UNIVERSITI PUTRA MALAYSIA

INFORMATION SEEKING BEHAVIOUR, HEALTH KNOWLEDGE, ATTITUDE AND PRACTICE OF PATIENTS IN HOSPITAL BESAR

TENGKU AMPUAN RAHIMAH, KLANG, SELANGOR DARUL EHSAN

TUNKU ZAIDAR BT. TUNKU ZAINAL ABIDIN

FBMK 1995 1

INFORMATION SEEKING BEHAVIOUR, HEALTH KNOWLEDGE, ATTITUDE AND PRACTICE OF PATIENTS IN HOSPITAL BESAR

TENGKU AMPUAN RAHIMAH ,

KLANG, SELANGOR DARUL EHSAN

By

TUNKU ZAIDAR ST. TUNKU ZAINAL ABIDIN

Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of Master of Science

at the Centre for Extension and Continuing Education, Universiti Pertanian Malaysia.

June 1 995

ACKNOWLEDGEMENTS

I would l ike to express my sincere thanks and appreciation to Professor Dr . Sulaiman M. Yassin , my chairman for h is gu idance and patience d u ring the writing of this thesis.

My appreciation also goes to Dr. Raja Ahmad Tajudin Shah and Dr. Turiman Suandi for their valuable comments and suggestions, and to Puan Saodah Wok for her statistics advice.

I am g rateful to the Selangor Health Director, Dr. Chee Chin Seang for his kind permission in al lowing me to conduct my study at the Hospital Sesar Tengku Ampuan Rahimah, and to the health staff of the h ospital for their assistance.

My very special thanks to my husband, Dr. Raja Jamaluddin who gave steadfast encouragement, support, ideas and criticisms, and mobi l ized me when I g ot d iscouraged . Not forgetting Zaimal Samarkand Yang who patiently stays up with me during the typing of this thesis.

Last but not least, I wou ld l ike to thank al l the other people who have contributed in one way or another in the writing of this thesis.

i i

TABLE OF CONTENTS

ACKNOWLEDGEMENTS L IST OF TABLES L IST OF FIGURES ABSTRACT ABSTRAK

C HAPTER

1

2

INTRODUCTION Hypertension In Malaysia Health Education Campaign In Malaysia

At National Level At State Level

Statement of Problem Sign ificance of the Study Objectives of the Study

General Objective Specific Objectives

LITERA TURE REVIEW Defin it Ion Related Theories and Research

PatIents' Health Consciousness Patients' Social EnVironment Patients' Communication Pattern

Solving Health Education Problems Identification of Target Group Examination/Assessment of Communication

and I nfluence Network Nature of Behaviour to be Changed

Role of CommUnication In Health Education Health Education Objectives Theoretical Background

Community Organization for Health The Health Commun ication-Behaviour Change Formu lation Un ified Theory of Human Behaviour The H ierarchy of Learning Model of Ray and Col leagues

III

Page

\ I VI IX

X

XII

1

4 5

7 7 7 8 9 9

9

11 1 1

1 2

1 3

1 3

1 3

1 5

1 5

1 6

1 6

18 2 3

25

25

26 26

27

Page

CommUnicat,on-Persuas,on Model of McGuIre 2 9 AttItude Change Model of AJzen a n d Fishbein 29

Conceptual Framework 33 Pred isposing Factors 35 Enabl ing Factors 35 Reinforcing Factors 36 Commun ication Patterns 36

3 METHODOLOGY 37 Matenals and Methods 37

Subjects 37 Procedure 37 Variables 38

limitatIons of the study 4 1 Study PopulatIon 4 1 Accuracy o f Data 42

4. FINDINGS O F STUDY 44 PredIsposing Factors 45

Patients demographIc Characteristics 45 Health Knowledge Level and Behaviour 5 1 Respondents Education Level, Knowledge Score and Ethn ic Group 56 Respondents Attitude Towards Hypertension 59 Respondents Beliefs on Likely Causes of Hypertension 60

Reinforcing Factors 6 1 Patients Enabl ing Factors to Health Care 62 U nderstanding Patients Commun ication Patterns 66

