Impact of the Use of Street Play Mode of Education on the Self-care Capacity of Village Women for Lifestyle Modification for Prevention of Hypertension

ABSTRACT IMAGE

INTRODUCTION

In 21^st century, the impact of epidemiological transition is clearly visible through the change in disease profile of our society.^[1] There is a decline in the incidence of communicable diseases (CDs). Non-communicable diseases (NCDs) such as hypertension (HTN), diabetes, cancer, cardiovascular diseases (CVDs), and stroke are on the rise at an alarming rate in both developed and developing countries with high mortality rates. CVD is the leading cause of death in women accounting for an estimated 17 million people each year. HTN, a major risk factor for CVDs, is fast becoming a major public health problem in India also. Globally, at least 50% HTN cases are remaining hidden and inadequately treated.^[2] This issue becomes more serious for women, whose health is often neglected due to their low social status in the society.^[3]

Globally, including India, the prevalence of HTN in adults is above 30%.^[4-6] HTN control in them can result in a sizable reduction of CVD mortality. Still, there is suboptimal awareness, treatment, and control of HTN in women. Hence, there is a need for more attention to be given to find out and treat the hidden and untreated HTN cases in women.

Health promotion, which focuses on the pre-pathogenesis phase of disease, that is, before the appearance of risk factors, is the best strategy for prevention of NCDs. Adoption of health promoting lifestyle positively contributes to quality of life. For inculcating a healthy lifestyle, a salutogenic approach has been tried by the investigators earlier.^[7-12]

Globally, at least 50% of the deaths, each year are related to lifestyle, which has emerged as an extremely useful construct in the health field theory.^[13] Hence, more attention is now being given to the role of human behavior in changing the lifestyle as a major strategy for both prevention of CVDs and for promotion of health.^[13] Health promotion is not directed against any disease but is intended to strengthen the host through a variety of approaches in the form of lifestyle and behavior change, health education, environmental modifications, and nutritional intervention.^[7-12]

At community/grass root level, there is a need to adopt a simple health promotion approach, which a primary healthcare worker can use.^[14]

Being a chronic disease, management of HTN requires active involvement of the patients themselves. Medicines are to be taken regularly, along with monitoring of laboratory investigations. This requires their adherence with the prescribed therapies. All this is intimately related to their behavior and habits. Various strategies have been tried in a plethora of health-care projects to bring about changes in health-related behavior of people.^[15] However, often they get bored by the traditional sermonizing approaches. It has been advocated that an “infotainment” style of communication may be tried to transmit the message across to the intended audience in a subtle way. It will be worthwhile to study how the use of this approach of lifestyle modification (LSM) will work as an intervention to manage HTN among the village women.

MATERIALS AND METHODS

The study was conducted during June–July 2023 in the field practice area of Community Medicine of a medical college. All adult women attending outpatient department (OPD) of the field clinics were included in this study. Women not willing to participate were excluded.

A pre-tested, pilot tested questionnaire was used for data collection. The participants were examined for medical history and anthropometric measurements (height, weight, and body mass index), blood pressure (BP), treatment details, etc., and relevant history for lifestyle pattern were documented in pre- tested questionnaire.

Spectra Slim+ vital sign monitor was used to digitally measure BP and diagnose HTN. It was regularly calibrated against a mercury sphygmomanometer. To rule out coat HTN the investigators ensured that before measuring the BP, the subjects were sitting relaxed for at least 5 min without talking. They were asked to sit on a chair with their back supported. They were also asked to keep both feet flat on the ground, with their arms at heart level.

Sample size was arbitrary (n = 200) out of all willing women attending OPDs during the study period.

The intervention was carried out at a field practice area under a medical college. Beneficiaries were village women in the study area. A list of interns posted in Community Medicine Department was made. They were groomed for the project by honing their skills through appropriate training for conducting surveys, data collection, and pro forma designing/pretesting and imparting various components of the intervention regime. Then, the script of the nukkad natak on a healthy lifestyle was prepared. Rehearsals were done for the same. Logistics were arranged. The study did not interfere with the existing health-care regimes being used by the concerned users.

First, a baseline assessment of the study population was done. This focused on basic socio-demographic data of the families, their health status, treatment seeking behavior, etc. Their healthy lifestyle-related knowledge was also tested through appropriate tools. A pro forma was developed to record the intervention sessions and impact thereof.

Then, the first intervention session of nukkad natak with camp approach was held for the study population at an appropriate venue (after discussion with them and with the village leaders who were briefed about the project before starting the survey).

Documentation of the post-intervention changes in the healthy lifestyle-related knowledge of the study population was done, immediately after the session. The tool for the same focused only on the issues addressed in the drama.

Appropriate statistical analysis was done using Excel sheets. Percentage, mean, median, mode, standard deviation, Paired t-test, etc., were used. Outcome variables were scores on healthy lifestyle-related knowledge for prevention of HTN.

