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Original Research Article S83
http://www.jhealthres.org J Health Res
vol.29, Supplement 1, 2015
LIFESTYLE MODIFICATION EFFECT ON
BEHAVIOR CHANGE AND PHYSICAL CONDITIONS
AMONG HYPERTENSIVE ELDERLY IN WEST JAVA,
INDONESIA
Neneng Kurwiyah Ihwanudin1, *, Anchaleeporn Amatayakul2,
Sirikul Karuncharernpanit3
1 Kasetsart University, Bangkok 10900, Thailand
2 Boromarajonani College of Nursing Nopparat Vajira, Bangkok 10230, Thailand
3 Boromarajonani College of Nursing Chakriraj, Ratchaburi 70110, Thailand
ABSTRACT:
Background: Lifestyle modification is one of the most essential methods in chronic diseases prevention,
cure and control, as in elderly with hypertension. The developed intervention with theoretical
framework as a guide could be used in the evaluation of the intervention. The intervention was based
on the theory that was more effective in health related behaviors than compared to the intervention
without theoretical framework. This study aimed to evaluate the effectiveness of the lifestyle
modification program with Social Cognitive Theory as a guideline on behavior change and physical
conditions among hypertensive elderly in the North Bekasi sub district, West Java, Indonesia.
Methods: A quasi experiment with two groups, pre and post- test design was applied. Participants were
selected from two Primary Health Centers (PHCs) in North Bekasi Sub District, using simple random
sampling method. The participants were 29 hypertensive elderly in each group from two different
primary health centers. The instruments used consisted of 2 parts; the lifestyle modification program
and a self-administered questionnaire including physical examination. Paired t-test and independent t-
test were used for data analysis.
Results: There was a significant difference of knowledge, situational perception, blood pressure, and
total cholesterol within intervention group (p<.001). The mean scores of knowledge, situational
perception of the intervention group were significantly higher and blood pressure, and total cholesterol
were decreased between the intervention group and comparison group (p<.001).
Conclusion: The lifestyle modification program had a positive effect on improving hypertensive elders’
knowledge, situational perception, and on maintaining their blood pressure and total cholesterol.
Keywords: Lifestyle modification program, Hypertensive elders, Behavior change, Physical conditions, Indonesia
DOI: 10.14456/jhr.2015.53 Received: May 2015 ; Accepted: July 2015
INTRODUCTION
Hypertension has been a significant health
problem for elderly people worldwide because it has
become a common chronic disease for them, and a
leading risk factor for many other diseases which
have been costly and have contributed to the
morbidity and mortality rates [1]. The prevalence of
hypertension is expected to increase every year,
* Correspondence to: Neneng Kurwiyah Ihwanudin
E-mail: nenengkurwiyah@yahoo.co.id
particularly in the elderly. Based on a report by the
Ministry of Health of Indonesia, the prevalence of
hypertension in 2008 was 37. 4% of the total
population aged 18 years and over, 29.8% of
hypertension cases were among the elderly aged
over 60 years and this has increased to 33% in 2011
[2]. Considering West Java’s growing elderly
population, a rapid increase in the prevalence of this
disease is expected and hypertension is considered
to be one of the major diseases and ranked as the top
causes of death in outpatient hospitals [3].
Cite this article as:
Ihwanudin NK, Amatayakul A, Karuncharernpanit S. Lifestyle modification effect on behavior change
and physical conditions among hypertensive elderly in West Java, Indonesia. J Health Res. 2015;
29(Suppl.1): S83-9. DOI: 10.14456/jhr.2015.53
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The prevention and management of
hypertension are major public health challenges, if
high blood pressure could be prevented or
diminished, a great deal of hypertension,
cardiovascular, and renal disease, as well as strokes
might be prevented [4]. However, the incidence of
ineffective health maintenance was high among the
elderly, as evidenced by the lack of participation in
healthy behaviours such as exercise and healthy
diets [5, 6]. According to the National Health and
Nutrition Examination Survey (NHNES), 11% to
63.3% of adults met the healthy diet parameters. The
low levels of lifestyle modification in elderly with
hypertension may have been a function of
individual, social and psychological factors [7].