Mass MedIa Exposu re 69 I nterpersonal I nteraction 70

RelatIonsh ip between CommunicatIon Pattern and Various Independent Variables 71 I nfluence on Dietary, Exercise and Health Habits 71 Main Source of Health Information by EthniC G roup 72 Health I nformation Source and EthniC Group 73 Main Source of Hea lth I nformatIon by Age 76 Knowledge Level and Main Source of Health I nformation 77 Education Level and Main Source of Health InformatIon 78

IV

Page

5 CONCLUSION AND RECOMMENDATIONS 80 Summary 80

Research Methodology 82 Findings 82 Communication Pattern 85

Recommendations 87 DIScussion 90

Pred isposing Factors 90 Enabling Factors 96 Reinforcing Factors 96 Communication Patterns 97

Conclusion 1 0 1

BIBLIOGRAPHY 1 08

APPENDICES 1 1 9 Appendix A Additional Figures 1 1 9 Appendix B Questionnaire 125

VITA 133

v

LIST OF TABLES

Table Page

1 . The Health Communication-Behaviour Change 31 Formulation

2 . List of Variables Measured 39

3. Distribution of Respondents by Ethnic Group 45

4. D istribution of Respondents by Ethn ic Group and Sex 46

5 . D istribution of Respondents by Age, Sex and Ethn ic 47 Group

6. D istribution of Respondents by Ethn ic Group and 48 Education Levels

7. D istribution of Respondents by Ethnic Group and 50

I ncome

8. Distribution of Respondents by Knowledge Score 52

9. Multiple Contingency Table Showing Relationship 53

between Sex and Knowledge Level Among Hypertensive Patients by Ethnic Group

1 0 . D istributi ion of Study Population on Knowledge of 54 Hypertension by Sex

11 . Distribution of Respondents by Knowledge Level 56 and Health Behaviou r

1 2. Mu ltiple Contingency Table Showing Relationship 58

Between Ethnic Group and Knowledge Level Among Hypertensive Patients by Knowledge Level

1 3. Frequency D istribution of Hypertension on Attitude 60 Towards Hypertension

14. Frequency Distribution of Hypertension Beliefs on 6 1 Likely Causes of High Blood Pressu re

VI

Page

15 DIstributIon of Study PopulatIon by SocIal Group 62 and Race

1 6 D IstributIon of Respondents by Perceived Family 63 Support

1 7 DIstribution of Respondents Understanding of Medical 63 Regime

18 D IstributIon of the Respondents by PerceptIon on 65 Present System of Care

1 9 Dlstnbutlon of Respondents on Barners to Health 66 Care

20 Frequency Distribution of Hypertensive on Source of 67

Health Information

21 Frequency Distribution of Hypertensive on Source of 68 Medical Advice

22 Frequency DistributIon of Hypertensive on Reliabil ity 69

of Source

23 Frequency Distribution of Hypertensive on Mass Media 70

Usage

24 Frequency Distribution of HypertensIve on I nterpersonal 7 1

I nteraction Regarding Their Health

25 Frequency DistributIon of Hypertensive on I nfluence of 72 of Mass Media and I ndividuals on their Dietary, Exercise and Health Habits

26 Frequency Distribution of Hypertensive on Mam Source 73 of Hea lth I nformation by Ethn ic Group

27 Multiple Contlgency Table Showing Relationship between 75

Main Source of Health I nformation and Ethn iC Group

28 Frequency Distribution of Hypertensive on Main 77

Source of Health I nformatIon by Age

VII

29.

30 .

Relationship between Knowledge Level and Main Source of Hea lth I nformation .

Mu ltiple Contingency Table Showing Relationship between Education Level and Main Source of Health Information Among Hypertensives .

vii i

Page

77

79

LIST OF FIGURES

Figure Page

1. Conceptual Framework 33

2 . Pie Chart Representing Education Level of Respondents 1 1 9

3 . Relationship Between Education Level o f Respondents 1 20 and Knowledge Score.

