test, on same day structure teaching program was conducted in

Kannada by the investigator for a period of 50 minutes by using appropriate visual aids.

(e) Post-test (O2)

The same structured interview schedule was used to collect the post test data. Post

test data was collected on 8th day after Structured Teaching Programme.

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9. PLAN OF DATA ANALYSIS

The data obtained was analyzed based on the objectives of the study using

descriptive and inferential statistics.

Statistical analysis of data includes;

• Organization of data in master sheet.

• Frequencies and percentages to be used for analysis of demographic

characteristics.

• Calculation of mean, standard deviation of pre-test and post-test scores.

• Application of paired t” test to ascertain whether there is significant difference in

the mean knowledge score of pre-test and post-test.

• Application of Chi-square to find the association between demographic variables

with knowledge scores.

SUMMARY

This chapter dealt with research methodology which included the research

approach using one group pre-test post-test design, the setting and population, the

development of the instrument/tool, structured teaching programme, the description of

data collection, data collection procedure and plan for data analysis.

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Figure 2: Schematic Representation of Research Design

                                                                PURPOSE 

To evaluate the effectiveness of structured teaching programme on DASH diet among hypertensive patients 

                            TARGET POPULATION: Hypertensive patients                                   

 Convenient Sampling Technique 

                                                   SAMPLE 

             60 Hypertensive patients in Kumbalagudu PHC area, Bangalore 

TOOL

Structured questionnaire to assess the knowledge regarding DASH diet among hypertensive patients 

                         PRE‐TEST                                   

       STRUCTURED TEACHING PROGRAMME 

        POST‐TEST               

ANALYSIS

              Descriptive and Inferential ststistics 

INTERPRETATION OF STUDY FINDINGS

      ACCESSIBLE POPULATION: Hypertensive patients residing at         Kumbalagudu PHC area, Bangalore 

     REPORT

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5. RESULTS

Analysis and interpretation of data

Analysis is the categorizing, ordering, manipulating and summarization of the

data to obtain the answers to the research questions. The interpretation of tabulated data

can bring light to the real meaning and effectiveness of the findings.

This chapter presents the analysis and interpretation of the data collected from 60

hypertensive patients at Kumbalagudu PHC area, Bangalore.

A quantitative approach was adopted to assess the effectiveness of structured

teaching programme on Dietary Approaches to Stop Hypertension among hypertensive

patients.

The data was collected using structured questionnaires. The data collected from the

respondents were organized, tabulated, analyzed and interpreted by applying descriptive

and inferential statistics, based on the objectives of the study.

OBJECTIVES OF THE STUDY

1. To assess the level of knowledge of hypertensive patients regarding DASH

diet.

2. To assess the effectiveness of structured teaching programme on

knowledge of hypertensive patients regarding DASH diet.

3. To find association between knowledge of hypertensive patients and

selected socio demographic variables.

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PRESENTATION OF DATA

The data were entered into the master sheet, for tabulation and statistical processing.

The findings were classified and presented under the following headings.

1. Distribution of samples according to demographic variables.

2. Aspect wise & overall distribution of pre and post test knowledge scores.

3. Comparison between pre-test and post-test knowledge scores.

4. Association between pre-test knowledge scores and selected demographic variables.

SECTION-I

DISTRIBUTION OF PARTICIPANTS BASED ON DEMOGRAPHIC VARIABLES:

Table 2: Classification of respondents by age (years)

Demographic characteristics of sample Frequency (f) Percentage (%) Age (in years) 35-45 10 16.70

45-55 32 53.30

55 & above 18 30.00

Above table depicts that majority (53.30%) of the respondents belongs to the age group of

45-55 years, 30% of respondents were in the age group of 50 & above and 16.70% of

respondents were in the age group of 35-45years.

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Figure 3: Distribution of respondents by Age (years)

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Table 3 : Classification of respondants by gender

Demographic characteristics of sample Frequency (f) Percentage (%)

Gender Male 47 78.30

Female 13 21.70

The above table depicts that majority of the respondents (78.30%) were males and

remaining 21.70% were females.

Figure 4: Distribution of respondents by gender

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Table 4: Classification of the respondents by dietary pattern

Demographic characteristics of sample Frequency (f) Percentage (%)

Dietary pattern Vegetarian 02 3.30

Mixed 58 96.70

From the above table it is observed that the majority (96.70%) of respondents were

following mixed type of dietary pattern and remaining 3.30% were vegetarian.

Figure 5: Distribution of respondents by dietary pattern

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Table 5: classification of the respondents by education

Demographic characteristics of sample Frequency (f) Percentage (%)

Education No formal education 8 13.33

Primary education 7 11.68

Secondary education 20 33.33

Higher secondary

education

20 33.33

Graduation & above 5 8.33

The above table depicts that 33% of respondents had secondary education, 33% had

higher secondary education, 13.33% had no formal education, 11.68% had primary

education and remaining 8.33% were graduated.

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Figure 6: Distribution of respondents by education.

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Table 6: classification of the respondents by occupation

Demographic characteristics of sample Frequency (f) Percentage (%)

Occupation

Coolie 2 3.30

House wife 6 10.00

Agriculture 24 40.00

Private employee 27 45.00

Govt.employee 1 1.70

Above table depicts that 45% of respondents were private employees, 40% were

agriculturist, 10% were housewives, 3.30% were coolie and remaining 1.70% were Govt.

employees.

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Figure 7: Distribution of respondents by occupation.

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Table 7: classification of the respondents by monthly income

Demographic characteristics of sample Frequency (f) Percentage (%)

Monthly income

(Rs)

1,000-5,000 31 51.70

5,001-10,000 17 28.30

10,001-15,000 10 16.70

15,001 & above 2 3.30

Above table depicts that majority (51.70%) of respondents had income between1000-

5000, 28.30% of respondents had income between5,001-10,000, 16.70% of respondents

had income between 10,001-15,000 and remaining 3.30% had income between 15,0001

and above.

Figure 8: Distribution of respondents by monthly income

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Table 8: Classification of the respondents by source of information regarding

importance of diet in hypertension.

Demographic characteristics of sample Frequency (f) Percentage (%)

Source of information

Health personnel 29 48.30

Friends & Relatives

0 0

Mass media 0 0

No information 31 51.70

Above table depicts that majority (51.70%) of respondents had no information and

48.30% of respondents were aware of importance of diet in hypertension by health

personnel.

Figure 9: Distribution of respondents by source of information regarding importance

of diet in hypertension.

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Table 9: Classification of the respondents by duration of hypertension

Demographic characteristics of sample Frequency (f) Percentage (%)

Duration of

hypertension

(years)

< 1 19 31.70

1-3 21 35.00

4-6 17 28.30

>6 3 5.00

The above table depicts that 35% of the respondents had duration of hypertension for 1-3

years, 31.70% of the respondents duration of hypertension was <1 year, 28.30% of the

respondents have history of hypertension for 4-6 years and remaining 5% of the

respondents duration of hypertension was >6 years.

Figure 10: Distribution of respondents by duration of hypertension.

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2. Overall and aspect wise distribution of scores during the pre-test and post-test

Table 10: Overall and aspect wise pre-test mean knowledge scores.

Sl. No.

Aspect wise

No of items

Range Median Mean SD Mean %

1 Knowledge regarding Hypertension and its complications

10 0-8 4 3.83 1.48 38.30

2 DASH diet

24 2-18 7 7.51 2.87 31.30

Overall 34 6-26 11 11.35 3.6 33.40

Table 10: shows the mean knowledge score obtained by the patients in the aspect of

knowledge regarding hypertension and its complications for maximum score of 10 was

3.83(SD-1.48) and mean score percentage was 38.3, in the aspect of DASH diet mean

knowledge score obtained by patients for maximum score of 24 was 7.51(SD- 2.87) and

mean score percentage was 31.29. The overall knowledge score obtained by the patients

with hypertension in the pre test was 11.35 with standard deviation of 3.6 and mean score

percentage was 33.38.

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Table 11: Overall and aspect wise post-test mean knowledge scores.

From the above table it is observed that the mean knowledge score obtained by the

patients in the aspect of knowledge regarding hypertension and its complications for

maximum score of 10 was 7.51(SD-1.12) and mean score percentage was 75.1, in the

aspect of DASH diet mean knowledge score obtained by patients for maximum score of

24 was 18.75(SD- 1.72) and mean score percentage was 78.12. The overall knowledge

score obtained by the patients with hypertension in the post test was 26.26 with standard

deviation of 2.30 and mean score percentage was 77.23.

SI NO

Area wise No of items

Range

Median Mean S.D Mean %

1 Knowledge regarding Hypertension and its complications

10 4-10 7.5 7.51 1.12 75.1

2 DASH diet

24 14-23 19 18.75 1.72 78.12

Combined

34 21-30 26 26.26 2.30 77.23

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3. Comparison between pre test and post test knowledge scores

Table 12: Aspect wise enhancement of knowledge scores on Dietary approaches to

stop hypertension.

Knowledge

aspect

Pre –test

Post –test

Percentage

of

enhancement Mean

S.D

Mean S.D

Hypertension

3.83 1.48 7.51 1.12 96.08

DASH diet 7.51 2.87 18.75 1.72 149.66

Overall 11.35 3.6 26.26 2.30 131.36

It was found from the present study (table 12) that the mean knowledge score of 3.83 and

7.51 in the pre-test and post-test respectively was found in the aspect of hypertension, with

an enhancement of 96.08 percentages. The highest enhancement of knowledge (149.66%)

was observed in the aspect of DASH diet with pre and post-test mean of 7.51 and 18.75

respectively. The overall pre and post-test mean scores were 11.35 and 26.26 which gives

an enhancement of 131.36 percent.

