Science Journal of Public Health

2016; 4(6): 506-516

http://www.sciencepublishinggroup.com/j/sjph
doi: 10.11648/j.sjph.20160406.25
ISSN: 2328-7942 (Print); ISSN: 2328-7950 (Online)

Effect of an Educational Intervention About Dietary

Approach to Stop Hypertension (DASH) on Changing
Knowledge, Attitude and Blood Pressure of Hypertensive
Patients Attending Zagazig University Hospitals
Eman E. Orabi
Public Health and Community Medicine Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt

Email address:
dr.eman.elshahat@gmail.com

To cite this article:

Eman E. Orabi. Effect of an Educational Intervention About Dietary Approach to Stop Hypertension (DASH) on Changing Knowledge,
Attitude and Blood Pressure of Hypertensive Patients Attending Zagazig University Hospitals. Science Journal of Public Health.
Vol. 4, No. 6, 2016, pp. 506-516. doi: 10.11648/j.sjph.20160406.25

Received: November 29, 2016; Accepted: December 9, 2016; Published: January 10, 2017

Abstract: Background: Hypertension is an important risk factor for cardio vascular illness and mortality all over the world.
The burdens of hypertension can be significantly controlled and reduced by lifestyle modification and treatment adherence.
DASH diet is proved to reduce blood pressure either alone or combined with other life style modification. Aim of the Study is
to evaluate effect of an educational intervention about Dietary Approach to Stop Hypertension (DASH) on Changing
knowledge, attitude and blood pressure of hypertensive Patients Attending Zagazig University Hospitals. Methodology: this
study was an interventional study carried out in cardiology outpatient clinic in Zagazig University Hospitals. The sample
included 132 hypertensive patients chosen by systematic random sampling. The patients were divided into two equal groups 66
patients in the intervention group (G1) and 66 patients in the control group (G2). Data were collected through interviewing
questionnaire which cover socio demographic characteristics, knowledge and attitude toward DASH diet. Results: The results
showed that there was no significant difference between both groups in socio demographic characteristics, knowledge and
attitude toward DASH before the intervention. There was significant improvement in all items of knowledge and attitude
toward DASH in studied group 1 after application of health education sessions. There was significant reduction in blood
pressure of studied group 1 after the intervention but there was no significant change in group 2. Conclusion: The health
education program for hypertensive patients about DASH diet proved its success in improving their knowledge, attitude and
reduction of their blood pressure level.
Keywords: Hypertension, DASH Diet, Life Style Modification, Health Education

1. Introduction
Hypertension is a persistent elevation of the systolic blood About one billion individuals or 26% of the adult
pressure at a level of 140 mm hg or higher and diastolic population worldwide had hypertension (Park et al, 2011),
blood pressure at a level of 90 mm hg or higher based on the while the prevalence of pre hypertension and hypertension in
average of two or more correct blood pressure measurement Egypt were estimated to be 57.2% and 17.6% respectively
taken two or more contact with health care providers (WHO, (Arafa and Ez-Elarab., 2011).
2015). The healthy DASH (Dietary Approaches to Stop
Poorly controlled hypertension is a significant worldwide Hypertension) diet plan was developed to lower blood
public health concern because of its morbidity, mortality, and pressure without medication in research sponsored by the US
economic burden especially among older adults (Ogedegbe et National Institutes of Health. The first DASH diet research
al, 2013). showed that it could lower blood pressure as well as the first
507 Eman E. Orabi: Effect of an Educational Intervention About Dietary Approach to Stop Hypertension (DASH) on Changing
Knowledge, Attitude and Blood Pressure of Hypertensive Patients Attending Zagazig University Hospitals