4. Hypertensives Main Source of Health I nformation 1 2 1

5. Relationship Between Respondents Source of Health 1 22 I nformation and Its Reliability .

6. Amount of Health I nformation Obtained by Respondents 1 23 from Mass Media and Other Sources.

7 . Respondents Frequency of Mass Media Usage and 1 24 I nterpersonal I nteraction .

ix

Abstract of thesIs submitted to the Senate of Umverslt, Pertaman Malaysia I n partial fu lfi lment of the reqUirements for the degree of Master of SCien ce

INFORMA TION SEEKING BEHAVIOUR, HEALTH KNOWLEDGE, ATTITUDE AND PRACTICE O F HYPERTENSIVE PATIENTS

Chairman Faculty

IN HOSPITAL BESAR TENGKU AMPUAN RAHIMAH , KLANG, SELANGOR DARUL EHSAN

by

TUNKU ZAIDAR BT. TUNKU ZAINAL ABIDIN JUNE 1 995

Prof Sulalman M Yassln , Ph 0

Center for Extension and Contin uing Education

The p urpose of this study was to analyze the various Interrelated

factors associated with health and information seeking behaViou r of

hypertensive patients

The population of this study consisted of 245 hypertensive patients

listed for their appointments at Hospital Besar Tengku Ampuan Rahlmah ,

Klang Twenty five percent of hypertensives have been selected dally for 1 0

consecutive days excluding Saturday and Sunday I nformation was collected

via a highly structured Interview, In which the questionnaires were

admin istered o ra l ly I ndependent variables Included In thiS study were age ,

sex, ethniC group, mantal status, education level , I ncome, health knowledge

level , attitude, bel iefs , health behaViour and social network The dependent

variables Included were sources of health information (teleVISion, radiO ,

newspaper, magazine, doctor, paramedic, family and fflends), their frequency

of referral , reliabil ity and perceived Influence

x

Findings of this study indicated that the h igher the educational level the

h igher was the health knowledge score of respondents. Overal l , hypertens ive

had a positive attitude toward their d isease and every patient was aware of

the importance of contro l l ing blood pressure. Patients with h igher health

knowledge scores reported a tendency to indu lge in good health related

behaviour. Knowledge was related to health behaviour. I nterpersonal

i nteraction was fou nd to be more important than mass med ia in influencing

d ietary, exercise and health habits . Doctors were considered most rel iable,

most influential and were also regarded as the leading source of health

i nformation .

XI

Abstrak Tesis yang d lkemukakan kepada Senat U niversitl Pertaman Malaysia bagl memenuhl sebahaglan danpada syarat untuk mendapatkan IJazah Master Sams

PERLAKUAN MENeARI MAKLUMAT, PENGETAHUAN KESIHATAN, SIKAP DAN KESIASAAN PESAKIT -PESAKIT HYPERTENSIF 01

HOSPITAL SESAR TENGKU AMPUAN RAHIMAH, KLANG, SELANGOR OARUL EHSAN.

Pengerusl Fakultl

oleh

TUNKU ZAIDAR ST. TUNKU ZAINAL ASIDIN JUN 1 995

Prof Sulalman M Yass ln , Ph 0

Pusat Pengembangan dan Pendldlkan LanJ utan

TUJuan penyelJdlkan Inl lalah u ntuk menganalJsIs faktor-faktor yang

berkaltan dengan perlakuan keslhatan serta pencanan maklumat oleh

pesaklt-pesaklt darah tlnggl

Popuiasl bagl kaJlan I nl terdlfl dan 245 pesaklt-pesaklt darah tlnggl yang

dlsenaralkan u ntuk temuJanJ I dl Hospital Besar Tengku Ampuan Rahlmah ,

Klang Dua pu luh hma peratus dan pesaklt telah dlplhh setlap han u ntuk 1 0

han kecuah han Sabtu dan Ahad Maklumat dldapatJ melalUl temubual

menggunakan soalsehdlk Angkubah bebas u ntuk kaJlan I n! adalah umur,

Jantlna, kaum, taraf perkahwlnan , tahap pengaJlan , pendapatan , pengetahuan

keslhatan , s ikap, kepercayaan , perlakuan dan kumpulan sosial Angkubah

bersandar kaJlan adalah punca-punca pengetahuan keslhatan , kekerapan

XI I

penggunaanya, kepercayaan pada sumber dan pengaruh sumber pada

per lakuan kesihatan pesakit.