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Figure 11: Distribution of aspectwise enhancement of knowledge scores on DASH.

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Table 13: Distribution of samples according to knowledge level on Dietary

approaches to stop hypertension.

Knowledge level

Classification of samples

Pre- test Post-test

Frequency (f) Percent (%) Frequency (f) Percent (%)

Inadequate (<50%) 39 65 0 0

Moderate (51-75%) 20 33.33 13 21.66

Adequate (>75%) 1 1.66 47 78.33

Total 60 100 60 100

Table 13: reveals that majority (65 %) of samples had inadequate knowledge, 33.33% had

moderate knowledge and 1.66% had adequate knowledge regarding dietary approaches to

stop hypertension in the pre-test. In the post-test, majority (78.33%) of the respondents

had adequate knowledge and 21.66% of the samples had moderate knowledge about the

topic.

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Figure 12: Distribution of respondents according to knowledge level on DASH.

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Table – 14: Aspect wise analysis of pre-test and post-test knowledge scores.

Aspect wise Pre –test Knowledge scores

Post –test Knowledge scores

t value (paired)

DF P value inference

Mean

S.D

Mean S.D

Hypertension

3.83 1.48 7.51 1.12 15.53 59 Significant <0.001

DASH diet 7.51 2.87 18.75 1.72 24.96 59 Significant <0.001

Overall 11.35 3.6 26.26 2.30 26.58 59 Significant <0.001

Note: *: Significant (P≤ 0.05); ** Highly significant (P≤ 0.001)

NS: Not significant (P>0.05)

The above table summarizes that the difference between the pre-test and post-test

mean knowledge score in the aspect of Hypertension is t=15.53 followed by DASH diet

t=24.96, were found to be highly significant. The calculated "t" value26.58 is greater than

the table value 2.106 at 0.05 level of significance. As there is increase in knowledge

scores among hypertensive patients in all the aspects of Dietary approaches to stop

hypertension after administering the structured teaching programme, the teaching

programme on Dietary approaches to stop hypertension was effective in terms of gain in

knowledge among Hypertensive patients.

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4. Association between pre test knowledge scores and selected demographic

variables.

Table – 15: Findings related to association between pre-test knowledge scores with

selected demographic variables.

Association between Age, Sex, Dietary pattern, and Education with level of knowledge

Category of response

Pre-test knowledge score Chi-square value

Df Critical value

Statistical Inference ≤ Median > Median Total

Age (yrs)

≤ 55 25 17 42

1.845 1 3.841 Not significant

> 55 14 4 18

Total 39 21 60

Sex

Male 30 17 47 Fisher's exact probability = 0.495

Not significant

Female 9 4 13

Total 39 21 60

Dietary pattern

Vegetarian 1 1 2 Fisher's exact probability = 0.581

Not significant

Mixed 38 20 58

Total 39 21 60

Education No formal/ Primary

9 6 15

1.790 2 5.99 Not significant

Secondary 16 5 21 Higher secondary/ Graduates

14 10 24

Total 39 21 60

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Association between Occupation, Income, Source of information and

Duration of HTN with level of knowledge

Category of response

Pre-test knowledge score Chi-square value

df Critical value

Statistical Inference ≤

Median > Median

Total

Occupation

Agriculturist 14 10 24

0.781 1 3.841 Not significant

Others (Private employee/ Housewife/ Coolie/ Govt. employee)

25 11 36

Total 39 21 60

Income

1001-5000 20 11 31

0.007 1 3.841

Not significant

> 5000 19 10 29

Total 39 21 60

Source of information Health personnel

18 13 31

1.356 1 3.841 Not significant

No information

21 8 29

Total 39 21 60

Duration of HTN (yrs)

< 1 15 4 19

2.592 2 5.99 Not significant

1- 3 13 8 21

> 3 11 9 20

Total 39 21 60

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Note: 1. The responses of some of the demographic variables have been merged as

the expected frequencies was less than or equal to 5.

2. Fisher’s exact probabilities are computed in a 2 x 2 contingency

tables where ever the expected cell frequencies are less than or equal to 5.

3. Not significant (P>0.05); Significant (P≤ 0.05)

The analysis of association between the selected demographic variables and the

overall knowledge score of hypertensive patients during pre-test reveals the following

information. The χ2 value was computed to find association between the pre-test knowledge

level of hypertensive patients on Dietary approaches to stop hypertension and selected

demographic variables. The calculated χ2 value is less than the critical value for all

demographic variables such as age, gender, religion, dietary pattern, educational status,

occupation, income, duration of hypertension and source of information were not

significant at 0.05 level. Thus research hypothesis (H2) was rejected for all the

demographic variables. Thus there is no significant association between pre-test knowledge

scores of hypertensive patients regarding DASH diet and selected socio-demographic

variables.

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6. DISCUSSION

Present study is to evaluate the “Effectiveness of a structured teaching programme on

knowledge of hypertensive patients on dietary approaches to stop hypertension in

Kumbalagud PHC area, Bangalore”.

A structured interview schedule was used to collect the data. A pre-experimental one-

group pre-test post-test design was used to evaluate the knowledge of 60 samples

(hypertensive patients) on dietary approaches to stop hypertension. The pre-test was

followed by implementation of structured teaching programme and post- test was

conducted after 7 days to evaluate the effectiveness of teaching programme.

The findings of the study are discussed under the following headings:

Section 1: Demographic characteristics

Section 2: Assessment of knowledge of hypertensive patients on dietary approaches to

stop hypertension .

Section 3: Evaluating the effectiveness of structured teaching programme on dietary

approaches to stop hypertension.

Section 4: Association between demographic variables and knowledge scores.

Section 5: Testing of the hypothesis.

Section 1

Demographic characteristics

In the present study, the findings reveal that majority (53.30%) of the respondents

belongs to the age group of 45-55 years, 30% of respondents were in the age group of 50

& above years and 16.70% of respondents were in the age group of 35-45years; regarding

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gender majority of the respondents (78.30%) were males and remaining 21.70% were

females; with regard to religion 100% of the respondents were Hindus.

In contrary to the findings of the present study a cross sectional study was conducted

to determine the age specific prevalence of hypertension and blood pressure levels in

relation to diet and lifestyle factors among North Indians, age range 25-64 years. The

study results that in both the sex, the prevalence rates and BP level increased with older

age.24

In relation to dietary pattern dietary pattern majority (96.70%) of respondents were

mixed type of dietary pattern and remaining 3.30% were vegetarian.

A study congruent with the present study findings a cross sectional survey was

conducted on 979 study participants in Sidama Zone, to assess the Prevalence and

determinants of hypertension in rural and urban areas. The Bivariate analysis shows that

hypertension was highly occurring more in those above 30 years old, those with the family

history of hypertension, and a BMI > or =25 kg/m2. Multivariate analysis showed similar

correlation of increased possibility of hypertension with being over 30 years, having a

family history of hypertension, a BMI > or =25 kg/m2 and excess meat consumption.23

With regard to education 33% of respondents had secondary education, 33% had

higher secondary education, 13.33% had no formal education, 11.68% had primary

education and remaining 8.33% were graduated; regarding occupation majority 45% of

respondents were private employees, 40% of respondent’s occupation was agriculture,

10% were housewives, 3.30% were coolies and remaining 1.70% were Govt. Employees;

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regarding monthly family income majority (51.70%) of respondents had income

between1000-5000, 28.30% of respondents had income between5,001-10,000, 16.70% of

respondents had income between 10,001-15,000 and remaining 3.30% had income

between 15,0001 and above.

A similar study supported by a cross-sectional analysis of the Survey of Lifestyle,

Attitudes and Nutrition (SLÁN). On 10364 individual to assess Sociodemographic, health

and lifestyle predictors of poor diets. The result shows that adjusting for age and gender, a

number of sociodemographic, lifestyle and health-related variables were associated with

poor-quality diet: social class, education, marital status, social support, food poverty (FP),

smoking status, alcohol consumption, underweight and self-perceived general health.

They were not significantly altered in the multivariate analysis, although the association

with social support was attenuated and that with food poverty was borderline significant

(OR = 1·2, 95 % CI 1·03, 1·45).26

With regard to source of information majority (51.70%) of respondents had no

information and 48.30% of respondents knew regarding importance of diet in

hypertension by health person; regarding duration of hypertension 35% of the respondents

gave history of 1-3 years, 31.70% of the respondent’s duration of hypertension was <1

year, 28.30% of the respondent’s duration of illness was 4-6 years and remaining 5% of

the respondents duration of hypertension was >6 years.

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Section 2

Assessment of knowledge of hypertensive patients on dietary approaches to stop

hypertension.

In the present study the pre test knowledge score of hypertensive patients on DASH

diet, majority (65 %) of samples had inadequate knowledge, 33.33% had moderate

knowledge and 1.66% had adequate knowledge.

