http://doi.org/10.33698/NRF0073 Navneet Kumari, Indarjit Walia, Sushma Kumari Saini
Abstract : An operational study on development of human resource for home based blood pressure monitoring among residents of Dadu Majra colony, UT, Chandigarh, was carried with a focus on involving, educating, training, supporting and empowering the study subjects, for measuring the blood pressure in home setting. A proactive health team was formed by collaboration of various health professionals. Snowball technique was used to enroll the study subjects. Fifty (18.7%) persons from the families of known hypertensive persons and fif teen (37.5%) health team members participated in the study to learn blood pressure monitoring. Aneroid or mercury sphygmomanometer was purchased by the 65 study subjects. Training was done by the investigator which emphasized on classification of blood pressure, standardized home based blood pressure measurement and interpretation of the readings. The duration of classes varied from 1 to 2 hours per day. Method of teaching used for training the study subjects included lectures, discussions, demonstrations and return demonstrations. The data revealed that the age of the study subjects ranged from 16 to 58 years with mean age 29.29±10.16 years. The level of education of the half (49.2%) of the study subjects was upto 10+2 with mean per capita income Rs.1702.8±751.4. The study subjects took maximum five days to learn recording of systolic blood pressure and six days to learn documentation in log book accurately. Number of persons on whom study subjects practiced blood pressure monitoring and documented in log book post training period ranged from 1-15 persons. Eighty (47.0%) hypertensive persons had improved drug compliance after blood pressure monitoring at home by the study subjects. Human resources developed represented all sections of the community.
Key words :Home based blood pressure monitoring, human resources, human resource development, proactive health team, operationalization
Correspondence at :Sushma Kumari Saini Lecture,National Institute of Nursing Education, PGIMER, Chandigarh, India.
Introduction
Blood pressure is very essential for sustaining life. It is the most important factor which ensures that the circulation of blood reaches all the tissues in our body. At the same time, an elevated blood pressure can be most inimical to life, if persisting over a period of time.1 Blood pressure is measured as systolic and diastolic pressure. The World Health Organization (WHO) classifies blood pressure ranges into 6 stages as shown in graphical indicator.2
Figure 1 : Classification of blood pressure by graphical indicator.
The Seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure and European Society of Hypertension-European Society of Cardiology (ESH-ESC) has also provided classification of blood pressure.3,4 In India, data on prevalence of hyper tension have been depicted by various studies carried out in urban and rural areas. These studies have been carried out in different time periods but cannot be compared because of differences in geographic areas, study designs, and criteria used in defining hyper tension. However, it is evident that hypertension is a significant problem in India.5 In the early 1970’s it became evident that only half of the hypertensive subjects in developed countries were aware of the condition. About half of them were being treated with drugs, and only half of those treated were adequately treated. This came to be known as the “rule of halves”, and the situation in the developing countries is likely to be far worse.6 In India, three million people die annually as a direct result of hypertension. With the increase in incidence of hypertension, there is great need for long term care that should be cost effective and can be carried out within the community or at home.7 The WHO has recommended patient participation as an important element in community based health programs for management of hypertension. The patient and his family is taught self care, i.e., to monitor blood pressure at home and keep a log book of blood pressure readings.8 Home blood pressure (BP) measurements are indispensable for the improvement of hypertension management in medical practice as well as for the recognition of hypertension in the population. Studies have suggested that home monitoring has following advantages: increased number of readings, improved compliance, reduced cost, elimination of white coat effect, assessment of response to treatment, easy learning, reduction in number of visits to doctor, give patients a sense of responsibility for their health, no alarm reaction, several measurements are possible and a true and accurate picture of blood pressure levels is seen.9,10,11,12.The concept of blood pressure monitoring came into existence since; the ancient Greek physician Galen first proposed the existence of blood in the human body. The word a sphygmomanometer, device used to measure blood pressure, comes from the Greek sphygmus (pulse), plus the scientific term manometer (pressure meter).13 Today modern technology has allowed the devices used to measure blood pressure to become more sophisticated than the likes of Scipione Riva-Rocci’s first sphygmomanometer. To monitor blood pressure there are different types of monitors as mercury Sphygmomanometer, aneroid sphygmomanometer, automated device, wrist device, finger device, ambulatory blood pressure monitor.14.The Japanese Society of Hypertension Working Group for Establishment of Guidelines for Measurement Procedures of Self-Monitoring of Blood Pressure at Home has established standards for all techniques and procedures of home BP measurements. It has given following recommendations15:
- Arm-cuff devices based on the cuff- oscillometric method that have been validated officially, and the accuracy of which has been confirmed in each individual, should be used for home BP
- The BP should be measured at the upper Finger-cuff devices and wrist-cuff devices should not be used for home BP measurements.
- Home BP should be monitored under the following The measurement should be made after micturition, sitting after 1 to 2 min of rest, before drug ingestion, and before breakfast.
- Home BP should be measured at least once in the morning and once in the evening for three days a
- All home BP measurements should be documented without selection, together with the date, time, and pulse Home BP measurements based on these guidelines can be considered an appropriate tool for clinical decision- making, and it is hoped that these guidelines will serve to reduce confusion and confirm the place of home BP measurement in clinical practice.Various studies were done all over the world on home based blood pressure monitoring that emphasized on the concept, advantages, training of the study subjects, type of sphygmomanometer to be used, documentation of blood pressure reading by patients, impact of blood pressure monitoring at home on diagnosis, treatment and cost effectiveness in hypertension. Effective self- management helps patients and families to adhere to the treatment regimens and minimize complications, symptoms, and disability associated with chronic problems. Hence, this study will be taken up to develop human resource for strengthening community health services, to meet the changing health needs of people in their local settings.
