Community-based interventions in hypertensive patients: a comparison of three health education strategies

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1 Lu et al. BMC Public Health (2015) 15:33 DOI 10.1186/s12889-015-1401-6 RESEARCH ARTICLE Open Access Community-based interventions in hypertensive patients: a comparison of three health education strategies Chu-Hong Lu1,2, Song-Tao Tang2, Yi-Xiong Lei1, Mian-Qiu Zhang2, Wei-Quan Lin1, Sen-Hua Ding2 and Pei-Xi Wang1* Abstract Background: Community-based health education programs may be helpful in improving health outcomes in patients with chronic illnesses. This study aimed to evaluate community-based health education strategies in the management of hypertensive patients with low socioeconomic status in Dongguan City, China. Methods: This was a randomized, non-blinded trial involving 360 hypertensive patients enrolled in the community health service centre of Liaobu Town, Dongguan City, China. Participants were randomized to receive one of the three community-based health education programs over 2 years: self-learning reading (Group 1), monthly regular didactic lecture (Group 2), monthly interactive education workshop (Group 3). Outcomes included the changes in the proportion of subjects with normalized blood pressure (BP), hypertension-related knowledge score, adherence to antihypertensive treatment, lifestyle, body mass index and serum lipids. Results: After the 2-y intervention, the proportion of subjects with normalized BP increased significantly in Group 2 (from 41.2% to 63.2%, p

2 Lu et al. BMC Public Health (2015) 15:33 Page 2 of 9 patients taking a more positive role in the management Participants and intervention of their health [6-10]. However, it is unclear what health Patients were recruited among hypertensive patients educational strategy works best in improving patients managed at the Community Health Service Centre in knowledge on hypertension and possibly clinical out- Liaobu Town, Dongguan City, China. Patients were comes in hypertensive patients. There is now an in- eligible if they met the following inclusion criteria: a creasing community-based effort in the prevention and clinical diagnosis of hypertension; conscious (capable of control of hypertension in China. Hypertension is a effective oral communication without help); age between major chronic disease that is often managed at commu- 40 and 75 years; completed primary school or higher nity health service centers in China. Health education education; able to communicate with educators; avail- may play a key role in the management of hypertensive ability to participate in assigned health education acti- patients [11,12]. The common tools of health education vities. Patients were not eligible if they met anyone of in community health centers in China include health post- the following exclusion criteria: pregnancy; mental dis- ers, health booklets, individualized lecture, and public lec- orders, dementia or cognitive impairment; other serious ture [13]. As a developing country, health education is still diseases with the need for special care such as malignant in an experimental stage in Chinese communities. There tumors, heart failure, kidney disease, AIDS. are some limitations in most currently available health The recruitment was conducted in September 2011. education programs in China. The contents in most With an estimated proportion of normalized blood health education programs are often difficult to under- pressure at 40.0% after 2-y of BP control medications, a stand for lay readers, considering that most patients have sample size of 102 per group is required to detect an relatively low educational levels. The educational methods improvement to 56.0% in normalized BP after the health may be somewhat boring and ineffective [14]. education intervention, with an alpha error of 5% and a The community health service center in Liaobu Town, power of 90%. In our study, a total of 360 eligible patients Dongguan City in recent years developed an interactive agreed to participate in the study. They were assigned health education workshops program in the manage- randomly to one of the three health education on ment of hypertensive patients. It is one of the national hypertension groups by a statistician who was blinded to health education demonstration project, and the first the intervention using a computer-generated random one to implement comprehensive health education fo- sequence number. Group 1 (self-learning reading, n=120) cusing on patients participation through dynamic and participants received orientation on reading materials to interactive workshops. The educational tools include learn knowledge on hypertension through the poster text cartoon pictures and animations illustrating cardiovascu- lar disease progress models, treatment and prevention measures. It is designed to accommodate the educational levels of the majority of hypertensive patients (primary "Hypertension health education syllabus and materials" ready or middle school) managed at community health centers in China. The aim of this study was to evaluate this new Identify and recruit hypertensive interactive health education workshops program in com- patients (n=360) parison with two common health education strategies (self-learning reading, regular didactic lecture) by asses- Carry out baseline survey sing the changes in hypertension-related knowledge, antihypertensive medications adherence, lifestyle and Randomized into three health anthropometric, biochemical and clinical parameters. education groups Methods Study design Group 1: self-learning Group 2: regular Group 3: interactive This study was a randomized, non-blinded community- reading (n=120) lecture (n=120) lecture (n=120) based health education trial involving 360 participants at the Community Health Service Centre in Liaobu Town, Drop-outs: 4 Drop-outs: 6 3 Drop-outs: 3 Dongguan City, China. The study was approved by the Research Ethics Board of Guangzhou Medical University (Guangzhou, China). Informed consent was obtained 2-y post-intervention 2-y post-intervention 2-y post-intervention follow-up survey: 116 follow-up survey: 114 follow-up : survey 117 from all study participants. The trial was registered at Chinese Clinical Trial Registry (registration number Figure 1 Flowchart illustrating patient recruitment and follow-ups in a community-based health education intervention trial in ChiCTR-OPC-14005283). We followed the CONSORT hypertensive patients in Liaobu Town, Dongguan City, China. guidelines in reporting RCTs.