Similar to the findings of present study a population-based survey of adults in

Northern Ireland was conducted on the awareness of hypertension or high blood pressure,

and of measures of prevention. Almost all subjects (92 per cent) had their blood pressure

checked, most within the last five years. The majority were aware that high blood pressure

is detrimental to health, but there was a low awareness of measures of prevention.49

Section 3

Effectiveness of structured teaching program on knowledge regarding Dietary

Approaches to Stop Hypertension among hypertensive patients.

The mean post-test knowledge score was 26.26 which is higher than mean pre-test

score of 11.35. The scores denoted that the structured teaching program was effective.

Thus, the research hypothesis, H1 was accepted by the researcher. Mean difference of pre

test and post test was 14.91. The significant difference between the pre-test and post-test

was tested by using paired ‘t’ test and level of significance was set at 0.05. The

computed‘t’ value of 26.58 is more than the table value of 2.1065 indicating that there is

significant difference between pre-test and post-test knowledge score. Thus, it clearly says

that the STP was effective in increasing the knowledge of subjects.

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Therefore, it was concluded that structured teaching programme was effective in

improving the knowledge of samples under study.

A study findings congruent with the study to assess effectiveness of planned

teaching programme on healthy lifestyle modifications to prevent cardiovascular diseases.

The total mean percentage of the pre-test knowledge score was 38.13% with mean and SD

15.25 ± 3.11 and the mean post-test knowledge score was 73.56% with mean and SD

29.41± 3.62. Significance of difference between the pre-test and post-test knowledge

scores was statistically tested using paired ‘t’ test and it was found to be very highly

significant (t=31.505, P<0.005).48

Section 4

Association between pre-test knowledge regarding DASH diet and selected variables.

There is no significant association found between knowledge scores with selected

sociodemographic variables like age, gender, religion, dietary pattern, education status,

occupation, income, source of information and duration of hypertension.

In contrary to the findings of the present study a cross-sectional analysis to investigate

sociodemographic and lifestyle predictors of poor-quality diet in a population was

conducted in Ireland. The study Results was Adjusting for age and gender, a number of

socio demographic, lifestyle and health-related variables were associated with poor-

quality diet: although the association with social support was attenuated and that with food

poverty was borderline significant (OR = 1·2, 95 % CI 1·03, 1·45).50

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Section 5

Testing of the hypothesis.

H1: There is significant difference between pre test & post test knowledge scores

regarding DASH diet among hypertensive patients.

The research hypothesis H1 stated in the study is accepted since there was significant

change found between the pre-test (38.3%) and post-test (75.1%) knowledge scores of

hypertensive patients regarding DASH diet as obtained paired t value(26.58 ) is greater

than table value(2.009575) at P < 0.05 level. Hence the stated research hypothesis H1 is

accepted.

H2: There is significant association between pre test knowledge scores with selected

demographic variables.

The computed χ2 values for selected demographic variables are less than the table

value at 0.05 level of significance. Hence the investigator reject the stated research

hypothesis because there is a no significant association between pre-test knowledge scores

and demographic variables like age, gender, religion, dietary pattern, education,

occupation, income, source of information and duration of hypertension.

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7. CONCLUSION

This chapter presents the conclusions drawn, implications, limitations, suggestions and

recommendations.

The focus of this study was to evaluate the Effectiveness of structured teaching

programme on the knowledge of hypertensive patients regarding DASH diet at

Kumbalagud PHC area, Bangalore. 60 samples were drawn from population using simple

random sampling technique. The data was collected by the structured interview schedule.

Data was analyzed and interpreted by applying statistical methods. The hypertensive

patients willingly participated in the study.

Further, the conclusion drawn on the basis of the findings of the study includes:

The overall mean and mean percentage of pre-test knowledge scores on DASH diet was

found to be 11.35 and 33.38% respectively. It indicates that the majority of the

respondents had inadequate knowledge on DASH diet.

The overall post test mean and mean percentage of knowledge score found to be

26.26 and 77.23% respectively. It indicates that STP was effective in enhancing the

knowledge of hypertensive patients regarding DASH diet.

On the other hand it was observed that sorce of information has significant association

with the respondent�s knowledge on DASH diet. But there is no significant association

found with other demographic variables such as age, gender, religion, dietary pattern,

education, occupation, income, and duration of hypertension.

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IMPLICATIONS

From the findings of the study, the following implications are stated. The

implications of this study are important in the areas of nursing education, practice,

administration and research.

Nursing education

Nursing education plays an important role in preparing the nurses for wellbeing of

the people in various areas. The present study has implication on nursing education. The

findings of the study in terms of its effectiveness may encourage the teachers and nursing

staff to impart education in an effective way. Nursing education should prepare nurses

with the potential for imparting health information effectively and assisting people in

developing their self-care potential. The nursing curriculum is a means through which

future nurses are prepared. The concept of health has been changing from time to time.

Traditionally, health has disease prevention as its central focus, which has emerged into

complex multidimensional models towards the phenomenon of health. In the present era,

more emphasis is given on preventive and promotive health aspects than curative.

Teachers need to be aware of their role in DASH diet. Nurse educators conduct health

education programme on DASH diet for hypertensive patients.

Nursing practice

The obligation of the nursing profession is the provision of care and service to the

human beings. Several implications may be drawn from the present study for nursing

practice. Health professionals, especially community health nurses should be motivated to

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give health teaching aspects of hypertension. They should regularly conduct health

education programmes and health camps in order to appraise the health status of each

hypertensive patient. These programmes should also help the student nurses to identify the

health problems of the hypertensive patients in their earlier stages and control them easily.

Thus, nurse plays an important role in early detection and treatment of hypertensive

diseases in community it directly helps for the effective implementation of health

education programme.

Nursing administration

Nursing administration is very important in the supervision and management of

nursing profession. The nurse administrators need to organize continuing nursing

programmes for nursing personnel and motivate them to conduct health education

programmes which are beneficial to the community. The nursing administrators should

see that adequate teaching time is allowed for the personnel for self-mastery during the

course so that they can apply their knowledge to different clients.

Nursing research

Nursing practice need to be based on scientific knowledge. Research should be

focused on health promotion programmes using various methods and techniques in

evaluating their effectiveness. Nurses can contribute to the profession to accumulate new

knowledge regarding different aspects of health education programme and can educate

and motivate the community towards health promoting activities.

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Limitations of the study

• The study is limited to Kumbalagudu PHC area, Bangalore.

• The study did not use any control group.

• The study assessed only knowledge component of hypertensive patients regarding DASH diet.

• Small number of respondents (60) limits the generalization of the study.

• Long-term follow-up could not be carried out due to time constraints. Recommendations

On the basis of the findings of the study following recommendations have been made:

• The study can be replicated in a larger sample in different settings.

• Follow up studies can be conducted to evaluate the effectiveness of the STP on

knowledge regarding complications of hypertension.

• A similar kind of study can be done among patients with cardiovascular diseases

for whom antihypertensive medication can be prescribed.

• A video assisted teaching can be done for a larger group.

• A similar study may be conducted in other back ward districts, taluks, villages etc.,

• Manuals, information booklets and self-instruction module may be developed.

• A long term study can be done to assess the impact of DASH diet.

• A study can be conducted using two groups, one as a control group and the other

as experimental group.

• A comparative study can be undertaken to compare the findings of the rural and

urban community.

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8. SUMMARY

Hypertension is the medical term for high blood pressure. It is defined as a

condition in which the patient repeatedly has high blood pressure readings. A high blood

pressure reading is 140/90 millimeters of mercury (mmHg) or higher. Hypertension is a

dangerous health condition that can be managed through personal behaviors such as eating

a healthy diet and engaging in regular physical activity, as well as taking medications that

lower blood pressure. Over a period of years, hypertension that is not controlled can cause

severe health complications such as neurological problems, metabolic diseases and organ

failure. The present study was to evaluate the effectiveness of STP on knowledge

regarding DASH diet among hypertensive patients at Kumbalagudu PHC area, Bangalore.

Objectives of the study

1. To assess the level of knowledge of hypertensive patients regarding DASH diet.

2. To assess the effectiveness of structured teaching programme on knowledge of

hypertensive patients regarding DASH diet.

3. To find the association between knowledge of hypertensive patients and selected socio

demographic variables.

Hypotheses:

H1: There is a significant difference between pre-test and post-test knowledge scores of

hypertensive patients regarding DASH diet.

H2: There is a significant association between knowledge scores of hypertensive

patients regarding DASH diet and selected socio-demographic variables.

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Limitations of the study

• The study is limited to Kumbalagudu PHC area, Bangalore.

• The study did not use any control group.

• The study assessed only knowledge component of hypertensive patients regarding

DASH diet.

• Small number of respondents (60) limits the generalization of the study.

• Long-term follow-up could not be carried out due to time constraints.

The present study aims at developing and evaluating structured teaching programme

regarding DASH diet.

The conceptual framework used in the study was based on the general system

theory by Ludwig Von Bertanlanffy (1969), the main focus is on the discrete parts and

their interrelationship, which consist of input, throughput and output.

In this study various literature were reviewed which includes, literature related to

prevalence and risk factors of hypertension, treatment and lifestyle modifications, DASH

diet, blood pressure and diet and effectiveness of training/teaching programme on

hypertensive patients.

The research design selected for the study was one group pre-test post-test design.

The independent variable was STP and dependent variable was knowledge of hypertensive

patients regarding DASH diet.

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The target population was hypertensive patients at Kumbalagudu PHC area,

Bangalore. Convenient sampling technique was used to select 60 hypertensive patients.

