Enferm Clin.

2020;30(S2):55---59

www.elsevier.es/enfermeriaclinica

The effect of culture-based education in improving

knowledge of hypertension patients in Makassarese
community in Indonesia夽
Andi Pramesti Ningsih, Nurhaya Nurdin ∗ , Arnis Puspitha, Silvia Malasari, Kusrini Kadar

Faculty of Nursing, Hasanuddin University, Indonesia

Received 29 May 2019; accepted 15 July 2019

KEYWORDS Abstract
Hypertension; Objective: This research aimed to determine the effect of culture-based education in improving
Culture-based knowledge of hypertension patients in the Makassarese Community, Indonesia.
education; Method: This study used a quasi-experiment with two groups pretest---posttest control group
Knowledge; design. The sample was 36 respondents, which were divided into two groups, which were given
Health literacy culture-based education and control group is given ordinary education. Each group was given a
pretest and posttest.
Result: This study shows that there was an increasing knowledge of the intervention group after
receiving cultural-based education. The research results showed t-value 1.92 with significant
p-value >0.005 with the mean values in the intervention group 27.78 and 11.67 in the control
group.
Conclusion: Education of culture-based hypertension affects increasing knowledge of people
with hypertension in the community. Therefore, it is expected that culture-based education
can be used as a health education program to increase the knowledge of hypertension patients
effectively.
© 2019 Elsevier España, S.L.U. All rights reserved.

Introduction
夽 Peer-review under responsibility of the scientific committee of Non-Communicable Diseases (NCDs) including hypertension
the International Conference on Women and Societal Perspective on have emerged as a huge global health problem in low- and
Quality of Life (WOSQUAL-2019). Full-text and the content of it is middle-income countries,1 particularly visible in Southeast
under responsibility of authors of the article. Asia where limited resources have been used to address this
∗ Corresponding author.
rising epidemic, including Indonesia. World Health Organi-
E-mail address: [email protected] (N. Nurdin). zation (WHO) reported that cardiovascular disease, as the

https://doi.org/10.1016/j.enfcli.2019.09.003
1130-8621/© 2019 Elsevier España, S.L.U. All rights reserved.
56 A.P. Ningsih et al.