Hasi l kaj ian in i menu njukkan, bertambah tingginya taraf pend idikan

seseorang semakin t inggi pengetahuan kesihatanya . Pada keseluruhanya ,

pesakit-pesakit mempunyai sikap positif terhadap penyakit mereka dan sedar

akan pentingnya mengawal tekanan darah . Pesakit yang mempunyal

pengetahuan kesihatan yang tinggi mengaku lebih kearah perlakuan

kesihatan yang baik. Pengetahuan pesakit mempunyai perkaitan dengan

perlakuan. I nteraksi perseorangan d i laporkan lebih mempengaruhi

pemakanan, senaman dan kebiasaan kesihatan pesakit berbanding d engan

media massa. Doktor d idapati pal ing d ipercayai , pal ing berpengaruh dan

d ianggap sebagai sumber utama pengetahuan kesihatan .

xi i i

CHAPTER 1

INTRODUCTION

Much of the premature death and disability expenenced throughout the

world has a social and behaviora l basIs These problems therefore requ i re

app lications of social sCIence theory, data and methods to achieve change

on a scale sufficient to affect the public health This wil l allow assessment of

patients causal l inks between socIal , environmental or behaviora l factors and

the dependent vanable of d isease outcomes such as stroke or heart attack,

or the physIologIcal states, such as elevated blood pressure that underl ie

these d Isease states

The preventIon of chronic d iseases has emerged as a major focus of

modern public health While some diseases and condltrons can perhaps best

be treated by InjectIons, surgery or other non-behavIoral manrpulatlons, most

chronic d iseases and cond itions of concern today cannot The way we

behave as indivIduals does to an extent affect both the occurrence of d isease

and the outcome of treatment Chronic d Iseases such as can ce r,

hypertension , diabetes mell itus and other forms of chronic d iseases are partly

caused by a particular behaviour and hopefully can be treated by behavioral

change

1

2

Communication and education can help to achieve changes in attitude,

knowledge and behaviou r. Communication is the basis of al l h uman

interrelationship without which education in any form cannot take p lace. I t is

th us an integra l part of health education . Health education is a form of

p lanned intervention attempting to influence largely unplanned natura l

processes in such a way as to bring about an improved health status. Health

education practice may uti l ize interpersonal commun ication methods ,

nonpersonal or both in combination .

Hypertension is a disease which is a serious mass publ ic health

problem despite the fact that at any given time, a majority of persons with it

are symptom - free. Hypertension is a si lent secret threat to the health of

people around the world; it is a chronic condition that leads to a variety of

serious complications and diseases . The complications of even mi ld

hypertension involve progression to moderate and severe hypertension . I t is

among the leading "Risk Factor" for the development of coronary heart

diseases and cerebrovascular accidents and also renal fa i lure . Hypertension

is a lso a contributing cause for at least one third of premature death due to

heart attacks and even a higher proportion of premature death due to stroke.

Hypertension is the dominant aetiology percussor in 75 percent of congestive

heart fai lure cases (Kannel et aI. , 1 972) . Mortal ity and morbid ity rises with

progressive increases in blood pressure .

3

We are confronted here with a medical condition that IS clearly of g reat

Importance and senousness There are two major Issues In the long-term

treatment of hypertension One IS to select an appropnate treatment plan for

the individual patients and the second IS to ensure that patients adhere to It

M ost persons with moderately elevated blood pressure expenence no

symptom and no d iscomfort Treatment for hypertension therefore requ i res

that patients be convinced to embark upon a long-term course of drug

treatment eventhough they feel well Further, I t IS virtually certain that Initiation

of treatment wil l not make these patients feel better, Indeed In many cases,

they wil l feel worse There IS presently no cure , hence the direct outcome of

any health education programme should be to control blood pressu re

Hypertension therefore Involves a condition that IS not as yet easily

prevented and that It reqUires a programme of behaviour change for

treatment and control The mere diSSemination of information with the aim of

Increasing health knowledge may not be sufficient to stimulate behaviour

change Many education campaigns have had l ittle or no measurable effect

on behaviour (O'Keefe, 1 97 1 ) and It appears that relationship between

know ledge and behaviour IS complex (Banc, 1 973, Enelow et ai, 1 975 ,

Henderson , et ai, 1 976 , Hochbaum, 1 958, Jacobson et ai , 1 977,

Tostesan , 1 975) ASide from dissemination of knowledge, a posItive resu lt

may reqUire a n umber of other favourable changes In the environment

4

Hypertension in Malaysia

I n Malaysia, cardiovascular d iseases are the most important g roup of

. k i l ler' d iseases. In 1989, 5294 (29.1 percent) of al l medically certified deaths

in Peninsular Malaysia were d ue to card iovascular d iseases . Between 1981

to 1 989 , the mortal ity rate rose from 15.3 per 100,000 persons to 37.0, a n

i ncrease of 1 4 1 . 8 percent. Hospital admissions for card iovascular d iseases

a lso showed a s imilar trend, increasing by 534 percent between 1965 and

1989 (Malaysia, Dept. of Statistics , 1989, 1986, 1991).