The tool developed and used for the data collection was structured questionnaire and

method of data collection was structured interview schedule.

The tool developed and used for the data collection was structured interview

schedule. 12 experts validated the content validity of the tool and the tool was found to be

reliable and feasible. The reliability of the tool was established by Spearman’s Brown

Prophecy formula where r = 0.93. The structured teaching programme consisted of various

aspects on DASH diet. The teaching plan was organized in sequence and in continuity.

Teaching plan was prepared with a view to enhance the knowledge of hypertensive

patients regarding DASH diet.

Pilot study was conducted on 7-09-2012 to 14-09-2012 as a part of the major

study, tool proved to be comprehensible, feasible and acceptable. The permission was

obtained from authorities of Kumbalagudu PHC area and hypertensive patients.

Data collection procedure for main study began from 1/11/2012 to 30/11/2012.

The investigator personally explained the need and assured them of the confidentiality of

their responses.

The pre-test was administered followed by a teaching programme; post-test was

administered 8 days after the teaching plan by using the same structured questionnaire

which used for pre-test.

The Data gathered were analyzed and interpreted according to objectives.

Descriptive statistics like mean, median and standard deviation, and inferential statistics

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like paired ‘t’ test was included to test the hypothesis and Chi-square test was included to

test the association of knowledge scores with demographic variables and the data obtained

are presented in the graphical form.

Major Findings of the Study

The major findings of the study were as follows:

A. Findings related to demographic characteristics of the subjects.

• Majority (53.30%) of the respondents were belonged to the age group of 45-55

years.

• Majority (78.30%) of the respondents were males.

• 100% of the respondents were Hindus.

• Majority (96.70%) of respondents consume mixed type of diet.

• Majority (33.33%) of respondents had secondary education and higher secondary

education, followed by no formal education (13.33%), primary education (11.68%)

and remaining (8.33%) were graduated.

• Majority (45%) of respondents were private employees.

• Majority (51.70%) of respondents had income between Rs.1000-5000/month.

• Majority (51.70%) of respondents had no information regarding DASH diet.

• 35% of the respondents had duration of hypertension for 1-3 years.

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B. Findings related to the pre-test and post-test mean percentage knowledge scores

of Hypertensive patients.

The mean knowledge scores of pre-test and post test are 11.35(SD-3.6) and

26.26(SD-2.30) respectively.

Highest pre test knowledge score obtained in the aspect of hypertension was

38.3%.

Highest post test knowledge score obtained in the aspect of DASH diet was

78.12%.

The overall post-test mean percentage knowledge score was found higher

(77.23%) when compared with pre-test mean percentage knowledge score

(33.38%).

Aspect wise enhancement of mean percentage knowledge scores in the aspect of

DASH diet was found higher (149.66%).

The statistical paired‘t’ test indicates that enhancement in the mean percentage

knowledge scores found to be significant at 5 percent level for all the aspects under

study.

C. Findings related to association between demographic variables and pre-test and

post-test mean percentage knowledge scores.

The Association between mean percentage knowledge score and demographic

variables were computed by using Chi-square test.

There was no significant association found between knowledge scores and selected

demographic variables such as age, gender, religion, dietary pattern, education,

occupation, income, source of information and duration of hypertension.

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ANNEXURE-A

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ANNEXURE-B

LETTER SEEKING EXPERT’S OPINION FOR THE CONTENT

Validity of the tool and Structured Teaching Programme

From,

Mr. Arun Babu

II year M.Sc Nursing,

Kempegowda College of Nursing,

Bangalore-560004.

To,

Forwarded through,

The Principal,

Kempegowda College of Nursing,

Bangalore- 560004.

Respected Sir/ Madam,

Sub: Requisition for expert opinion on content validity of the research tool.

I, Arun Babu, a post graduate student of Kempegowda College of Nursing, Bangalore, as

a partial fulfillment of the master degree in Community Health nursing of Rajiv Gandhi

university of medical sciences, Bangalore, have selected the below mentioned topic for the

dissertation.

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Title of the project: “Effectiveness of Structured Teaching Programme on knowledge

regarding DASH diet among hypertensive patients at a selected Kumbalagudu PHC

area, Bangalore.”

Objectives:

(i) To assess the level of knowledge of hypertensive patients regarding DASH

diet before the administration of structured teaching programme.

(ii) To assess the effectiveness of structured teaching programme on

knowledge of hypertensive patients regarding DASH diet.

(iii) To find the association between knowledge of hypertensive patients and

selected socio demographic variables.

I kindly request you to validate my structured questionnaire for its appropriateness and

relevancy.

I am here with enclosing the copies of

a) Structured Questionnaire.

b) Criteria rating scale/ check list.

c) Blue print for reference.

d) Content validity certificate.

I kindly request you to go through the content and give your expert and valuable

suggestions in the columns given and mark ( ) if you agree.

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90 

 

Your expert opinion and kind cooperation will be highly appreciated and gratefully

acknowledged.

Thanking you in anticipation,

Yours faithfully,

Place: Bangalore

Date: (Mr. Arun Babu)

Signature of guide: Signature of principal:

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ANNEXURE –C

CONTENT VALIDITY CERTIFICATE

This is to certify that the tool and Structured Questionnaire developed by Mr. Arun Babu

II year M.Sc Nursing student of Kempegowda College of Nursing, Bangalore (Affiliated

to Rajiv Gandhi University of Health Sciences) is validated by the undersigned and can

proceed to conduct the main study for dissertation entitled as “Effectiveness of

Structured Teaching Programme on knowledge regarding DASH diet among

hypertensive patients at a selected Kumbalagudu PHC area, Bangalore.”

Place:

Date:

(Name and Signature of the

expert with designation and

with seal of the institution)

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ANNEXURE-C (1)

CRITERIA RATING SCALE FOR VALIDATING THE STRUCTURED

KNOWLEDGE QUESTIONNAIRE ON DASH DIET.

Respected Madam/Sir,

Kindly go through the content and place the tick mark (√) against the questionnaire

in the following columns ranging from very relevant to not relevant. When the question is

found to be not relevant and needs modification kindly give your valid opinion in the

remarks column. The structured questionnaire is presented in 2 parts.

Part I: Consists of 9 items related to the Demographic variable under the study.

Part II: It is designed to elicit information regarding DASH diet.

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93 

 

Part-I

Sl.No. Very

Relevant

Relevant Needs

Modification

Not

relevant

Remarks

1.

2.

3.

4.

5.

6

7.

8.

9.

Part-II

Structured knowledge questionnaire on Hypertension and DASH diet

Sl No

Very Relevant

Relevant Needs modification

Not relevant

Remarks

1.

2.

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3.

4.

5.

6.

7.

8.

9.

10

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

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95 

 

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

Suggestions if any:

Over all opinion of the validator:

Signature of the validator

Name and address of the validator

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ANNEXURE D

LIST OF EXPERTS WHO VALIDATED THE TOOL AND STRUCTURED

TEACHING PROGRAMME

1. Mr. Sridhar M.Sc. (N)

Principal, HOD Medical surgical nursing

Fortis college of nursing

Bangalore.

7. Mr.Sibi Alexander

Head of the department

Medical Surgical Nursing

B.M.S Hospital Nursing college

Bangalore

2. Mr.Dinesh.S

Principal, Head of the department

Community Health Nursing

PadmashreeInstitute of Nursing

Bangalore

8. Mr. Gangaboraiah

Professor of Statistics

Kempegowda Institute of Medical

Science.

Bangalore-04

3. Mr.Prakash.H.D

Head of the department

Community Health Nursing

Governament college of Nursing

Bangalore

9. Dr.S.T.Yavagal.M.D,DM(Cardiology)

Professor& Head of the department

KIMS Bangalore

4. Mr.Prasanna Kumar.O

Lecturer & P.G.Guide

Department Community Health Nursing

Governament college of Nursing

Bangalore.

10. Dr.Keshav.H.K. M.B.B.S, M.D

Asst Professor Department of Medicine.

KIMS, Bangalore

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5. Dr.Threessiamma.P.M. MSc(N),PhD

Associate Professor

Head of the department

Community Health Nursing

Fortis Institute of Nursing

Bangalore

11. Dr.Kavitha.D.S

Dietician

M.Sc Food & Nutrition

KIMS Bangalore

6. Mrs.Shani.E.Mathew

Head of the department

Community Health Nursing

Vydehi Institute of Nursing

Bangalore

12. P.M.Arulmozhi Baskaran

Head of the department

Community Health Nursing

Narayana Hrudayalaya college of Nursing

Bangalore

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ANNEXURE – E

COPY OF THE CONSENT FORM

I am voluntarily willing to participate in the study conducted by Mr. Arun Babu on

“Effectiveness of Structured Teaching Programme on knowledge regarding DASH

diet among hypertensive patients at selected Kumbalagudu PHC area, Bangalore”. I

will also co-operate with the researcher in providing necessary information. I was

explained that the information provided would be kept confidential and used only for

above mentioned study purpose.

Signature of the Investigator Signature of the Participant

Date:

Place:

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ANNEXURE – F

STRUCTURED KNOWLEDGE QUESTIONNAIRE

QUESTIONNARE:

A structured knowledge questionnaire to assess the knowledge of hypertensive

patients regarding DASH diet.

In the present study, questionnaire is designed to elicit the knowledge of

hypertensive patients regarding DASH diet. The participants are requested to respond

accurately to the questions. The information provided by the participant will be

exclusively utilized for the partial fulfillment of P.G. programme and the information will

be kept confidential.