Objective: To develop human resource for home based blood pressure monitoring among residents of Dadu Majra colony.
Assumptions
- Public is willing and have the capacity to learn monitoring blood pressure at home of their relatives and
- Public have capacity to purchase
- Measuring and documenting blood pressure of people with high blood pressure is facilitated if and when human resource for blood pressure monitoring is available
Material and Methods Dadu Majra Colony is situated on Northwest corner of Chandigarh and is at a distance of 5 km from National Institute of Nursing Education (NINE) P.G.I., Chandigarh and 6 km from the Interstate Bus Terminus of Chandigarh. Dadu Majra Colony is well equipped with all modern sanitary facilities like an underground drainage system, tap water supply, electricity and other amenities like market, anganwadi, middle schools, a senior- secondary school, adult education centers, a government allopathic dispensary and many private practitioners. There is a regular bus service to the area. It was chosen for the study as it was adopted by the National Institute of Nursing Education for providing clinical experience for the students during their posting in community health nursing and thus it was convenient for the investigator. The target population comprised of all the adults of Dadu Majra colony, willing to learn monitoring of blood pressure and having family members, friend, clients, or others having altered blood pressure. The study focussed on all the 2670 households of Dadu Majra Colony with a total population of 16,400.Enrollment of family members of known hypertensive persons was done by Snowball technique while Health team members working in Dadu Majra Colony were enrolled as per their demand. The proactive health team was built by the integration of various qualified health professionals. The team articulates experts from the field of nursing, medicine, nursing students, paramedics and health workers and was formed prior to data collection. The list of known hypertensive persons was prepared with the help of ANM, nursing student, Help age India, pharmacist and Anganwadi workers. The known hypertensive persons were also asked about the other hyper tensive persons in their contact, for recruiting more subjects from among their acquaintances. Thus the sample group grew like a rolling snowball. The family members of all known hypertensive persons were visited individually in their homes by the investigator and were provided the oppor tunity to learn blood pressure monitoring at their home. Six types of tools were used in the study to gather required information.The target population in the study comprises of health team members (40) and family members of known hypertensive clients identified by snowball technique (266). From the target population 20(50%) of the health team members and 149(56%) family members of the hypertensive clients showed their willingness to participate in the study. Out of willing participants 15 (37.5%) health team member and 50 (18.7%) persons from the families of known hypertensive clients par ticipated in the study to learn blood pressure monitoring. The barrier to learn home based blood pressure monitoring includes lack of time, cost and perception of inaccuracy and barriers, for purchase of sphygmomanometer were, living near dispensary, illiteracy and failure to recognize benefits. The study subjects needed continuous motivation to purchase sphygmomanometer. About 38.5% of the study subjects took 1-4 days to purchase sphygmomanometer and 21.5% of them took 5-8 days for it, where as, 23.1% study subjects purchased sphygmomanometer during 9-12 days. About 16.9% of them even took 13-16 days to purchase sphygmomanometer. the training session lasted for an average of 1 to 2 hrs that included the following: (1) detailed instructions for the conditions of measurement and the correct technique (2) introduction and importance of blood pressure monitoring at home (3) Types of sphygmomanometer (4) Blood pressure monitoring by palpatory method (5) Documentation of log book (6) A test of patients’ ability to take blood pressure correctly with simultaneous measurements until investigator and study subjects’ difference recording of BP in was <5 mm Hg on two successive readings; and Module on home based blood pressure monitoring was handed to all study subjects. According to the convenience and choice of the study subjects, group classes were organized. The venue of the classes was mainly homes of study subjects. The health team members had classes in anganwadi and dispensary. The time of the classes was decided by the study subjects and the investigator jointly. The duration of classes varied from 1 to 2 hours. Method of teaching used for training the study subjects included lectures, discussions, demonstrations and return demonstrations. The daily assessment of the progress of the study subjects was noted along with any difficulty faced by the subjects in learning of blood pressure monitoring
Results:The proactive health team members played an important role in accomplishment of the project. They collaborated with the investigator at various stages of the study and played various roles. Socio-Demographic Profile of Study Subjects (table 1)Age of the study subjects ranged from 16 years to 58 years with mean age 29.29±10.16 years. The study subjects in the age of 21-30 years were 41.5%, 30-40 years were 20% while 13.9% were above the age of 40 years. Eighty percent of the study subjects were found to be females. The females were more in number because the training classes were conducted during the day when there were only females at home as most of the men had gone to work. The level of education of the half (49.2%) of the study subjects was upto 10+2. subjects with education up to matric level accounted for 29.2%, while those with middle level were recorded 9.2%. Only 8 study subjects i.e. 12.4% got education till graduation and post graduation. Thus most of the study subjects i.e.87 % got education up to 10+2 only.Most 51(79.7%) of the study subjects were earning and had per capita income of their families in the range of Rs. 500-4000. Fourty six percent of the total study subjects had a per capita income of Rs. 500-1500, whereas 1.5% families had a monthly per capita income of Rs.3501-4000. The mean per capita income of the study subjects was Rs.1702.8±751.4.The socio economic status of the study subjects was classified as per Kuppuswami’s scale. The study revealed that half (50.8%) of the study subjects were from Lower middle class while the 30.8 % of them were of Upper middle class and 18.5% of upper lower class.