Lifestyle modification is a complex behaviour
influenced by multiple factors within the
environmental, social, cultural, psychological, and
cognitive domains [8]. The current challenges to
health care providers, researchers, government
officials, and the general public is developing and
implementing effective clinical and public health
strategies that lead to a sustained lifestyle
modification [9].
Based on the report by the health department of
West Java province, elderly people with
hypertension were more resistant to following
lifestyle modifications even though the health
personnel had already discussed the importance of
lifestyle modifications, and regardless that their
blood pressure was still high after taking
antihypertensive medication. During this time,
hypertensive patients tended to only rely on
medication to lower blood pressure, few of them
participated in physical exercise, even less
consumed vegetables and fruits, but many consumed
salty foods and used monosodium glutamate [MSG]
on cuisine, and consumed foods high in fat and also
smoked tobacco products[10].
Therefore, the intervention was based on a
theory that was more effective in promoting health
related behaviours, than compared to interventions
without theoretical framework. Since a developed
intervention as well as guides could be used in the
evaluation of the intervention [11]. In addition, the
aspect that most affected behaviours, when nursing
intervention was done, were interpersonal aspects
that were best guided by the Social Cognitive
Theory (SCT).
The social cognitive theory SCT proposed that
personal, environmental, and behavioural factors
operated as reciprocal, interacting determinants of
each other that was influences of an individual’s
ability to control lifestyle modification and its
determinants (i.e., personal, environmental, and
behavioural factors) [12].
The purpose of this study was to modify a
Primary Health Centers’ Program based
comprehensive lifestyle modification program. The
activities of the lifestyle modification program in
this study were include providing knowledge related
hypertension, physical exercise and Dietary
Approach Stop Hypertension (DASH) eating plan,
group brainstorming and group discussion,
presenting role model, practicing gymnastic fitness,
and self-monitoring of gymnastic fitness and DASH
eating plan for hypertensive elderly in West Java,
Indonesia and to test its effectiveness.
METHODS
Design
A quasi-experimental design with two groups
with pre and post-test was used in this study.
Sample
The sample size calculated using Cohen’s
approach [13] to power analysis for two independent
t-tests the sample was 26 participants for each group.
To anticipate withdrawal, the number was increased
by 20 % of the calculation, so the final number of
participants was 32 in each group. Researcher
selected participants and PHC with simple random
sampling.
Data collection
Preparation phase
Initially, the research study and ethical approval
had been obtained from Boromarajonani College of
Nursing Nopparat Vajira Review Board. Further,
permission was approved from the Board for
National Unity and People’s Protection
(Kesbangpol) Bekasi District, and the Head of two
PHCs in the North Bekasi district. The participants
received information about the study and the
information sheet, the consent form also provide for
them for the permission to join in the study. After
collection of the consent form and check, the
participants filled the questionnaires and had a
physical examination.
Implementation phase
During the program implementation, participants
in the comparison group obtained the usual health
education with regard to lifestyle modification that
is on a regular basis in the PHC. The program
consists of 5 activities within 7 weeks. The times of
activities were set by participants in order to avoid
disturbing usual activities. Data was carried out
from the second week of August to the first week of
September 2014. After 7 weeks of this intervention
program, the second data collection was conducted.
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Table 1 The activity of the lifestyle modification program for behavior change and physical conditions.
Period
Activity
Week 1
Activity 1: Brainstorming (approximately 45-60 minutes)
Group activity to brainstorming in order to share self-knowledge and self-experience about
lifestyle modification and developing the same perception about lifestyle modification.
- Guiding sharing activity about participants’ knowledge related to lifestyle modification.
- Guiding discussion among groups
- Summarizing and made conclusion in same perception about the benefit and consequences of
lifestyle modification
Week 2
Activity 2: Provide knowledge about lifestyle modification (approximately 45 - 60 minutes).
The researcher gave slide presentation about lifestyle modification (physical exercise and DASH
eating plan) in order to enhance level of knowledge on hypertension, benefit and consequences of
lifestyle
Week 2
Activity 3: Group discussion (approximately 45-60 minutes).
Group discussion about information that researcher give related to the topic (hypertension and
lifestyle modification including physical exercise and DASH eating plan), discuss about problem
solving when obstacle occur during implementing lifestyle modification.