The questionnaire is presented in two parts:

• Part I: Consists of 9 items related to the demographic variables under the study.

• Part II: It is designed to elicit the knowledge of hypertensive patients regarding

DASH diet. It consists of 34 items.

Part-I

SOCIO DEMOGRAPHIC DATA

Sample code ________________ Dear participant,

I would like you to answer following questions related to your socio- demographic data. Kindly respond as accurately as possible.

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1. Age in years................................. 2. Gender a. Male [ ]

b. Female [ ] 3. Religion a. Hindu [ ]

b. Muslim [ ]

c. Christian [ ]

d. Any other specify……………. 4. Dietary pattern: a. Vegetarian diet [ ]

b. Mixed diet [ ] 5. Educational status ..................... 6. Occupation of the participant ................. 7. Family income per month (Rs).................. 8. Do you have source of information regarding importance of diet in hypertension: a. Yes/No......................

b. If Yes specify-----------

9. How long have you been diagnosed with hypertension? a. < 1 year [ ]

b. 1 - 3 years [ ]

c. 4 - 6 years [ ]

d. 6 years and above [ ]

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Part-II INSTRUCTIONS: I Mr. Arun Babu, student of MSc nursing, would like to ask some information about Dietary Approaches to Stop Hypertension.each answer has four options (a,b,c,d) , I request you to answer all the questions .

Questions regarding hypertension 1. Hypertension means: a. Increased blood pressure [ ]

b. Decreased blood pressure [ ]

c. Increased cholesterol level [ ]

d. Increased blood sugar level [ ] 2.one among the following is the normal value of Blood in adults (25- 35years) is: a. 140/70 mm of hg [ ]

b. 160/90 mm of hg [ ]

c. 120/80 mm of hg [ ]

d. 90/60 mm of hg [ ] 3. In Elderly (60-75 years), the average level of normal Blood Pressure is: a. 180/100 mm of hg [ ]

b. 140/90 mm of hg [ ]

c. 190/110 mm of hg [ ]

d. 195/11 5mm of hg [ ] 4. Risk factors for Hypertension are a. Hereditary and life style patterns [ ]

b. Reaction during blood transfusions [ ]

c. Through physical contact among patients [ ]

d. Harmful radiation from the sun [ ] 5. Hypertension is found most commonly among: a. Men between 20 - 25 years [ ]

b. Females between 25 -30 years [ ]

c. Females between 30 -35 years [ ]

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d. Men between 45 - 50 years [ ] 6. Hypertension can be most effectively controlled by: a. Exercise and Diet [ ]

b. Vaccination and First Aid [ ]

c. Accupuncture [ ]

d. Massage Therapy and Aromatherapy [ ] 7. One of the following drug which causes hypertension some times is: a. Pain Killers [ ]

b. Antibiotics [ ]

c. Birth Control Pills [ ]

d. Sleeping Pills [ ] 8.Regular exercise among hypertensive clients will help to: a. Increase the cholesterol levels in the body [ ] b. Increase the blood pressure [ ] c. Reduce the blood pressure in the long run [ ] d. Maintain the adequate minerals in the body [ ] Questions regarding complications of Hypertension 9. The body organs mainly affected by Hypertension are: a. Lungs, ears, stomach, spleen [ ] b. Heart, brain, kidneys & eyes [ ] c. Ear, nose & throat, stomach [ ] d. Muscle, rectum, colon & uterus [ ] 10. One of the following is not complication of hypertension: a. Heart attack [ ] b. ulcer [ ] c .Stroke [ ] d. Kidney failure [ ]

Questions regarding DASH diet 11. DASH stands for a.Dietary approaches to suppress hypertension [ ]

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103 

 

b. Dietary approaches to stimulate hypertension [ ] c.Dietary approaches to stop hypertension [ ] d.Dietary approaches to save hypertension [ ] 12. Dietary management of Hypertension includes: a. Liberal amount of fresh fruits and low fat foods [ ]

b. Oily and Fatty foods [ ]

c. Food rich in Iron and Calcium foods [ ]

d. Food rich in Sodium and Calcium [ ] 13. DASH diet helps to a. Increase blood pressure [ ] b.Control Hypertension [ ] c.Maintain normal body temperature [ ] d.Increase body weight [ ] 14. Rich source of sodium is: a. Fruits and dairy products [ ]

b. Canned food and bakery products [ ]

c. Green leafy vegetables [ ]

d. Grains and cereals [ ]

15. Sodium intake can be controlled by: a. Eating more meat and diary products [ ]

b. Adding canned foods in diet [ ]

c. Eating more fresh fruits and removing added salt from recipes [ ]

d. Increasing the intake of salads and ketchup [ ] 16. While buying frozen and canned foods one should observe for : a. Those rich in minerals and fat [ ]

b. Those labelled rich in sodium only [ ]

c. Those labelled rich in fat and sodium [ ]

d. Those labelled low in sodium or without added salt [ ] 17. While purchasing processed milk as a component of DASH diet one should opt for a. Rich in fat and protein [ ]

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b. Low in fat or fat free [ ]

c. Rich in sodium and vitamin c [ ]

d. Rich in potassium and sodium [ ] 18. One among the following should be considered while selecting sweets: a. Fat-free or low-fat cookies [ ]

b. Coconut cookies [ ]

c. Butter cookies [ ]

d. chocolate cookies [ ] 19. Fast foods should be consumed in moderate quantity because they: a. Are poor sources of Sodium and fat [ ]

b. Are high source of minerals [ ]

c. Help to maintain the water levels in the body [ ]

d. Increase sodium and cholesterol levels in the body [ ] 20. In hypertensive patients fat intake must be restricted to: a. 60 gm/day [ ]

b. 35 gm/day [ ]

c. 50 gm/day [ ]

d. 100 gm/day [ ] 21. Rich sources of low fat food group are: a. Egg and meat [ ]

b. Canned food and bakery products [ ]

c. Milk and milk products [ ]

d. Green leafy vegetables [ ] 22. One among the following is appropriate while consuming fruits: a. A piece of fruit with meals and one as snacks [ ]

b. A piece of fruit on a weekly basis [ ]

c. Fruit juice on a monthly basis [ ]

d. A piece of fruit on a monthly basis [ ] 23. Frequency and amount of consuming Nuts should be:

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105 

 

a.1/2 cup 4-5 times a week [ ]

b.1 cup4-5 times a week [ ]

c.1/3 cup 4-5 times a week [ ]

d.2 cup 4-5 times a week [ ] 24. Assorted spices beneficial in hypertension include one among the following: a. Rose water and Indian Pickle [ ]

b. Turmeric and Cardamom Seeds [ ]

c. Clover and Black Salt [ ]

d. Black pepper and basil [ ] 25. Fruits and Vegetables rich in Potassium and magnesium are: a. Tomatoes and Banana [ ]

b. Cabbage and Watermelon [ ]

c. Cucumber and Strawberries [ ]

d. Apple and onions [ ] 26. The quantity of salt intake for normal person per day is: a. 5-6 Teaspoon [ ]

b. 7 -8Teaspoon [ ]

c. 1 -4Teaspoon [ ]

d. 9 -10Teaspoon [ ] 27. Recommended salt intake for hypertensive patients per day is: a. 3 Teaspoon [ ]

b. 1 Teaspoon [ ]

c. 2 Teaspoon [ ]

d. 2/3 Teaspoon [ ] 28. Meat, poultry and fish products should be cooked by: a. Boiling with skin and fat [ ]

b. Fry deeply in oil [ ]

c. Trimming skin and fat then boil [ ]

d. Deep fry in butter or ghee [ ]

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106 

 

29. Best alternative to meat would be: a. Fatty foods [ ]

b. Sodium rich foods [ ]

c. Canned foods rich in saturated fats [ ]

d. Egg white [ ] 30. Cooking oil which is recommended for healthy living is: a. Groundnut oil [ ]

b. Sun flower oil [ ]

c. Coconut oil [ ]

d. Palm oil [ ] 31. While buying rice it is advisable to select one of the following: a. Basmati rice [ ]

b. White rice [ ]

c. Brown rice [ ]

d. Steamed rice [ ] 32. For normal person, ideal frequency of tea/coffee to be consumed in a day is: a. once [ ] b. Thrice [ ] c. Four times [ ] d. More than four times [ ] 33. With regard to coffee/tea intake DASH recommends: a. Have coffee/ tea as part of the weekly diet [ ] b. strictly avoid use of coffee/tea [ ] c. Have coffee/tea if you have high blood pressure [ ] d. Have coffee/tea twice on a daily basis. [ ] 34. One among the following statements is true with regard to smoking: a. Completely disregarded as they have no effect [ ] b. Encouraged as they help reduce tension [ ] c. Recommended as they have a positive effect [ ] d. Should be avoided as they have adverse effects [ ]

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ANNEXURE – F (1)

ANSWER KEY FOR STRUCTURED QUESTIONNAIRE

QUESTION

NUMBERS

KEY

ANSWERS

QUESTION

NUMBERS

KEY

ANSWERS

QUESTION

NUMBERS

KEY

ANSWERS

1 a 13 b 25 a

2 c 14 b 26 c

3 b 15 c 27 d

4 a 16 d 28 c

5 d 17 b 29 d

6 a 18 a 30 b

7 c 19 d 31 c

8 c 20 a 32 a

9 b 21 d 33 b

10 b 22 a 34 d

11 c 23 c

12 a 24 d

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108 

 

ANNEXURE – F (2)

BLUE PRINT OF STRUCTURED TEACHING PROGRAMME ON DASH DIET

Sl.No

Selected aspects on DASH diet

Knowledge Comprehension

Application Total no. of question

Percentage (%) Items No.

of qts.