RESULTS

Table 1 demonstrates that 79% of the women in the village have normal BP, with 19% of them had mild and 2% had moderate HTN. As shown in Table 2, most hypertensive women (72%) were not taking medications. As shown in Table 3, out of 12 hypertensive women who were taking antihypertensive medications, half of them were regular in it. According to Table 4, 54.5% of over 60 years age group women were hypertensive as compared to 36.4% in 40– 60 years age range (Chi-square: 29.23; df: 2; P < 0.001 (Fig. in parentheses are %). Table 5 shows that among the housewives, 23.9% had HTN, as compared to 4.2% in students/skilled workers (Chi-square: 4.855, df: 1, P-value: 0.032; Fisher’s exact test). There was no association between educational/socioeconomic status of women and HTN. Table 6 demonstrates that there was a significant improvement in the score of self-care capacity-related knowledge of the women after the intervention (Paired t-statistic: 24.79, d.f.: 199, P = 0.000). Table 7 shows that there was a significant improvement between pre- and post-intervention score of HTN treatment knowledge of the subjects (Paired t-statistic: 79.82, d.f.: 199, P = 0.000). As shown in Table 8, there was a significant improvement between pre- and post-intervention score of knowledge of women about the HTN diet (Paired t statistic -13.820; d.f. = 199; P = 0.000).

The impact of using a village-based camp approach organizing street plays (nukkad nataks) on the self-care capacity of women for LSM for prevention of HTN in the study area is illustrated below in the form of subjective responses received from the study population–

1. Our respondents liked the idea of organizing drama to propagate health-related messages.

2. This was their first experience of participation (both as an audience as well as amateur actors).

3. They were glad to see, within their home setting that members from the health care team at RHTC, discussed individually with them about HTN prevention through LSM.

4. In general, the women liked the health communication technique used by our team through drama.

5. Use of local dialect in the drama enthused them.

6. Through demonstration mode during the drama, interested women learned to use the digital sphygmomanometer for HTN monitoring.

7. Through role play they were told about the crucial role of the family support in HTN management/prevention.

8. Participant women and their families were also assured about necessary treatment and referral support for HTN as per the need.

9. The interest of the respondents was evident by the way they asked questions during the open house session.

10. Majority of them wanted similar events in future. They were eager to attend educational sessions on HTN management.

DISCUSSION

HTN is the most common risk factor for CVDs such as coronary heart disease, stroke, renal disease, and peripheral vascular disease, which are the most common cause of death and disease globally as well as in India.^[16-18] Awareness level of their HTN status among the patients was reported to 25–42% in India in various studies. The pooled estimate for awareness of BP in rural and urban India was 25.1% (21.0–29.1) and 41.9% (35.1–48.9), respectively.^[4-6] The pooled estimate for the percentage of treated among those diagnosed with HTN in rural and urban areas as reported by researchers was 24.9 (16.7–33.0) and 37.6 (23.9–51.2), respectively.^[19-21]

Hidden HTN phenomenon was amply demonstrated in this study, as most hypertensive women (72%), were not taking the prescribed medications. Regarding treatment adherence, only 50% among those who were taking antihypertensive medications were regular in it. This reflects a casual approach of the providers as well as the users regarding HTN management in the study area.

The pooled estimate for percentage of hypertensive patients having their BP under control in rural and urban India was 10.7 (6.4–15.0) and 20.2 (11.6–28.8), respectively. Thus, less than one-fourth of the Indian HT population has their BP under control. This is a serious matter of concern for policy makers. As per the rule of halves also, 50% of the HT people are undiagnosed. In any case, adherence to HTN treatment in known cases is poor everywhere (24.9–37.6% in India).^[20-27]

Apparently, the current public health/mass level strategies are not working in this context. This is a serious matter of concern for policy makers. The low awareness and treatment levels among hypertensive patients signify a lower knowledge, attitude, and practice levels among patients. To address this issue, there is a need to foster a conducive communication ambience to convince HT patients to take the treatment prescribed by the concerned physician.

Globally also, adherence to any prescription or advice has been reported to be <50%. Reasons for this may be due to lack of realization of the gravity of the situation.^[20,21]

It is a matter of human behavior change. Health belief model is applicable here through its “perceived susceptibility” and “perceived severity” paradigms. People may consider themselves not susceptible to develop HTN. Those who are diagnosed with HTN may not consider it as a severe enough disease which deserves attention/care.^[9,10]

It is well known that HTN may have serious cardiovascular and cerebrovascular complications with potentially fatal consequences. In this context, there is a need to put the relevant messages across to the HTN patients and their families in an effective way.

The use of drama can be useful to achieve this, as demonstrated by our study results.^[28-39]

The prevalence of HTN in the study population of RHTC (one in every five) was lower than its counterparts in UHTC population, that is, 39%.^[40]

Social prescription concept was also implicit in our drama-based intervention as a group of people with similar sociodemographic and morbidity backgrounds were addressed through this strategy.^[41] In Indian rural settings, like elsewhere, people do tend to follow the social norm through group dynamics. People do share their experiences and problems with others. They tend to follow advice, if they witness others doing the same thing.

There was significant improvement in the scores of self-care capacity, HTN diet, and treatment-related knowledge of the respondents after the intervention. The modalities of organizing health education sessions through infotainment mode for HTN were appreciated by the respondents. Our respondents liked the idea of organizing drama to propagate health-related messages.

CONCLUSION

One in every five persons in the study population of RHTC had HTN. Most hypertensive women (72%), were not taking medications. Only half of those who were taking antihypertensive medications, were regular in it. After the camp approach supplemented with Nukkad Natak based intervention, there was a significant improvement in the scores of HTN diet and treatment-related knowledge and self-care capacity of the respondents for prevention of HTN. Our respondents liked the idea of organizing drama to propagate health-related messages.