Week 3
Activity 4: Presenting role model (approximately 60 minutes).
The researcher invite the elderly with hypertension who success in lifestyle modification as a
model. The model shared stories about their experience related physical exercise and DASH eating
plan and how they can deal with unhealthy behaviour.
Activity 5: Demonstration of gymnastic fitness and self-monitoring of gymnastic fitness and daily
DASH eating plan
Week 4,5,
until week 7
Activity 5: Practicing gymnastic fitness three times a week with duration 60 minutes was leading by
researcher and follow up of the daily DASH eating plan and discuss if the participants have any
problem related DASH eating plan.
The lifestyle modification program for behaviour
change and physical conditions
The lifestyle modification program for
behaviour change and physical conditions were
modified by the researcher based on construction of
social cognitive theory including knowledge,
situational perception, and physical conditions
including blood pressure, and total cholesterol
(Table 1).
Research instruments
This study used a self-administrated
questionnaire and physical examination to collect
the data. Five instruments were used to obtain the
data, included: the demographic characteristics; the
hypertension evaluation of lifestyle and
management knowledge scale (HELM); the social
cognitive constructs related to physical exercise
questionnaire; the social cognitive constructs related
to DASH eating plan questionnaire; and measuring
the physical conditions including: systolic and
diastolic blood pressure, and total cholesterol.
The demographic characteristic questionnaire
was developed by researcher included age,
education, duration of hypertension, income,
gender, marital status, and religion.
The hypertension evaluation of lifestyle and
management knowledge scale (HELM) was
developed by Schapira et al. [14]. The instrument
consists of 11 items. In this study, the HELM scale
was translated into Indonesian language and was
tried out with 30 hypertensive elders who had the
same inclusion criteria with the sample study. The
instrument has good internal reliability with
Cronbach’s alpha .89.
The social cognitive constructs related to
physical exercise questionnaire was developed by
Plotnikoff et al. [15]. The instrument was rated on a
7 point Likert scale, and has an internal reliability
with Cronbach’s alpha .98 .4)
The social cognitive constructs related to
DASH eating plan questionnaire was developed by
Dewar et al. [16]. The instrument was rated on a 6
point Likert scale, and has an internal reliability with
Cronbach’s alpha.95
Measuring the physical conditions included:
systolic and diastolic blood pressure, and total
cholesterol.
Ethical consideration
Approval to conduct the study was granted by
the Ethics Review Board (ERB) of Boromarajonani
College of Nursing Nopparat Vajira (BCNNV)-
Bangkok, ERBNo.46/214.
Data analysis
The differences of demographic characteristics
between groups were determined by frequency,
percentage, mean (x
̄), and standard deviation. The
paired t-test was used to measure the difference of
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Table 2 Baseline demographic characteristic compared for intervention group and comparison group (n = 29)
Demographic characteristics
Intervention group
Comparison group
p-value
Mean
SD
Mean
SD
Age
65.55
3.18
65.90
2.22
.634
Education
9.10
2.34
6.34
3.76
.001
Duration of hypertension
4.38
1.64
4.41
1.50
.934
Monthly income in IDR
1.40
3.3
1.33
3.3
.389
Table 3 Baseline demographic characteristic compared for intervention group and comparison group (n = 29)
Demographic characteristics
Intervention group
Comparison group
p-value
n
%
n
%
Gender
Male
5
17.2
11
37.9
.080
Female
24
82.8
18
62.1
Marital status
Married
18
62.1
19
65.5
.789
Widow
11
37.9
10
34.5
Religion
Islam
29
100
27
93.2
.155
Christian
2
6.8
Table 4 Comparison of knowledge, situational perception, blood pressure, and total cholesterol before and after
participating lifestyle modification program in the intervention group (n=29)
Factors of behaviour change
and physical conditions
Intervention group
t
p-value
Before participating
After participating
Mean
SD
Mean
SD
Knowledge
5.24
1.06
10.79
.41
1.68
.001
Situational perception
39.48
4.39
48.34
1.42
1.33
.001
Systolic blood pressure
149.31
10.33
136.21
6.22
-.56
.001
Diastolic blood pressure
92.07
5.59
83.45
4.84
.23
.001
Total cholesterol
231.34
31.05
221.86
30.72
-.36
.001
knowledge, situational perception, blood pressure,
and total cholesterol within the intervention and
comparison groups before and after the intervention.