number one killer in the world is caused over 17 million group to evaluate the effect of culture-based health educa-
deaths represent 13% of global deaths2 including disease, tion to the level of knowledge of patients with hypertension.
congenital heart disease, and hypertension.3 Patients with There were as many as 36 respondents involving in this study
hypertension in Indonesia are estimated at 15 million, but chosen by using purposive sampling techniques that have
only about 4% can control hypertension.1,4 To effectively met the inclusion criteria including patients with hyper-
control hypertension, sufficient knowledge and awareness tension aged 40---59 years and using the native language,
of the clients of the risks of hypertension are needed willing to participate and involving in all activities in this
and important.5 Based on the results of the Basic Health study. The 36 respondents were divided into two groups, 18
Research (2013), where the prevalence of hypertension was respondents in the intervention group that receive health
higher in the group with low education and those who do education using culturally based in this case Makassarese
not work.4 Disease Control and Environmental Health (P2PL) culture and 18 respondents in the control group receiving
Makassar City Health Department in 2015 revealed that usual health education provided in the community center
hypertension ranks third major cause of death in the amount provided in Bahasa language.
of 370 population.6 Interventions in this study using a cultural approach and
Some studies in China and Indonesia show the level of using modified precede-proceed method into 3 phases (orig-
knowledge people with hypertension is still low regarding inal method using 8 phases). The 3 phases used in this study
their illness and how to manage their condition,7---10 espe- were data collection phase which was pretest knowledge
cially about complication and treatment of hypertension. for both groups, 2nd phase was the implementation of 3
There are many factors that contribute to low levels of learning sessions (basic knowledge of hypertension, diet,
this knowledge, one of which is health education programs and physical activity, stress management, and social sup-
and cultural backgrounds.11 This suggests that the health port) then the 3rd phase was the post-test for both groups.
education program requires proper management in preven- Each session in the provision of education conducted for
tion, especially in a community. The provision of health 30 min using media poster. The questionnaire that was used
education to patients should focus on cultural aspects that in this study was Culturally Adapted Hypertension Education
exist in society,11 including the language used. Results of (CAHE) invented by Beune et al.12 and was translated into
research in 2014 in Africa showed that culture-based health Bahasa (Indonesian language) by a nursing lecturer whom
education interventions could improve patient compliance expert in health education topic and back-translated into
with uncontrolled hypertension to lifestyle changes that sup- English by another lecturer with similar expertise. Valid-
port the treatment needs of patients with hypertension.12 ity test result (between 0.324 and 0.857) and Cronbach’s
Thus, health education programs are needed, and health alpha (0.849) showed that this instrument valid and reliable
care professionals must be able to incorporate local cultural for this study. Ethic approval was sought from the Fac-
elements such as using local language providing health edu- ulty of Medicine Ethic Committee Universitas Hasanuddin
cation about hypertension,11---13 to make patients understand (Ethic No. 1095/H4.8/5/31/PP36-KOMETIK/2017). Before
the content of health education.14 It is important for health this study began, respondents were given to inform consent
care professional to master cultural competency in provid- explaining about what this study aim and what is the role of
ing health care provision for people in community.15 Cultural researcher and respondents. Data were analyzed using SPSS
competence can be defined as ‘‘the ability of providers and 20.0 statistical test using a paired t-test and independent
organizations to effectively deliver health care services that t-test.
meet the social, cultural, and linguistic needs of patients’’
and it closes the gap, enables better communications, and
ultimately unites people in spite of their differences.16 Result
As mentioned above, knowledge of patient regard-
ing their condition can be improved by proper health Questionnaires were distributed to all groups and contained
education17 by including cultural aspect when preparing to demographic data information and clinical status of the
deliver health education. Although there have been many respondents. Table 1 show details data about demographic
studies done in Indonesia related to the effect of health data and clinical status of respondents.
education, unfortunately, it is difficult to locate published The table shows a majority of respondents are female in
articles related to this area of study in Indonesia. However, both groups with half of the respondents only have lower
from the researcher’s personal experience as a community education in the intervention group (50%) while in control
health nurse, health education is provided as it is, without group more than half were graduated from senior high school
any preparation and any consideration of important aspect, (61.1%). More respondents working at home as a housewife
including health literacy and cultural background of the in both groups and intervention group more than half (55.6%)
patient. They deliver health education in Bahasa (Indonesian of respondents do not have a family history with CVD while in
Language), but in fact, some of those patients cannot under- control group 72.2% respondents have a family history with
stand Bahasa well. Thus, the researcher was interested to CVD. Mean age in intervention and control groups are 54.6
see the effect of cultural-based health education to increase and 52.7, respectively. Blood pressure means in both groups
knowledge of people with hypertension in the community. are 150/80 for the intervention group and 160/100 for the
control group. Table 2 shows the result of level knowledge
Method differences before and after the intervention.
From the table above, it can be seen that although
This research used a quantitative method using quasi- respondents in both groups experienced the effect of health
experiment design with two groups pre and post control education on their knowledge (p-value <0.05), and both
Culture-based education for hypertension patients 57

Table 1 Demographic and clinical characteristics of respondents (n = 36).

Variable Intervention group (culture) Control group (conventional)

n % n %
Gender
Male 5 27.8 7 38.9
Female 13 72.2 11 61.1
Education
Elementary School 9 50.0 4 22.2
Junior High School 3 16.7 3 16.7
Senior High School 6 33.3 11 61.1
Occupation
Not working 5 27.8 4 22.2
Housewife 6 33.3 7 38.9
Entrepreneur 4 22.2 4 22.2
Farmer 1 5.6 0 0
Retired 2 11.1 3 16.7
Family history
Have family with CVDa 8 44.4 13 72.2
No family has CVDa 10 55.6 5 27.8
Total 18 100 18 100

Clinical status Mean (min---max) Mean (min---max)

Age 54.6 (40---58) 52.7 (44---59)
Blood pressure 150/80 (140/80---180/90) 160/100 (140/80---190/100)
a Cardiovascular disease.