3 Lu et al. BMC Public Health (2015) 15:33 Page 3 of 9 messages on blackboards and health education booklets absentees, the next available lecture would be arranged monthly. Group 2 (regular lecture, n=120) participated in within a month. a public didactic lecture on hypertension monthly by The health education on hypertension intervention phone invitation. Each lecture lasted about 30 minutes. lasted two years from September 2011 to October 2013, Group 3 (interactive education workshop, n=120) partici- and the study flowchart is presented in Figure 1. The pated in an interactive participatory education workshop health education on hypertension syllabus was deve- on hypertension knowledge monthly. The interactive loped by cardiovascular experts. The health education education workshop on hypertension was given through syllabus is comprised of 5 chapters with 60 sections, the active involvement of participants in the use of visual including hypertension-related knowledge, healthy diet, health education tools (cartoon pictures, animation, food regular physical exercise, alcohol drink and cigarette models, salt spoons, oil pots, pedometer and cardiovascu- smoking cessation, and adherence to anti-hypertensive lar disease models). The number of individuals in group 2 medications. The learning materials were disseminated and group 3 shall not be less than 10 in each class. For through the three different health education strategies. Figure 2 CONSORT flow diagram of participant allocation, follow-up and analysis.

4 Lu et al. BMC Public Health (2015) 15:33 Page 4 of 9 The numbers of drop-outs were 4, 6 and 3 in groups 1, modifications were assessed on self-reported salt intake, 2, and 3, respectively, leaving 116, 114 and 117 subjects physical activity, smoking and alcohol use, according to in the three groups, respectively, at the end of the the Chinese guidelines for prevention and treatment of study intervention for assessing the intervention effects hypertension [15]. Appropriate salt intake was defined as Figure 2. a salt intake of no more than 6 g per day, as estimated from monthly home consumption of salts divided by the Measurements of intervention effects product of 30 days multiplied by the number of indi- The primary outcome was the change in the proportion viduals in the household. Regular physical activity was of subjects with normalized BP after the 2-y health defined as moderate exercise lasting no less than 30 mi- education intervention. Other outcomes included the nutes, >=3 times per week. Current smokers were de- changes in hypertension-related knowledge, lifestyle, fined as those who smoked at least one pack of cigarette anthropometric, biochemical (serum lipids) and clinical per month over the last 6 months. Alcohol drinkers parameters. were defined as those who drank alcohol at least once per Hypertension related knowledge was scored based on week over the last 6 months. participants responses to questions (Table 1). Self-reported Blood pressure (BP) was measured on the right arm regular use of medications for hypertension refers to strict using the mercury sphygmomanometer, and the average of adherence to medications following the medical instruc- three readings was taken. Systolic/diastolic blood pressures tions - defined as the number of missed medications less were classified as normal (