Items No. of qts.

Items No. of qts.

1 Questions regarding hypertension

1,3

2 2,4,5 3 6,7,8 3

8 23.52

2 Questions regarding complications of hypertension

9 1 10 1 0 0

2

5.88

3 Questions regarding DASH diet

11, 14,23,24,25,26,27,3233.

9

12, 21, 22, 28, 29, 30, 34.

7

13, 15, 16, 17, 18, 19,20,31.

8

24

70.58

TOTAL 12 11 11 34 100

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109 

 

ANNEXURE – G

LESSON PLAN FOR STRUCTURED TEACHING PROGRAMME ON:

(Dietary Approaches to Stop hypertension)

Name of the investigator : Mr.Arun Babu

Group : Hypertensive Patients

Venue : Community area

Topic : DASH diet

Time : 45 Minutes

Size of the group : 5-10 members

Method of teaching : Lecture and Discussion

Language : Kannada and English

Audio Visual Aids : Flash Cards,charts

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OBJECTIVES

GENERAL OBJECTIVES:

At the end of the teaching hypertensive patients will gain in depth knowledge on Dietary Approaches to Stop Hypertension and

applies the same knowledge in control of hypertension.

SPECIFIC OBJECTIVES:

Hypertensive patients will be able to,

1. defines hypertension

2. lists out the causes for hypertension

3. enumerates the risk factors for hypertension

4. explains the signs and symptoms of hypertension

5. describes the complications of hypertension

6. explains the importance of lifestyle modifications for control of hypertension

7. discuss about dietary approaches to stop hypertension(DASH) diet

8. define DASH diet

9. explains the principles of DASH diet

10. explains the importance of DASH diet

11. discuss about components of DASH die

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111 

 

TIME

EXPECTED

OUTCOME

CONTENT

TEACHER

ACTIVITY

LEARNER

ACTIVITY

A.V aids

REAL LEARNERS

OUTCOME

2mins

5mins

Defines

hypertension

Lists out the

causes for

hypertension

1.DEFINITION

Hypertension is a persistent elevation of the systolic blood pressure at a level of 140 mm Hg or higher and the diastolic blood pressure at a level of 90 mm Hg or higher.

2.CAUSES FOR HYPERTENSION

The etiology of hypertension can be classified as either primary or secondary.

Primary hypertension:

The exact cause of primary hypertension is unknown. Several contributing factors of hypertension are

Increased sodium intake Greater than ideal body weight Diabetes mellitus Excessive alcohol consumption Cigarette smoking

Teacher defines

hypertension and

explains the meaning

of hypertension.

Teacher discusses

causes by using flash

cards.

Learners

listen

Learners

listen and

clarify their

doubts

Flash

cards

Flash

cards

What is

hypertension?

What are the

causes of

hypertension?

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112 

 

2mins

Enumerates

the risk factors

for

hypertension

Stress Elevated levels of cholesterol &

triglycerides Secondary Hypertension

Secondary hypertension is elevated blood pressure with a specific cause and often can be identified and corrected.

Causes are:

Renal diseases Tumor of the adrenal gland Neurologic disorders such as Brain tumor, head injury Estrogen replacement therapy Oral contraceptive pills Cirrhosis Pregnancy induced hypertension Non steroidal anti-inflammatory drugs

3.RISK FACTORS FOR HYPERTENSION

Age Alcohol Cigarette smoking Diabetes mellitus Elevated serum lipids

Teacher explain the

risk factors

Learners

listen and

clarify the

doubts.

Flash

card

What are the risk

factors for

hypertension?

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113 

 

2mins

Explains the

signs and

symptoms of

hypertension.

Excess sedentary sodium Gender Obesity Family history Ethnicity Sedentary lifestyle Socioeconomic lifestyle Stress

4. SIGNS AND SYMPTOMS • Referred as the “ silent killer” • Frequently asymptomatic until target

organ disease occurs or recognized on routine screening

• Symptoms often secondary to target organ disease.

• Can include: Fatigue, reduced activity

tolerance Dizziness Palpitations Dyspnea Headache Blurred vision Nausea and vomiting Chest pain and shortness of

breath.

Teacher explains the

signs and symptoms

of hypertension

Listeners

clarify

doubts

Flash

card

What are the

signs and

symptoms of

hypertension?

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114 

 

2mins

Discribes the

complications

of

hypertension.

5.COMPLICATIONS OF HYPERTENSION

• Target organ diseases occur most frequently in:

Heart Brain Peripheral vasculature Kidney eyes

• hypertensive heart disease coronary artery disease left ventricular hypertrophy heart failure

• cerebrovascular disease stroke

• peripheral vascular disease • nephrosclerosis • retinal damage • atherosclerosis • end stage renal disease • hemorrhage, blindness

6. LIFESTYLE MODIFICATIONS

The first line of treatment for hypertension is lifestyle change which includes: dietary

Teacher explains the

complications of

hypertension

Listener

listen

Flash

card

What are the

complications of

hypertension?

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115 

 

6mins

Explain the

importance of

lifestyle

modifications

for control of

hypertension

changes ,physical exercise, and weight loss. These have all been shown to significantly reduce blood pressure in people with hypertension. If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication.

a) EXERCISE:

• maintain normal body weight for adults (e.g. body mass index 20–25 kg/m2)

• engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week)

• exercising regularly

b) HABITS:

• limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women.

• Smoking should be avoided as they have adverse effects.

Discuss the lifestyle

modifications

Listener

listen

Flash

card

How lifestyle

modifications

are important in

Controlling

hypertension?

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116 

 

         c)  MEDICATIONS

Diuretics

Adrenergic inhibitors

Direct vasodilators

Angiotensin inhibitors

Calcium channel blockers

d) DIET

consume a diet rich in fruit and vegetables (e.g. at least five portions per day)

eating a nutritious, low-fat diet

decreasing salt (sodium) intake

e) FOLLOW-UP CARE The most important element in the management of high blood pressure is follow-up care.

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117 

 

2mins

Discuss the

dietary

approaches to

stop

hypertension

• Routine blood pressure check-up are important to monitor readings and decide upon a treatment plan.

• Routine physical examinations and screening blood tests may be suggested to help monitor the success of blood pressure management.

• Follow-up visits are a great opportunity for monitoring for other associated risk factors, such as high cholesterol, smoking cessation, and obesity.

7. DIETARY APPROACHES TO STOP HYPERTENSION(DASH) DIET

Introduction

DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet is a lifelong approach to healthy eating that's designed to help treat or prevent high blood pressure (hypertension).

The DASH diet may offer protection against

Teaches about

dietary approaches to

stop hypertension

Listeners

listen and

clarify

doubt

Flash

cards

and

charts

What are the

dietary

approaches to

stop

hypertension?

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118 

 

2mins

Define DASH

diet.

osteoporosis, cancer, heart disease, stroke and diabetes.

a) Meaning

The DASH diet encourages you to reduce the sodium in your diet and eat a variety of foods rich in nutrients that help lower blood pressure, such as potassium, calcium and magnesium.

8.Definition: DASH is an eating plan that,

• Is low in saturated fat, cholesterol, and total fat

• Focuses on fruits, vegetables, and fat-free or low-fat dairy products

• Is rich in whole grains, fish, poultry, beans, seeds, and nuts

• Contains fewer sweets, added sugars and sugary beverages, and red meats.

e.g. vitamins, garlic, fish oil, L-arginine, soy, herbs, phytosterols, and chelation therapy.

9.PRINCIPLES OF DASH DIET • Lowering blood pressure

Teacher defines

DASH diet

Learners

listen

Flash

card

What is dash

diet?

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119 

 

2mins

2mins

Explain

principles of

DASH diet

Explain

importance of

DASH diet in

hypertension.

• Lower the risk of heart disease, stroke and cancer.

• Support reaching and maintaining a healthy weight.

10.IMPORTANCE OF DASH DIET IN HYPERTENSION A Diet is not just a plan for losing weight; a diet refers to the way we eat. Dietetic management includes:

• Set up a healthy eating plan with foods low in saturated fat, total fat, and cholesterol, and high in fruits, vegetables, and low fat dairy foods such as the DASH eating plan.

• Write down everything that you eat and drink in a food diary. Note areas that are successful or need improvement.

• If you are trying to lose weight, choose an eating plan that is lower in calories.

Teacher explains

principles of DASH

diet

Teacher explains the

importance of DASH

diet in hypertension.

Learners

listen

Listeners

listen

Flash

cards

Chart

What are the

principles of

DASH diet?

What are the

importance of

DASH diet in

hypertension?

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120 

 

10mins

Discuss about

components of

hypertension.