Hypertension is not only a risk factor of cardiovascular d iseases, but

a lso the most potent one; for example two th i rds of the people in the

commun ity with card iovascular d iseases were hypertens ive, and the

card iovascu lar mortality rate of hypertensive was twice that of non

hypertensive (Kannel , 1974). Hypertension must be the foremost publ ic

health problem facing Malaysia . I ts h igh prevalence (14 percent of

population) and the card iovascular r isk associated with it combine to

emphasize its importance (Kandiah et aI. , 1980). I t is easily the most common

cause of medical admissions as have been shown by another hospital

morbid ity study (13 percent of med ica l admission) (L im, 1990).

Hypertension is essential ly asymptomatic, its treatment is of long

d u ration , often inconvenient and may not be wel l tolerated . Given that the

benefits of antihypertensive treatment are now so well documented (Veterans'

Administration Cooperative Study, 1967, 1970, 1980, 1985) and many of the

card iovascular compl ications are thereby preventable, the marked

5

prevalence of complicated hypertension as Ind icated by ItS admission rate

must surely be regarded as a s ign of med ical fai lure

I n a study done In Mentakab, Pahang, It was found that a lmost a l l

complicated hypertensive had poorly control led hypertension The reason

given was that most hypertensive do not continue with their treatment A

common reason for dropping out of treatment Cited by 85 percent of patients

IS their lack of motIvatIon to continue treatment

Three key factors that affected the patients attitude towards continuing

treatment were ( 1 ) patients lack of understanding concerning hypertension

and It IS treatment, (2) erroneous beliefs held by patIent concerning

hypertension and It IS treatment, (3) patients perceIved bamer to treatment

as provIded by the health services (LIm et ai, 1 99 1 ) Therefore an effective

health education programme and hea lth promotIon a Imed at hypertensive

patients should be formu lated

Health Education Campaign in Malaysia

I n the past, the MInistry of Health has Implemented various preventive

and curative programmes to Improve the peoples health The strategies used

In the prevention and control of infectIOUs d Iseases have resu lted In a

decrease of such diseases However as the country WinS the battle over

endemIC infectIOUs diseases and the people become more affl uent ,so our

"festyle changes These changes In lifestyle have led to changes I n the

disease pattern In the country from' environ mental ' to 'lifestyle' diseases

6

On May 25, 1 99 1 , the Mlntstry of Health launched a nationwide

'Healthy Lifestyle' campaig n USing the health care approach , the campaig n

was aimed at promoting a healthy way of life among ind ividuals, and society

as a whole The three main objectives of the campaign were

*

*

*

To create greater awareness of the dangers of 'l ifestyle' d iseases

amongst MalaYSians

To educate MalaYSians on the preventive measures which can be

taken

To promote a healthy l ifestyle amongst MalaYSians

The pnonty diseases which have been selected for this campaig n are

1 Cardiovascular Diseases

2 Sexual ly-Transmitted Diseases/A IDS

3 Food POisoning

4 Cancer

5 Diabetes Mellitus

6 Childhood Diseases

To ensure a ful l understanding of each Priority d Isease , the Healthy

Lifestyle Campaign was spread over SIX years with one disease being

high lighted each year The campaign was carned out at both national and

state levels to ensure proper dissemination of all lifestyle messages

7

At National Level

The activities at national level included talks and spot announcements

on radio and television. D issemination of health messages via newspapers,

magazines and other print med ia. Nationwide educational activities were to

be carried out by Health Ministry Personnel through exhibitions, group

d iscussions and demonstrations.