5 Lu et al. BMC Public Health (2015) 15:33 Page 5 of 9 hip bone using a non-extendable tape. Serum lipids levels married. There were more women than men in each of were obtained from regular clinical tests, including fas- the three study groups. Over 80% participants had com- ting total cholesterol, triglycerides, LDL-cholesterol, HDL- pleted education less than high school. cholesterol. The effect of health education on hypertension Data analysis knowledge, adherence to medications treatment and The trials primary outcome (BP) was assessed by the lifestyle (Table 3) general practitioners in the community health centres At the baseline, most participants (about 2/3) did not who were blinded to the intervention group, and research regularly take BP lowering medications. After the 2-year assistants recorded the data in EXCEL. A statistician who health education intervention, there were statistically was blinded to the intervention analyzed the data. using significant increases in hypertension-related knowledge the statistical analysis software SPSS 13.0. To compare the scores in all the three intervention groups. However, the changes in outcomes after vs. before the intervention in increase was significantly greater in the interactive edu- study participants, paired t-test (for continuous variables) cation workshop group 3 (mean score increased from or paired Chi-square test (for dichotomous variables) was 3.4 to 8.6) than in the regular lecture group 2 (mean used. To compare the differences among the three inter- score increased from 2.7 to 6.6) or self-learning reading vention groups at the baseline and after the intervention, group 1 (mean score increased from 3.6 to 5.8). Regular ANOVA (for continuous variables) or Chi-square test use of medications for hypertension and regular physical (for categorical variables) was applied. Logistic regression activity were significantly more frequent after the inter- analysis was used to estimate the odds ratio (OR) of vention in all the three groups, but the improvements normalized BP (

6 Lu et al. BMC Public Health (2015) 15:33 Page 6 of 9 Table 3 Baseline and post-intervention hypertension knowledge score, adherence to antihypertensive medications and lifestyle variables in hypertensive patients by mode of health education on hypertension (Group 1, reading n=116; Group 2, regular lecture n=114; Group 3, interactive workshop, n=117) Group Baseline Post-intervention Pa Pb Pc Hypertension knowledge

7 Lu et al. BMC Public Health (2015) 15:33 Page 7 of 9 Table 4 Baseline and post-intervention anthropometric, clinical and biochemical parameters in hypertensive patients by mode of health education on hypertension (Group 1, self-learning reading; Group 2, regular lecture; Group 3, interactive workshop) Group Baseline Post-intervention Pa Pb Pc Normalized blood pressure 0.872

8 Lu et al. BMC Public Health (2015) 15:33 Page 8 of 9 Table 5 Adjusted ORs of normalized blood pressure in general, the improvements in clinical risk factors (e.g. hypertensive patients after health education intervention LDL) were the best in the interactive education work- Variable Normalized blood pressure shop group. The only exception is that the improvement (

9 Lu et al. BMC Public Health (2015) 15:33 Page 9 of 9 regular use of medications. Nevertheless, we expected 7. Wade AH, Weir DN, Cameron AP, Tett SE. Using a Problem Detection Study that such inaccuracies in self-reported data were random (PDS) to identify and compare health care provider and consumer views of antihypertensive therapy. J Hum Hypertens. 2003;17:397405. and would not affect the validity of the comparisons. 8. Horne R. One to be taken as directed: reflections on non-adherence (non-compliance). J Soc Adm Pharm. 1993;10(4):1506. 9. Weinman J. Providing written information for patients: psychological Conclusion considerations. J R Soc Med. 1990;83:3035. In conclusion, interactive education workshops may be 10. Viswanathan H, Anderson R, Thomas III J. Evaluation of an antiretroviral the most effective strategy in community-based health medication attitude scale and relationships between medication attitudes and medication non-adherence. 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Chinese Primary Health Care. 2004;18(9):379. cholesterol. 14. Chen M, Wang XK, Zhu YH. The importance of health education in community (Chinese). Soft Sci Health. 2008;6:46970. Competing interests 15. Liu LS, Wang W, Yao SH. Guidelines for the prevention and treatment of The authors declare that they have no competing interests. hypertension in China (Chinese). J Hypertens: Chin; 2010. 16. Kruger SH, Gerber JJ. Health beliefs and compliance of black South African outpatients with antihypertensive medication. J Soc Adm Pharm. 1998;15(3):2019. Authors contributions 17. Gao X, Nau DP, Rosenbluth SA, Scott V, Woodward C. The relationship of CHL, STT and PXW were responsible for the study design. YXL, MQZ, WQL disease severity, health beliefs and medication adherence among HIV and SHD were responsible for data collection. CHL, STT and PXW conducted patients. AIDS Care. 2000;12(4):38798. the data analyses. CHL and STT drafted the manuscript. PXW finalized the 18. 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