The Effect of Community-Based Intervention on Self-Management of Hypertension Patients

Introduction: Hypertension is one of the chronic diseases that can cause complications. Patients need a support system in the management of the disease. One of the ways to prevent hypertension complications is by using self-management. Community involvement is integrated into the program to have a social support system in performing self-management. Objective: This study aimed to determine the effect of a community-based intervention on the self-management of hypertension patients in one district in West Java. Methods: The study method is a quasi-experiment with pre and post-test control group design. The samples consist of 60 respondents taken by using the cluster sampling technique. The subjects were divided into control groups who were given routine treatment from primary health care and intervention groups who were given community visit groups about self-management for four weeks, including health education, counselling, and support. The data were collected using a questionnaire about hypertension self-management sub-variables: diet, smoking, physical activities, stress management, body weight control, alcohol, blood pressure monitoring, and medication. The data analysis techniques were descriptive and inferential statistics using a t-test. Results: The study showed that the total score for self-management after the intervention was significantly higher than the total score before the intervention (M= 131.62; SD = 12.9; p=0.02). The intervention group's self-management total scores were considerably higher than the control group in the 4 th week (p=0.005). Discussions: Community nurses can do one of the interventions by involving the community and forming hypertension volunteer groups that can act as educators to increase hypertension self-management.


INTRODUCTION
Cardiovascular disease is a significant cause of morbidity and mortality worldwide (Patel, Ordunez, Connell, Lackland, & Dipette, 2018;).According to data from the World Health Organization (WHO), in 2013, ischemic heart disease and stroke are ranked first and two of the top 10 causes of death in the world, which causes 7 million (11.2%) and 6.2 million (10.6%) people Based on all data collected from the WHO, in 2015, it is estimated that deaths from heart and blood vessel disease will increase to 20 million, and they will continue to grow until 2030, with an estimated 23.6 million people dying from heart and blood vessel disease (WHO, 2020) 2014).One area that has the highest hypertension population is the DTP Rajamandala Community Health Center.Based on data from the DTP Rajamandala Health Center in 2015, there were 3,110 total visits of hypertensive patients in the DTP Rajamandala Health Center working area and occupying the three most extensive diseases each month (DTP Health Center Rajamandala, 2015).
Management in patients with hypertension is essential, one of which uses a self-management model for patients.Self-management of hypertension patients can be seen from knowledge about the disease and its symptoms, adherence to treatment, healthy lifestyle changes, and blood pressure monitoring (Warren & Semour, 2012).Based on research by Hayes (2010) states that, good management is one of them by stopping smoking habits, maintaining a healthy diet and healthy physical activity.Study conducted by Prasetyo, Sitorus & Gayatri (2012) found that self-efficacy, social support, education and complications have a significant relationship with self-care management.
Self-management in patients with hypertension is expected to improve knowledge, attitudes, and treatment-related to hypertension.Self-management can be carried out through community-based education programs.The formation of Hypertension caring community groups is an effort of a community nursing program designed to increase public knowledge so that the community has the power to build itself through interaction with the environment.The formation of community care groups is a community-based education program that can be interpreted as an educational program from the community, by the community, and for the organization (Bagong, 2005).The previous study by Saraswati et al. (2014) reported that community-based education programs could improve self-management.Another study reported community-based intervention about selfmanagement of Hypertension and Diabetes Mellitus patients could improve blood pressure and blood glucose (Sari, Yamin & Santoso, 2017).As the systematic review, self-management programs is found among the reviewed studies on enhancing self-efficacy in Koreans with hypertension and diabetes mellitus (Jang & Yoo, 2012).This study aimed to identify the influence of Hypertension care groups on the self-care of hypertensive patients in Cipatat District, West Bandung Regency.

METHOD Research Design
The type of research used in this study is quasi-experimental using a research design of one group pretest-posttest with a control consisting of two groups.

Population and Samples
The population is people who have hypertension.The samples consist of 60 respondents taken by using the cluster sampling technique.The samples were divided into the intervention group and the control group with 30 respondents.Sampling the area in this study is to use probability sampling techniques with a consecutive sampling approach according to the inclusion criteria.Pre-test and post-test were carried out in each group.

Instrument
The questionnaire consisted of a questionnaire about the characteristics of respondents (questionnaire A), a questionnaire about self-management of hypertension consists of weight control, exercise, diet, stress management, stopping alcohol behaviour, blood pressure monitoring and treatment of hypertension (questionnaire B).

Research Procedure
The implementation of a community-based self-management education program for hypertensive patients was carried out on each respondent who was included in the intervention group in the study.In contrast, the control group was given a self-management program after four routine check-ups.
Trained cadres carry out the implementation of this community-based self-management program.The cadre training was carried out by the research team, which was carried out several times.The movement for cadres or volunteers who care about hypertension consists of communication training, hypertension self-management and measuring blood pressure in patients using a digital sphygmomanometer.
Trained cadres or volunteers carry out selfmanagement implementation for four weeks on respondents.Before implementation, the research team carried out a pre-test.The first and second weeks are hypertension self-management education.Education is carried out together with the patient's family.The third and fourth weeks are follow-ups on the implementation of selfmanagement ca the respondents.After that, the researchers conducted post-test measurements.