Table 2 Data analysis of respondents knowledge before and after intervention in both groups.
Knowledge Mean SD p-value

Culture conventional Culture conventional Culture conventional

Before 57.22 56.67 17.758 15.339
After 80.00 68.33 14.522 13.827 0.000a 0.004a
a Data analysis was run using paired t-test analysis.

groups showed increasing mean knowledge before and after influenced by several factors that existed in respondents.
the intervention, but intervention group knowledge showed One of them is the education level of respondents who were
an increasing level of knowledge significantly compare to in the control group, where the majority of them had a high
control group. Knowledge of respondents in the control school education level. The level of education is a factor
group only increased by 1.5 points, while those in the inter- of considerable influence in obtaining information that can
vention group level of knowledge increased by 3.2 points. support health. Demographic data showed that the educa-
From the analysis of the level of knowledge between the tion of the respondents in the intervention group was lower
intervention and control groups using independent t-test than in the control group education. This may affect the
showed that the average level of knowledge before and level of acceptance of the respondent by the theory that the
after intervention in the intervention group was 27.78 while higher the level of education, the higher the person’s ability
for the control group was 11.67. As for a positive t-value to receive the information provided.7 Reception of informa-
(1.923) showed that there was differences level of knowl- tion in the provision of knowledge is also influenced by the
edge before and after intervention in both groups. However, age and experience of the respondents. Older people show
the differences between the two groups were not significant a level of maturity and strength; thus, they will be more
as the p-value was 0.006 > 0.005. mature in thinking.18 However, increasing age resulted in
the decline of cognitive functions, and that age will prolong
the time to recall information that has been obtained.18
Discussion Health education has been proven can improve patient
knowledge about their condition.17 This study also prove
This study shows that there is no significant difference in that after receiving health education knowledge of hyper-
the level of knowledge in both groups might have been tension patients was increased. Thus, providing health
58 A.P. Ningsih et al.