The independent t-test was used to examine the
difference of knowledge, situational perception,
blood pressure, and total cholesterol between the
intervention and comparison groups after the
intervention.
RESULTS
The mean age of the participants was 65.55
years old in the intervention group and 65.90 years
old in the comparison group. Most of the
participants in both groups were female and they
were classified as married, and most of them were
Muslim. The participants in the intervention group
had completed nine years of education, and the
participants in the comparison group were
completed six years of education. Most of the
participants in both groups have been suffering from
hypertension for less than 5 years. The average
monthly incomes were IDR 1.40 and 1.33 million
for the intervention group and the comparison group
respectively. Statistically, there were no significant
differences of demographic characteristics between
the intervention group and comparison group except
education (Table 1 and 2).
Comparison of knowledge, situational perception,
blood pressure, and total cholesterol before and
after participating lifestyle modification program
in the intervention group and comparison group
The scores of independent variables between
before and after participating lifestyle modification
program in the intervention group and comparison
group were compared with paired t-test (Table 3 and
4). The results showed that the score of knowledge
and situational perception was significantly higher,
and for blood pressure and total cholesterol was
decreased after intervention than that before
participation in the program (p< .001). Intervention
group and comparison group had a significant
improvement in knowledge and situational
perception, decreasing in blood pressure, and total
cholesterol after participation in the program
(p< .001). Moreover, the increasing score of
knowledge and situational perception, decreasing
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Table 5 Comparison of knowledge, situational perception, blood pressure, and total cholesterol before and after in the
comparison group (n=29)
Factors of behaviour change and
physical conditions
Comparison group
t
p-value
Before
After
Mean
SD
Mean
SD
Knowledge
4.79
.98
3.83
.85
1.68
.09
Situational perception
37.93
4.47
38.76
3.60
1.33
.18
Systolic blood pressure
151.03
12.91
150.69
8.84
-.56
.58
Diastolic blood pressure
91.72
6.02
90.34
4.21
.23
.82
Total cholesterol
234.07
26.02
238.72
26.52
-.36
.72
Table 6 Comparison of knowledge, situational perception, blood pressure, and total cholesterol between the intervention
group and comparison group before participating lifestyle modification program (n=29)
Factors of behaviour change and
physical conditions
Intervention group
Comparison group
t
p-value
Mean
SD
Mean
SD
Knowledge before
5.24
1.06
4.79
.98
1.68
.09
Knowledge after
10.79
.41
3.83
.85
39.78
.001
Situational perception before
39.48
4.39
37.93
4.47
1.33
.19
Situational perception after
48.34
1.42
38.76
3.60
13.33
.001
Systolic blood pressure before
149.31
10.33
151.03
12.91
-.56
.58
Systolic blood pressure after
136.21
6.22
150.69
8.84
-7.22
.001
Diastolic blood pressure before
92.07
5.59
91.72
6.02
.23
.82
Diastolic blood pressure after
83.45
4.84
90.34
4.21
-5.79
.001
Total cholesterol before
231.34
31.05
234.07
26.02
-.36
.72
Total cholesterol after
221.86
30.72
238.72
26.52
-2.24
.03
blood pressure and total cholesterol after
participation in the program was higher in
intervention group compare to the increasing of
knowledge, situational perception, decreasing blood
pressure, and total cholesterol after intervention in
the comparison group. This indicates the
participants would have more knowledge, good
situational perception, and could maintain blood
pressure and total cholesterol if they received the
lifestyle modification program.
Comparison of knowledge, situational perception,
blood pressure, and total cholesterol between the
intervention group and the comparison group
before and after intervention
The score before the intervention lifestyle
modification program for knowledge, situational
perception or respond of statement from participants
about their mental representation of the physical
environment influencing their ability to eat healthy
foods and physical exercise, blood pressure, and
total cholesterol in comparison group was
significantly higher than the intervention group
(p> .05) (Table 5 and 6). After intervention,
knowledge and situational perception was
significantly higher, and blood pressure and total
cholesterol was decreased for the intervention group
than the comparison group (p< .001). It can be
conclude that the participants who attend the
lifestyle modification program had a higher
behaviour change and maintain the physical
conditions than those who did not attend the
program.