At State Level

Primary Health Care approach was conducted at state level , that is ,

i nter-sectoral collaboration and community participation . I n the former, other

government agencies (eg. M in istry of I nformation, Min istry of Education ,

Rukun Tetangga groups, etc.) and non governmental civic organ isations (eg.

Rotaract, Lions , Kiwanis , etc.) were encouraged to participate either d i rectly

i n the Ministry's promotional activities or through their own efforts.

Statement of Problem

The purpose of this study was to analyze the various factors

associated with health behaviour and the information seeking behaviour of

hypertensive patients. This study attempted to answer these questions 1 ) The

various health information source of hypertensive regard ing their i l lness, its

perceived rel iabil ity , and its influence on health related behaviour? 2) H ow

does health knowledge affect patients' health behaviour? 3) What are the

problems and barriers to health care faced by patients?

8

Many health workers may feel daunted by the task of attempting to

help people change their habits and become healthier. What can mere words

do to get people away from l ifelong customs and habits which seem to be

lead ing them to premature death? For health education to be effective ,

programme of commun ication must be carefully selected . This can on ly be

achieved by u nderstand ing the factors associated with patients' health

behaviour.

Significance of the Study

There is no point in spending time and money on health education if it

d oes not work ! With this in mind , this study consisted of gathering and

analysing as much baseline i nformation on factors related to patients health

behaviour and their various source of health information. With this information

on ly can a suitable and effective commun ication programme be developed

to ensure a more systematic, balanced and workable health education which

meets the requ irement of hypertensive patients.

As have been mentioned of the several complications of this disease

which may eventual ly lead to premature mortality, nevertheless, increased

premature mortal ity is by no means the on ly problem. A sizable amount of

d isabi l ity in the labour force IS also another problem The economic losses to

the ind ividuals involved are great, as are the costs to the government and

society a t large. Vast resources are spent on medical care for these people.

The economic losses to the government and society is from the d isabil ity and

morbid ity caused by this d isease . It is not d ifficult to conclude that this

9

problem has a big impact on our society general ly and that the contro l of

hypertension would, besides al leviating emotional d istress,make resources

avai lable for other pressing needs .

Th is study hopes to assist health educators to develop q uality h ealth

education that would meet the needs and requ i rement of hypertensive

patients in the hope of achieving favou rable behaviora l and u lt imately

favourable health outcomes. It is also expected to provide a basis for

p lann ing educational strategies and material for the publ ic i n general a nd

patient i n part icular, that wi l l be helpfu l at national. commun ity and local

levels.

Objectives of the Study

General Objective

The purpose of this study is to analyze the various factors i nfluencing

health behaviour of hypertensive patients and their sources of health

information .

Specific Objectives

1 . To examine the pred isposing factors influencing patients health

behaviour which include patients health knowledge, attitude, bel iefs

and demographic variables .

2 . To analyze the enabl ing factors such as patients' problems a nd

barriers to health care in terms of transportation , inaccessib i l ity to

1 0

health facIl ity , costs, and understanding of their med ical regime, and

their perception on the present system of care

3 To examine the reinforcing factors which Include patients

family situation, peer groups and persons who Influence them,

and patients affi l iation with other social groups

4 To explore patIents' health communicatIon patterns In seeking

information on their health conditions

CHAPTER 2

LITERA TURE REVIEW

ThIS chapter IS organIzed accord ing to the followIng tOPICS (a)

defin ItIon (b) related theories and research (c) solving health educatIon

problems (d) role of communrcatlon In health educatIon (e) health educatIon

objectIves and (f) theoretIcal backg round

Definition

Health educatIon IS defIned as a learnIng process Intended to result I n

the voluntary adoptIon of behavIour benefIcIal to health Impl iCIt In th IS

defIn It ion IS the concept of commun ication Learn ing Implies receipt of a

communrcatlon , fol lowed by a change In behaViour of an IndIV idual or group

Education In the usual general sense IS often regarded , particularly I n the

western world , as good for :ts own sake and as an end In Itself Health

education , however, must contribute to an outcome In wh ich there IS a

behaVioural change associated WIth a demonstrably Improved health status

of the i nd IVidual , g roup, and community

The prevention of chronrc d iseases has emerged as a major focus of

modern public health Present knowledge Ind icates that adoption of healthy

lIfestyles and environments are key elements of such preventive actIon

11