11.Components of DASH diet

i. Protein In severe hypertension the protein has to be restricted to 20 gm/day where as the mild and moderate hypertensive can have 1 gm/kg body weight. For example if the person is 60kg then he can have 60 gms of protein / day. ii. Fats It is better to avoid high intake of animal fat which contain saturated fatty acids. The cholesterol rich foods such as liver, meat, egg yolk, crab and prawns should be minimised in the diet. The dietary fats should consist of vegetable oil like, olive oil and sunflower oil. The recommended fat for hypertensive patient is 60gms. iii.Minerals and Vitamins

• Low sodium and high potassium diet will help to lower high blood pressure. Moderate sodium restriction 2- 3 gm per day decreases diastolic blood pressure 6- 10 mm of Hg.

• Potassium intake should be increased.

Teacher discuss

about components of

hypertension

Learners

listen

Flash

cards

What are the

components of

DASH diet?

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Food sources of potassium should be increased to patients. For example apricots, tomato, chickoo, watermelon, banana, leafy vegetables, bitter gaurd, brinjal and potato should be included in the daily diet since they contain low sodium and high potassium. Hypertensive patients with kidney disease should avoid a high intake of potassium as it puts an excessive load on the kidney.

• Vitamins should be adequate to the recommended allowances that can be achieved by consuming fruits and vegetables.

Effect of sodium on Blood pressure Sodium: Essential in small amounts, Your body needs some sodium to function properly. Benefits of sodium � Helps maintain the right balance of fluids in your body

� Helps transmit nerve impulses

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� Influences the contraction and relaxation of muscles Hazards of sodium People who are sodium sensitive retain sodium more easily, leading to excess fluid retention and increased blood pressure. If you're in that group, extra sodium in your diet increases your chance of developing high blood pressure, a condition that can lead to cardiovascular and kidney diseases. Identification of food stuffs rich in sodium

• The best way to determine sodium content is to read food labels. The Nutrition Facts label tells you how much sodium is in each serving. It also lists whether salt or sodium-containing compounds are ingredients.

• Examples of these compounds include: Monosodium glutamate (MSG) ,Baking soda ,Baking powder ,Disodium phosphate ,Sodium nitrate or nitrite

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Main sources of sodium

� Processed and prepared foods, such as canned vegetables, soups, luncheon meats and frozen foods. .

� Sodium-containing condiments. One teaspoon of table salt has 2,325 mg of sodium, and 1 tablespoon of soy sauce has 1,005 mg of sodium. � Natural sources of sodium. Sodium naturally occurs in some foods, such as meat, poultry, dairy products and vegetables. For example, 1 cup of low-fat milk has about 110 mg of sodium. cut your sodium intake

• Eat more fresh foods and fewer processed foods.

• Eats lots of fresh fruits and vegetables. They need no added salt. They also increase potassium stores, which helps lower blood pressure.

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• Opt for low-sodium products. Look for unsalted snacks (if you need them) and foods that have reduced sodium.

• Limit the use of Salad dressings, sauces, ketchup and mustard all contain sodium.

• Use herbs, spices and other flavourings to enhance foods. Learn to flavor foods with lemon juice, parsley, garlic, or onions, instead of salt.

• Not adding salt when cooking rice or hot cereal.

• Buying foods labeled "no salt added," "sodium-free," "low sodium" or "very low sodium"

Lower sodium DASH diet: You can consume up to 1,500 mg (2/3 teaspoon of table salt) of sodium a day.

iv. Fluids

Fluid restriction is not necessary for

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hypertension unless the patient is having oedema and heart failure where the fluid restriction is regulated according to the urine output.

v. Grains (6 to 8 servings a day) Grains include bread, cereal, rice and pasta. Examples of one serving of grains include 1 slice whole-wheat bread, 1 ounce (oz.) dry cereal, or 1/2 cup cooked cereal or rice. Focus on whole grains because they have more fiber and nutrients than do refined grains. For instance, use brown rice instead of white rice and whole-grain bread instead of white bread. Look for products labeled "100 percent whole grain" or "100 percent whole wheat."Grains are naturally low in fat, so avoid spreading on butter or adding cream and cheese sauces. Some examples of whole grain food choices include: Brown rice, oatmeal, popcorn, whole wheat bread, noodles, corn flakes, white bread white rice.

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vi. Vegetables (4 to 5 servings a day)

Tomatoes, carrots, broccoli, sweet potatoes, greens and other vegetables are full of fiber, vitamins, and such minerals as potassium and magnesium. Examples of one serving include 1 cup raw leafy green vegetables or ½ cup cut-up raw or cooked vegetables.

Fresh or frozen vegetables are both good choices. When buying frozen and canned vegetables, choose those labelled as low sodium or without added salt.

Beneficial vegetables and spices for hypertension

A number of common vegetables and spices have beneficial effects in controlling hypertension. Incorporate these into your cooking. Alternately, you can make a tea or a vegetable soup.

Garlic: Garlic is a wonder drug for

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heart. It has beneficial effects in all cardiovascular system including blood pressure. In a study, when people with high blood pressure were given one clove of garlic a day for 12 weeks, their diastolic blood pressure and cholesterol levels were significantly reduced. Eating quantities as small as one clove of garlic a day was found to have beneficial effects on managing hypertension. Use garlic in your cooking, salad, soup, pickles, etc. It is very versatile.

Onion: Onions are useful in hypertension. What is best is the onion essential oil. Two to three tablespoons of onion essential oil a day was found to lower the hypertension. This should not be surprising because onion is a cousin of garlic.

Tomato: Tomatoes are high in gamma-amino butyric acid (GABA), a compound that can help bring down blood pressure.

Broccoli: This vegetable contains several active ingredients that reduce

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blood pressure. Carrot: Carrots also contain several

compounds that lower blood pressure. Saffron: It contains a chemical called

crocetin that lowers the blood pressure. You can use saffron in your cooking. You can also make a tea with it. Unfortunately, it is very expensive.

Assorted spices: spices such as fennel, oregano, black pepper, basil and tarragon have active ingredients that are beneficial in hypertension. Use them in your cooking.

vii.Fruits (4 to 5 servings a day) Many fruits need little preparation to become a healthy part of a meal or snack. Like vegetables, they're packed with fiber, potassium and magnesium and are typically low in fat. � Have a piece of fruit with meals and one as a snack, then round out your day with a dessert of fresh fruits topped with a splash of low-fat .

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viii. Dairy (2 to 3 servings a day) Milk, cheese and other dairy products are major sources of calcium, vitamin D and protein. But the key is to make sure that you choose dairy products that are low-fat or fat-free because otherwise they can be a major source of fat. Examples of one serving include 1 cup skim or 1% milk, 1 1/2 oz. cheese. Go easy on regular and even fat-free cheeses because they are typically high in sodium. ix.Lean meat, poultry and fish (6 or fewer servings a day) Meat can be a rich source of protein, vitamins, iron and zinc. But because even lean varieties contain fat and cholesterol, don't make them a mainstay of your diet — cut back typical meat portions by one-third or one-half and pile on the vegetables instead. Examples of one serving include 1 oz. cooked skinless poultry, seafood or lean meat, 1 egg. � Trim away skin and fat from meat and then broil, grill, roast or poach instead of frying.

� Fish: has always been considered health

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food. Fish oils are known to maintain blood pressure. Eat heart-healthy fish, such as salmon and tuna. These types of fish are high in omega-3 fatty acids, which can help lower your total cholesterol Consuming fish like Mackerel (Bangada), Tuna and Surmai at least thrice a week will help you reduce your daily dose of medicines.

x.Nuts, seeds and legumes (4 to 5 servings a week) Almonds, sunflower seeds, kidney beans, peas and other foods in this family are good sources of magnesium, potassium and protein. They're also full of fiber which are plant compounds that may protect against some cancers and cardiovascular disease. Serving sizes are small and are intended to be consumed weekly because these foods are high in calories. Examples of one serving include 1/3 cup (1 1/2 oz.) nuts, 2 tablespoons seeds or 1/2 cup cooked beans or peas. Soybean-based products, can be a good alternative to meat because they contain all of the amino acids your body needs to make a complete protein, just like meat.

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xi. Sweets (5 or fewer a week) You don’t have to banish sweets entirely while following the DASH diet – just go easy on them. Examples of one serving include 1 tablespoon sugar, jelly or jam. Whenever you eat sweets, choose those that are fat-free or low-fat, such as sorbets, fruit ices, jelly beans, hard candy, and low-fat cookies. xii. Alcohol and caffeine Drinking too much alcohol can increase blood pressure. The DASH diet recommends that men limit alcohol to two or fewer drinks a day and women one or less. The DASH diet doesn’t address caffeine consumption. The influence of caffeine on blood pressure remains unclear. But caffeine can cause your blood pressure to rise at least temporarily. If you already have high blood pressure or if you think caffeine is affecting your blood pressure. 12.DASH DIET CHART

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Food group Daily servings Serving sizes

Grains 6-8 1 slice bread

1 oz dry cereal

½ cup cooked rice, pasta or

cereal

Vegetables 4-5 1 cup raw leafy vegetable

1/2 cup cut-up raw or

cooked vegetable

1/2 cup vegetable juice

Fruits 4-5 1 medium fruit

1/4 cup dried fruit

1/2 cup fresh, frozen, or

canned fruit

1/2 cup fruit juice

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Fat – free or

Low- fat milk and milk

products

2-3 1 cup milk or yogurt

11/2 oz cheese

Lean meats, poultry and

fish

6or less 1 oz cooked meats, poultry,

or fish

1 egg+

Nuts, seeds and legumes 4-5 week 1/3 cup or 11/2 oz nuts

2 Tbsp peanut butter

2 Tbsp or 1/2 oz seeds

1/2 cup cooked legumes

(dry beans

and peas)

Fats and oils 2-3 1 tsp soft margarine

1 tsp vegetable oil

1 Tbsp mayonnaise

2 Tbsp salad dressing

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Sweets and added sugars 5 or less/week 1 Tbsp sugar

1 Tbsp jelly or jam

1/2 cup sorbet, gelatin

1 cup lemonadeB O X 3

Sodium 1,500 to 2,400

mg a day

1,500 mg of sodium equals

about 4 grams, or 2/3

teaspoon of table salt

CONCLUSION:

The patient with hypertension will achieve and maintain goal BP as defined for the

individual, understand, accept and implement the therapeutic plan.