education should need more preparation, choose the best epidemic of chronic noncommunicable diseases? A system-
strategy to that the topic can be delivered well, and the atic review with meta-analysis. PLOS ONE. 2017;12:e0179186,
patient can absorb the information easily.19 Primary health http://dx.doi.org/10.1371/journal.pone.0179186.
care services sometimes do not have enough time to pro- 2. World Health Organization. New initiative launched to tackle
vide a long-sophisticated health education program for cardiovascular disease, the world’s number one killer. WHO;
2016. Available from: https://www.who.int/cardiovascular
patients.20 In some health clinics in developed countries
diseases/global-hearts/Global hearts initiative/en/ [Internet;
such as in the US, clinicians are sometimes struggling to fit cited 18.12.18].
multiple agenda items into the 15-min visit, hence cannot 3. Karo S. Cegah dan Atasi Penyakit Jantung & Pembuluh Darah.
meet every need of their patients with chronic conditions. Jakarta: Praninta aksara; 2016.
Half of the patients leave primary care visits, not under- 4. Research & Development of the Ministry of Health Repub-
standing what their doctor told them. The results showed lic of Indonesia. The results of basic health research
that health education strategy to use culture strategy is (Riset Kesehatan Dasar) 2013. Ministry of Health Republic
needed. This cultural approach will increase the confi- of Indonesia; 2013. Available from: http://www.depkes.go.
dence and awareness of the health information provided.11 id/resources/download/general/Hasil%20Riskesdas%202013.pdf
[Internet; cited 10.09.16].
Approach using culture is considered more able to increase
5. Bustan MN. Manajemen Pengendalian Penyakit Tidak Menular.
public knowledge, especially in areas with cultural value is
Jakarta: Rineka cipta; 2015.
still quite high. Needs of patients with health personnel com- 6. Dinas Kesehatan Kota Makassar. Profil Kesehatan Kota Makassar
petency in understanding aspects of the prevailing culture Tahun 2015. Available from: http://dinkeskotamakassar.
in the community are very important in determining the com/index.php/2017-02-09-09-30-56?download=17:profil-
action to be taken.13 Development of health services by the kesehatan-kota-makassar-tahun-2015 [Internet; cited
cultural aspects of each patient’s condition is an important 18.09.18].
issue.21 Therefore, the health workers as much as possi- 7. Li X, Ning N, Hao Y, Sun H, Gao L, Jiao M, et al. Health liter-
ble in partnership with social scientists, anthropologists, acy in rural areas of China: hypertension knowledge survey. Int
and researchers develop and evaluate health education pro- J Environ Res Public Health. 2013;10:1125---38, http://dx.doi.
org/10.3390/ijerph10031125.
grams. This is because of cultural competence is a standard
8. Dirhan. Hubungan Pengetahuan, Sikap dan Ketaatan Bero-
for the delivery of information to patients who come from
bat dengan Derajat Sistole and Diastole Pasien Hipertensi
different cultural backgrounds. di Puskesmas Sukamerindu Kota Bengkulu. J Ilmiah Farmasi.
2012;9.
Conclusion 9. Wang C, Lang J, Xuan L, Li X, Zhang L. The effect of health
literacy and self-management efficacy on the health-related
quality of life of hypertensive patients in a western rural area of
Based on the discussion that has been described above, China: a cross-sectional study. Int J Equity Health. 2017;16:58,
health staff must understand the culture in the community http://dx.doi.org/10.1186/s12939-017-0551-9.
to provide an easy-understandable explanation. Providing 10. Pirasath S, Kumanan T, Guruparan M. A study on knowl-
health education that using the local language of the com- edge, awareness, and medication adherence in patients with
munity will help the hypertension patient understand easily hypertension from a tertiary care centre from Northern Sri
about the topic that is taught. This will certainly facilitate Lanka. Int J Hypertens. 2017;2017:9656450, http://dx.doi.org/
the public in identifying the medical term that is often used 10.1155/2017/9656450.
by health staff when explaining or providing health educa- 11. Malini H, Copnell B, Moss C. Considerations in adopt-
tion. This cultural approach is not an easy thing so that ing a culturally relevant diabetes health education pro-
gramme: an Indonesian example. Collegian. 2017;24:183---90,
building up networks of public health experts and policy-
http://dx.doi.org/10.1016/j.colegn.2015.11.002.
makers, increasing the understanding of non-health sectors 12. Beune EJ, Moll van Charante EP, Beem L, Mohrs J, Agyemang
of their role in NCDs prevention, including hypertension, is CO, Ogedegbe G, et al. Culturally adapted hypertension edu-
very important. Also, health staff should be encouraged to cation (CAHE) to improve blood pressure control and treatment
always upgrading their knowledge and skills about health lit- adherence in patients of African origin with uncontrolled hyper-
eracy and health education. Providing them with training to tension: cluster-randomized trial. PLOS ONE. 2014;9:e90103,
understand cultural competency is necessary. http://dx.doi.org/10.1371/journal.pone.0090103.
13. Gross B, Anderson EF, Busby S, Frith KH, Panco CE. Using
culturally sensitive education to improve adherence with anti-
Conflict of interest hypertension regimen. J Cult Divers. 2013;20:75---9.
14. National Academies of Sciences, Engineering, Medicine.
The authors declare no conflict of interest. Integrating health literacy, cultural competence, and language
access services: workshop summary. Washington, DC: The
National Academies Press; 2016. Available from: https://www.
Acknowledgment nap.edu/catalog/23498/integrating-health-literacy-cultural-
competence-and-language-access-services-workshop
Thank you for all the participants and research assistant who 15. Abrishami D. The need for cultural competency in health care.
were very helpful in this study. Radiol Technol. 2018;89:441---8.
16. Hughes J. Why is cultural competence in healthcare so
important? HEALTHCARESTUDIES.COM; 2016. Available from:
References https://www.healthcarestudies.com/article/Why-Is-Cultural-
Competence-in-Healthcare-So-Important/ [Internet].
1. Schröders J, Wall S, Hakimi M, Dewi FST, Weinehall 17. Andrianys I, Kadar K, Massi N. Precede---proceed education
L, Nichter M, et al. How is Indonesia coping with its model towards health literacy of hypertension patient within
Culture-based education for hypertension patients 59

the working area of Pattingalloang Health Centre Makassar. ICON 20. Wong-Rieger D, Rieger FP. Health coaching in diabetes: empow-
J. 2017;1. ering patients to self-manage. Can J Diabetes. 2013;37:41---4,
18. Wu JR, Moser DK, DeWalt DA, Rayens MK, Dracup K. Health liter- http://dx.doi.org/10.1016/j.jcjd.2013.01.001.
acy mediates the relationship between age and health outcomes 21. Saha S, Beach MC, Cooper LA. Patient centered-
in patients with heart failure. Circ Heart Fail. 2016;9:e002250, ness, cultural competence and healthcare quality. J
http://dx.doi.org/10.1161/CIRCHEARTFAILURE.115.002250. Natl Med Assoc. 2010;100:1275---85, http://dx.doi.org/
19. Jarvis J, Skinner TC, Carey ME, Davies MJ. How can structured 10.1016/s0027-9684(15)31505-4.
self-management patient education improve outcomes in peo-
ple with type 2 diabetes? Diabetes Obes Metab. 2010;12:12---9,
http://dx.doi.org/10.1111/j.1463-1326.2009.01098.x.