Hypertension one large scale study conducted in 2014 [1].

Hypertension is
one of the most common conditions encountered in primary care. It is a major
cardiovascular risk factor. It affects nearly around one third of adult
population in Sri Lanka according to one large scale study conducted in 2014 1.
While hypertension can be associated with serious medical complications, it is
responsible for a significant portion of health budget in Sri Lanka.


Many clinical
guidelines for management of hypertension advocate lifestyle modifications for
all patients with hypertension regardless of weight, severity of hypertension
and intake of medications 2 3 4. On the other hand, despite the existence
of free health service and availability of public health initiatives in Sri
Lanka, poor adherence to medications and lack of knowledge and awareness of
hypertension and knowledge about lifestyle measures in the management of
hypertension among patients with hypertension is of a major concern.

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Diet and
exercises, cessation of smoking, moderation of alcohol, reduced salt intake,
limitation of caffeine and other drinks with caffeine, relaxation therapy is
proven to be effective in non-pharmacological management of hypertension 5
6 7 whereas dietary supplements like garlic and cocoa preparations, calcium
and magnesium supplements, vitamin C, Omega 3 fatty acids, Co-enzyme Q10 may be
beneficial 6 7.


By improving the
awareness about these lifestyle practices among hypertension patients,
clinicians can expect better clinical outcomes in patients with mild to
moderate hypertension and, perhaps, a better way to encounter ‘difficult to
manage hypertension’ cases in clinical practice. If effectively combined along
with medications it will be very cost effective for the health system in the
country. The other advantages include reduction in cost of medications for the
patient and less liable to be exposed to side effects of medications. These
non-pharmacological measures have beneficial effects on other medical
conditions such as diabetes and dyslipidaemia and prevention or delay of drug
treatment with its potential adverse effects 5 6 8 9



General Objective


To assess the knowledge, awareness
regarding hypertension and its non-pharmacological management among patients
who are attending to medical clinics in National Hospital of Sri Lanka (NHSL).


Specific Objectives

socio-demographic characteristics of Hypertension patients who present to medical
clinics in NHSL

Assess knowledge
regarding Hypertension


hypertension awareness among clinic patient with hypertension


Assess awareness
regarding diet and dietary supplements, exercises and weight reduction and
other lifestyle modifications among Hypertension patients attending to medical
clinics in NHSL.




Study design – descriptive cross-sectional study


Study setting – medical clinics in NHSL


Study population – diagnosed patients with hypertension
who are attending to all medical clinics in NHSL



All diagnosed
patients with hypertension who are currently taking at least single agent of
antihypertensive according to clinic records.

All patients
should be more than 30 years of age.

All patients must
be followed up in medical clinics in NHSL for minimum period of 3 months.

Patients with a
known cause(s) of secondary hypertension will be included.

Hypertension patients
with other co-morbidities will also be included.



Patients who
cannot give verbal consent will be excluded.

Mentally disabled
and patients with documented or agreeable cognitive impairment will be excluded.

Patients with
recorded or agreeable significant psychiatric disorders will be excluded.

Severely or
Acutely ill hypertensive patients will be excluded.

Patients with
hearing impairment will also be excluded.


Sample size – Sample of 300 patients will be
included in the population.

Sample method – There are at-least 5 medical clinics
per week in NHSL and each clinic sees roughly 100 patients with hypertension
out of about 250 all patients per clinic. According to calculated study sample
and the duration 15 patients need to be interviewed per day. Every 5th patient
out of the population will be taken in to study. If a patient is not agreed to
be participated in the study, the next patient would be interviewed.

Study duration – in order to avoid patient being
re-interviewed, the study will be completed in four weeks as most patients are
visiting clinics in 4 weekly cycles.

Study instruments – relevant data will be obtained via a
structured, interviewer
administered questionnaire which will be paper based. This method with trained
interviewer not only encounters different levels of education of the
participants but also provides some clarifications, if needed, for participants
regarding the questions during the interview. Initial questionnaire will be
based on information obtained through literature review and relevant
modifications will be made according to the opinion after discussion with
Consultant Physician, Community physician, Family Physician, Dietitian. Then,
the phase and validity of the questionnaire will be ensured after taking
approval from a specialist in nephrology. Before execution it will be
translated to national languages (Sinhala and Tamil) and back translated to
ensure no language errors. Finally, it will be pre-tested in a pilot group of
similar participants from a different setting.

consists of four components.

characteristics of participants (age, gender, address, occupation, marital
status, education, income)

Knowledge about hypertension

Awareness about

Diet, exercises and
other lifestyle modifications



Data collection

This study will
adopt the mixed approach of data collection methods which consists of
qualitative and quantitative technique. Two pre-intern doctors will be involved
in the process of collecting data from subjects after providing adequate
information and training on data collection. The training of interviewers
entails a question-by-question and consensus-building process on how to ask
each question based on intent and current terms in common usage. The routine
consultation pattern will not be disturbed, as interview will be taken place
when patient is finishing their turn of consultation. Any participant can
withdraw study at any time either after consent or during interview. The data
collection will be carried out all clinic days over a period of 4 weeks until
target study population is achieved.


Data Analysis

Collected data
will be entered manually using Microsoft Word and Microsoft Excel and will be
analyzed by using Statistical Package for Social Sciences. (SPSS) 20. Responses
of participants regarding reasoning and awareness will also be analyzed using
descriptive methods.    



Ethical concerns

Firstly, ethical
clearance will be obtained from Ethical Review committee of Faculty of Medicine,
University of Colombo. As the data collection is interviewer based study,
informed verbal consent obtained from all subjects prior to the commencement of
interview and privacy and confidentiality of information will be ensured
because information regarding subject’s identity will not be gathered.
Permission will be obtained from The Director of NHSL and from all Consultant
physicians of medical clinics. Study will be carried out with minimal
interference to the proceedings of the consultations and clinic routine.

This study will
be done in a completely patient friendly way with minimal disturbance to the
clinic patients and no invasive or hazardous diagnostic measures or
interventions will be used. There will be no sponsorship for the study and
study will be carried out by my personal funds. Participants who have poor
awareness regarding hypertension, diet and supplements, exercises and other
lifestyle modifications will be offered a health education session by
Pre-intern doctors following each data collection. Interviewers are thoroughly
advised against any sort of criticism over participants responses, attitudes
and practices, in order to avoid participant dissatisfaction.



 This survey will be a pilot study of assessing
knowledge regarding non-pharmacological methods in management of hypertension,
and will suggest aspects to improve in health education, there by better
control of hypertension and its complications and may help to minimize the cost
of health budget.