Summary:

Hypertension is a silent killer disease which needs to be identify as early as possible and

manage with lifestyle modifications, especially dietary approaches are most important to

stop hypertension.

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Bibliography:

1.Lewis, Heitkemper, O’Brien. Medical-Surgical Nursing.7th edition. pp 761- 783.

2.Joyce. M. Black. Medical- Surgical Nursing. 7th edition.

3.Take a healthy diet to prevent hypertension:htt://www.blood.pressure.updates.com.

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ANNEXURE – H

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1) ������ (��������� )____________________________

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a) ��������� b) �������

5) ������������ ����_____________________________

6) ������______________________________

7) ������� ���� (��������)___________________________ 8) ���� ���������� ������� ���� ��������������

���������� a) ����/���� b) �������� (���������)

9) ����� ���� ���������� ���������� ����� �����

����� ���������� a) 1 �������� ����� b) 1-3 ���� ��� c) 4-6 ���� ��� d) 6 ����������� ������

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�����-II

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���� ��������������� ����������� ��������� ����� ����� ������������ ���� ����� �������������. ������ ���������� ������������ ������ ������������ ������� ������� ����� �������. �������� ���� ����� ����� ������������ ������������� ������.

1. ����� ������� �����, a) ���������� ���������� b) ���������� ������������� c) ������������� ��� ���������� d) ������� ��� ����������

2. �������������� ������� ������������ a) 140/70 �� �� ���� �� b) 140/90 �� �� ���� �� c) 120/80 �� �� ���� �� d) 90/60 �� �� ���� ��

3. ��������� (60-70�������� ) ������ ������������ a) 180/100 �� �� ���� �� b) 140/90 �� �� ���� �� c) 120/80 �� �� ���� �� d) 90/60 �� �� ���� ��

4. ���� ���������� ��������� �������� ��������� a) ���������� ����� ���� ������ b) ���� ���� �������������� �������� ������

���������� c) ������� �������������� ���������� d) ������ �������� �������

5. ���� ���������� ����������� ����������� a) 20-25 ����� ���������� b) 25-30 ����� ������������ c) 30-35 ����� ������������ d) 45-50 ����� ����������

6. ���� ��������������� ��������������

����������� ����� a) ������� ����� �������� b) ��������� ����� ����� ����� ������������ c) ������ �������� ����� �������� �����

������������

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d) ����� ����� ����� �������� ������������

7. �������������� ���� ������ ��������� ���� �������������� ���������������

a) ���� ������ ��������� b) ���� ��������� c) ���������� ��������� d) ������� ��������� 8. ���� ���������� ������� ������� �����������

���� ����������� a) �������� ����������� � ������ ����������� b) ���� ���������� ����������� c) �������������� ��������������� �����

��������� d) ���� ����o������� ������� �����������

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9. ���� �������������� ���������� ������ ���������� ���� ������

a) ��������, �������, ������, ����� b) ����,������,��������� ����� �������� c) ����, ����,����� ����� ������ d) ������, ������, ����������,�������

10. �������������� ���� ���� ������ ���������

�������������� a) �������� b) ������ c) ����� d) ��������� ������

11. DASH ����� ��������� a) ������ ���������� �� ����������� ����� ������� b) ������ ���������� �� ���������� ����� ������� c) ������ ���������� �� ������ ����� ������� d) ������ ���������� �� ���� ����� �������

12. ���� ��������������� ����������� ����������

���� ���� a) ������ ����� ����� ����� ����� ������� ����� b) ����� ����� ������ ��������� ���� c) ������� ��� ����� ���������� ��������� ���� d) ������� ��� ����� ���������� ��������� ���� 13. ���� ��������������� ����������� ���������

����� a) ���������� ����������� b) ���� ��������������� ���������� c) ������ ���� ����������� ����������� d) ���� ��� �����������

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14. ������� �������� ��� a) ����� ���� ����� ���������� ���������� b) �������� ���� ����� ����� ����� c) ����� ��������� d) ����� ����� ���� �������

15. ������� ���������� ����������� ����� a) ������ ���� ����� ���������� ��������� ����� b) �������� ��������� ���������� c) ���� ����������� ���������� ����� ��������

����� ����������� d) ����� ����� ����� ���� ����������� ����������

16. ������������ ����� ���������� ����

������������ ���������� �������������� ��� a) ������������ ������� ����� ������ ���������

��������� ���������� b) ������ ����� ���� ��������� ���������� c) ������ ����� ������ ��������� ���������

���������� d) ������ ����� ���� ���� ����� ���� �����������

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17. ���������� ������� ����� ���� �������� ����� ������� �������������������

a) ������ ����� �������� ��������� ���������� ����������

b) ������ ���������� ���������� ���������� c) ������ ����� ������� �� ���������� ����������

���������� d) ��������� ����� ������ ��������� ����������

���������� 18. ���� ����������� �������� �������������� ��� a) ������ ����� ���� ������ ����� ���� ������ b) ������ ������ c) ������ ������ d) �������� ������

19. ����� ���� ����������� ������� ���������

������ ������ a) ������ ����� ������� ������ ����� ������� ��� b) ��������� ���� ����������������� c) ��� ���� ����� �������� �������������������� d) ��� ��������� ������������ ����� �������

����������� �������������.

20. ���� ������� ��������������� ������� �������������������� ����� ������

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a) 28 ����� /��� b) 75 ����� /��� c) 50 ����� /��� d) 100 ����� /���

21. ����� ��������� ����� ������ a) ������ ����� ���� b) �������� ���� ����� ����� �������� c) ���� ����� ����� ���������� d) ����� ���������

22. ������� ������� ������������ � ��������������

����������� a) ������� ���� ����� ����� ���� �������� ����

����� ����� ��������� b) ������� ���� ����� ����� ��������� c) �������� ���� �� ������ �� ��������� d) �������� ���� �� ���� ����� ����� ��������� 23. �� ��������� ���������� ������ a) ½ ��� ������� 4-5 ���� b) 1 ��� ������� 4-5 ���� c) 1/3 ��� ������� 4-5 ���� d) 2 ��� ������� 4-5 ����

24. ���� ���������� ���� ��������� ����� �����

������������ a) ������ ���� ����� ���������� b) ������ ����� ������ c) ���� ����� ��������� d) ���� ����� �����

25. ��������� ����� ����������� ����

�������������� ����� ����� ������ a) ����� ����� ���� ����� b) �������� ����� �������� ����� c) ������ ���� ����� ������������ d) ���� ����� �������

26. ��������� ��������� �����������

���������������� ������ ������ a) 5-6 �� ��� b) 7-8 �� ��� c) 1-4 �� ��� d) 9-10 �� ���

27. ���� ���������� ������� �����������

���������������� ������ ������ a) 3 �� ��� b) 1 �� ���

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c) 2 �� ��� d) 2/3 �� ��� 28. ���� ����� ����� ����� ����� ����� a) ������ ����� ���� ������� ��������� b) ���������� �������� c) ���� ����� ������ ������ ��������� d) ������ ����� ���������� ��������

29. ����� ���� ����������� ���� a) ��������������� ���� b) ����� ��������� ���� c) ������ ������� ��������� �������� ������� d) ������� ����� ��� 30. ����� �������� �������� ����� a) ���� ����� b) ���������� ����� c) ������ ����� d) ���� �����

31. ���������� ���������� ��������������� ��� a) ������� ����� b) �������� ����� c) ���� ����� d) ������� �����

32. ���� ������� ��������� ������������ ���� ����

�������� ���������������� ������ a) ���� �� b) ���� �� c) ������ �� d) ����������� ������ ��

33. ���� ��������������� ����������� ��������� ������ ��������� ���������� ����

a) ����������� ���������� b) ������ ���������� c) ���� ����������������� ������ �������� d) ������� ���� �� ������ ��������

34. ���������� ������������ � ��������������

���������� a) ��� ������ ������ ����������� ���� �����������

������������� b) ��� ������ ����� ����������� �������� c) ��� ���� ���� ������ ������ ��������� d) ������ ���� ������������������ ��������.

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ANNEXURE – I

���� ��������������� ����������� ��������� ����� �������� ����� ���������

���������� ������� ����� : ����� ����

����� : ���� ����������� �������

���� : ������ �������

���� : ���� ��������������� ����������� ��������

��� : 45 �����

����� ������ ���� : 5-10 ����

����� ����� :����� ����� �����

���� : ����� ����� �����

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(������� 4 -5 ��) ����� ����������� ������� ����������. ����������� ����������� �������,���������� ����� �������� ��������������� ���� ������ ��������������.���������� ������� ���� ���������� ��������� ����� ����������� ������ ��������������� �������������������.

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