DISCUSSION
This study has shown there is a significant
improvement score of knowledge and situational
perception, decreased of blood pressure and total
cholesterol from before and after intervention in the
intervention group. It could be inferred that the
program included many varieties of activities that
could promote knowledge and situational
perception, and it could influence as a result.
The findings shows the participants in the
intervention group had a higher score in knowledge,
situational perception, and a decrease in blood
pressure and total cholesterol after obtaining the
lifestyle modification program on behaviour change
and physical conditions. This is consistent with
Sharma [17] who stated that knowledge is an
essential component for any behaviour change. It is
a necessary precondition for change, but often is not
sufficient for making the behaviour change. This
finding is consistent with previous research showing
that, the participants who had knowledge of the
purpose of a treatment and how to monitor the
progress of the treatment goals, will make the patient
participation stronger in the management of the
disease. Health education increased participants’
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knowledge of health and can give them information
about their health care and health care choices [18].
Therefore, according to the program within this
study, it provided factors related to knowledge,
including sharing experience, providing knowledge,
and group discussion.
Related to the situational perception in physical
exercise and DASH eating plan, the participants in
the intervention group had a positive situational
perception by providing some activities and
strategies to improve the positive situational
perception about physical exercise and DASH
eating plan. Participants in the intervention group
had high scores for situational perception in physical
exercise and the DASH eating plan. This finding is
consistent with study conducted by Mahdizadeh
[19] the participants who had correct information
can perceive and correct in interpret the
environment, the researcher created activities that
consisted of brainstorming about perception and the
interpretation of the environment of physical
exercise and DASH eating plan, rectifying the
misperception about physical exercise and the
DASH eating plan, and group discussion. Any
misperceptions hinder the behaviour change, thus
efforts must be made to remove misperceptions and
to promote social norms that are healthy.
The level of physical conditions level including
Systolic and Diastolic blood pressure, and total
Cholesterol might be decreased by doing physical
exercise at least 30 minutes 3 times a week and using
the DASH eating plan for a short period of 7 weeks.
These findings were consistent with several
previous studies which focus on 6 weeks on
behavioural intervention to improve DASH dietary
patterns and physical activity, the result showed at
the end of the intervention Systolic and Diastolic
blood pressure decreased, and the BMI also
decreased [20, 21]. According to the AHA
recommendation on diet and lifestyle revision, it
mentioned that improving diet and lifestyle is a
critical strategy for cardiovascular diseases risk
reduction, including low level of total Cholesterol,
Triglyceride, high level HDL, increased HR
Intensity, and maintaining blood pressure. The study
conducted by Smith et al. [22] combining the DASH
diet, exercise, and caloric restriction and resulted in
significant reduction in blood pressure, BMI, and
serum lipid. Moreover, the difference in physical
exercise and diet pattern interventions between this
study and another study could have influenced
changes in physical conditions level.
Although all the objectives had been met in this
study, nevertheless, there were limitations. The
intervention was provided over 7 weeks with no
continuous follow up, which may not be a
sustainable program. The program is only intended
for hypertensive elderly, so that the program may
not be effective against other chronic diseases and
other age groups, and also most of the participants
were female hypertensive elderly.
Based on the findings, this study has suggested
the way of encouraging people with hypertension to
participate in physical exercise and a healthy diet at
community centre. Also follow up studies to
evaluate the sustainability of the program are
needed. Although the elderly should be encouraged
to be independent, support from others was also
needed to ensure that they maintained their regular
and adequate physical exercise and healthy diet to
prevent the onset of the chronic diseases among the
elderly in West Java, Indonesia.
CONCLUSION
The result indicates that the lifestyle
modification program has a positive effect on
improving hypertensive elderly’s knowledge,
situational perception, and maintaining their blood
pressure and total cholesterol.
ACKNOWLEDGMENTS
The authors would like to express appreciation
to the: elderly in West Java, Indonesia for their
participation, Directorate General of Higher
Education (Ministry of Research, Technology, and
Higher Education of the Republic of Indonesia),
Boromarajonani College of Nursing Nopparat
Vajira an affiliated institution of Kasetsart
University for the support.
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