Data Analysis
Data analysis used univariate and bivariate.Univariate analysis using frequency distribution and percentage.Bivariate analysis using t-test.

Ethical Clearance
Implementing the community-based selfmanagement program has received permission from the West Bandung district health office.

RESULTS
Based on the table, it can be known.All Muslim respondents in the control and intervention groups were 100%.More sex was women than men in the control group, 87.5%, while all women were in the intervention group.The most elementary education level in the control group is 66.7%, and the intervention group is 62.5%.In the control group, 91.6% and 92.5% of intervention groups were not working.Based on the table, it can be seen that the variables of age, gender, education, and occupation show a p value> 0.05.This indicates that the four variables in the intervention and control groups are homogeneous.Based on table 3, the results of testing the hypothesis p-value is 0.057.This shows that selfmanagement between the intervention and control groups had no significant difference before being treated.Based on the results of hypothesis testing, a p-value of 0.005 was obtained which sh,owed that hypertension self-management after being given a community-based education program was significantly different.Thus it can be concluded that community-based education programs greatly influence self-management in elderly hypertension in sub-district West Java.

DISCUSSION
Based on the results of paired t-test, it can be seen that in the control and intervention groups' results obtained, there are differences in values between pre-test and post-test.The intervention group had more meaningful distinctions.The results showed a different test of the average selfmanagement of hypertension before and after the intervention of the hypertensive care group in the control group, and the intervention found that there were significant differences, which meant that there was an influence of community-based education programs on hypertension selfmanagement.Based on the study results, programs that have been routinely carried out may improve hypertension self-management behaviour.Still, the increase in hypertension self-management behaviour is higher in the control group.
This can be caused by factors that can influence community-based education programs towards changes in behavioural self-management of hypertension, namely the self-management theory used, the methods used, and the media for implementing education and motivation programs for hypertensive patients.The self-management theory used in this study is the CDSMP theory.Implementing CDSMP aims to improve coping, especially in patients with chronic diseases such as heart disease, hypertension, and DM.The program's implementation based on this theory emphasises more on providing health education to improve understanding and monitoring of diseases, skills in maintaining a healthy life, and strategies to enhance emotional well-being (Bandura, 2004).
Research conducted by Junling et al. (2012) regarding the formation of group visits for hypertensive patients in China in 1024 hypertensive patients stated that patients who were included in the group visit would receive health services in a group format and experienced a significant reduction in blood pressure, while dietarybehaviourr, drug consumption, and physical activity have increased.Several choices of interventions that can be done to carry out selfmanagement are by providing education and information by using a handbook for patients, conducting interviews angivingng motivation by health care providers, support and mencouragement from peers, and the implementation of self-management programs led by people who can provide inspiration, support and role models for patients.By the opinion that intervention efforts should focus on community empowerment, in this case involving cadres to be able to influence the lifestyle of hypertensive patients, especially in vulnerable groups (Camphell, 2014), and can be an alternative policy in improving health services (Fulton, 2011) This community-based education program can be successful due to 4 things: material, educator, media and time.Each respondent involved in the study is entitled to receive material on hypertension, the pillars of hypertension care and self-management.the pillars of hypertension treatment provided are by the JNC (Chobanian, 2003).Several studies related to the material's content have been studied, which distinguishes it from other research related to the method used.This is supported by Flynn, et al., (2013) who conducted research on the effects of selfmanagement interventions for hypertension clients with the re,sults showing that implementing health education programs using booklet media can improve self-management behaviour.This is supported by other research, which states that selfmanagement interventions in people who suffer from chronic diseases include activities that focus on patient needs, decision making, problemsolving, emotional management, improving patients' ability to manage disease conditions and encouraging patients to be active in health services.
Based on research on Diabetes Mellitus clients conducted by Sari et al. (2017), additional educational methods carried out by the community and carried out by cadres improve patient selfmanagement outcomes.This can be proven from the results of self-management of hypertension in this study.In addition, the educators, trained cadres, can act as reminders, support systems and controllers for the respondents' self-management.
The media and the time of giving are influential things in this research.Attractive and educative media used are modules that have been tested and shown to respondents.According to theory, excellent and beautiful media can increase the significance of the knowledge gained by respondents.In addition, the time of providing education also influences the importance of this study.This education is based on several studies that report that behavioural changes can be seen within a month.These results are also in accordance with research conducted by Lee (2013) in the community towards 23 elderly for the control group and 26 elderly for the intervention group in patients with hypertension using self-care programs through health education and discussions for 5 sessions.

CONCLUSION
There are differences in the average values of pre-test and post-test self-management of hypertension in the intervention group before and after the education carried out by the Hypertension Care group.Community-based education programs can be used as one of the district's policies in the prevention and management of hypertension self-management programs.

Table 1 . Frequency Distribution and Analysis of Homogeneity Test Social Demographic Characteristics of Respondents in the Intervention Group and Control Group (N = 60)
Note : 1=Chi Square, 2 = Fisher Exact