line blood pressure medications, even with a sodium intake the intervention group (G1) and 66 patients in the control
of 3300 mg/day. Numerous studies have shown that the group (G2). As the mean attendance of hypertensive patients
DASH diet reduces the risk of many diseases, including some is about 10 patients /day so each third patient will be chosen
kinds of cancer, stroke, heart disease, heart failure, kidney in the sample.
stones, and diabetes. It has been proven to be an effective
way to lose weight and become healthier at the same time. 2.1.4. Patients Included in Study
(Heller, 2016) 132 hypertensive patients attending cardiology outpatient
DASH is a flexible and balanced eating plan that requires clinic in Zagazig University Hospitals.
no special foods and instead provides daily and weekly Inclusion criteria:
nutritional goals. This plan recommends: Patients with hypertension (systolic >140 mm hg,
(1) Eating vegetables, fruits, and whole grains diastolic >90 mm hg), Aged > 18 years and attending
(2) Including fat-free or low-fat dairy products, fish, cardiology outpatient clinic in Zagazig University Hospital
poultry, beans, nuts, and vegetable oils regularly.
(3) Limiting foods that are high in saturated fat, such as Exclusion criteria:
fatty meats, full-fat dairy products, and tropical oils Age 18 years old or less, Patients with any physical or
such as coconut, palm kernel, and palm oils mental disability that hinder the intervention e.g., blindness
(4) Limiting sugar-sweetened beverages and or deafness, Patients with diagnosed secondary hypertension
sweets.(National Heart, Lung, and Blood (renal or endocrinal), Patients with isolated systolic
Institute,2015) hypertension.
Beside its beneficial effect on blood pressure, DASH is 2.1.5. Data Collection Tools
designed to be a well-balanced diet for the all population. The intervention group received pre test to assess their
DASH is recommended by the United States Department of knowledge and attitude before the health education sessions
Agriculture (USDA) as an ideal eating plan for all American then they received post test after two months of the
(USDA, 2010). intervention to evaluate the effect of the health education
The DASH diet reduces systolic blood pressure by 6 mm sessions, while the control group received pre test to assess
Hg and diastolic blood pressure by 3 mm Hg in patients with their knowledge and attitude then they received post test after
pre-hypertension (Systolic 120-139 mm Hg, diastolic 80-89 two months without any intervention.
mm Hg). Those with hypertension (Systolic ≥140mm Hg, These data were collected by using:
diastolic ≥90mm Hg) dropped by 11 and 6 mm Hg, (1) An interviewing Arabic pre–test questionnaire which
respectively. These changes in blood pressure occurred with was designed by (Habib et al., 2016) for hypertensive
no changes in body weight (U.S. Department of Health and patients.
Human Services., 2006). It also reduces bad cholesterol It included the following items:
(LDL) and the 10-year risk of heart attack (Chen et al, 2010). (A) Socio demographic characteristics of the patients:
The World Health Organization defined Health Education such as age, gender, education of husband and
as any combination of learning experiences designed to help wife… etc.
individuals and communities improve their health, by Social class was scored as follows: education and cultural
increasing their knowledge or influencing their attitudes domain for both husband & wife (score = 30), family domain
(WHO, 2015). (score = 4), economic domain (score = 3), occupational
domain (for both husband & wife) (score = 10), home
2. Pateints and Methods domain (score = 1), health care domain (score = 5) and total
score will be 53. Socioeconomic level was then classified
2.1. Technical Design into Very low: <13.5, Low: 13.5 - < 27, Middle: 27-< 40 and
2.1.1. Type of Study High: ≥40 (El-Gilany, 2012)
An interventional study (B) Questions to test the knowledge of the patient and
include the following points:
2.1.2. Site of Study 1) General knowledge about DASH:- hearing about
The present study was conducted at cardiology outpatient DASH, Importance of having lots of fruits and
clinic in Zagazig University Hospitals. vegetables, Suitable type of dairy products, Effect of
excess salt and salty foods on blood pressure, The best
2.1.3. Sample Size and Sampling Technique type of bread, Does excess fats and fatty foods effect
The sample size was calculated using (open Epi) program blood pressure, Suitable type of fats, The best type of
assuming that the level of knowledge after health education oil, Effect of exercise on blood pressure and Effect of
(70%) and level of knowledge before health education (50%) smoking on blood pressure
(Habib et al., 2016), at confidence interval 95% and at power 2) Knowledge about serving size in DASH:- The suitable
80%, the estimated sample was 132 hypertensive patients. serving size of fruits and vegetables, dairy products,
Patients will be chosen by systematic random sampling meat, poultry, fish, seeds, dry beans, grains, and
technique then divided into two equal groups 66 patients in sweets.
 Science Journal of Public Health 2016; 4(6): 506-516 508

(C) Questions to test the attitude towards DASH:- data collection, and detect the obstacles of the study. The
Following the DASH plan lower blood pressure, patients included in pilot study were not included in the main
Limiting salt intake control blood pressure, Having sample.
fruits instead of sweets as a desert and Stop smoking
and making exercise help to lower blood pressure. 2.2.2. Data Collection and Work Field
Scoring of patient knowledge: in the questions about the (1) Data collection and health education sessions were
suitable serving size, all answers are correct so:-Getting less done between March 2016 to september 2016 with average
than or equal to 50% of answers or don’t know is considered two months lapse between pre and post test.
wrong. (2) The researcher collected the pre-test questionnaires by
Getting more than 50% of answers is considered right. *In meeting the hypertensive patients attending cardiology
other questions The right answer equals 1 The wrong answer outpatient clinic in Zagazig University Hospital after
equals 0.Maximum score equal 17, Minimum score equal 0. explaining to them the objectives of the study.
Good knowledge > 50% while, Poor knowledge ≤ 50%. (3) The blood pressure was measured by mercury
Scoring of attitude questions: sphygmomanometer before and after the intervention.
Answers were: Agree equal 1 degree, Disagree equal 0 (4) Health education sessions provided for hypertensive
degree, Maximum score equal 4,Minimum score equal 0, patients in the cardiology outpatient clinic (group 1).
Good score > 50% and Poor score ≤ 50% (5) The post-test questionnaires were collected to assess
(2) The same pre-test questionnaire was used as a post test knowledge and attitude after health education sessions for
to assess knowledge and attitude of the intervention both groups.
group (G1) after health education sessions, while the 2.2.3. Administrative Design and Ethical Aspects
control group (G2) completed this post test without any The necessary official permissions were obtained:
intervention. Approval obtained for performing the study from Zagazig
(3) Measuring blood pressure. University Hospital manager and the head of cardiology
Blood pressure was measured before the intervention and department after explaining the purpose of the study to
two month after it for both groups. The blood pressure was them. Approval from the Institutional Review Board of
measured by mercury sphygmomanometer. Reading blood Faculty of Medicine, Zagazig University. An informed
pressure by auscultation is considered the gold standard by consent was obtained from hypertensive patients involved
the Heart, Lung and Blood Institute of the National Institute in the study after explaining purpose to them. The study
of Health (NIH). The blood pressure was measured while group was not exposed to any harm or risk and their data
patients were in seated position with flexed arm, the flexed were confidential.
elbow should be at the level of the heart and supported and if
the patient is anxious, wait a few minutes before taking the 2.2.4. Data Management
pressure. (Clark et al., 2012). Collected data were presented in tables and suitable graphs
(4) Health education message. and analyzed by computer software (statistical package SPSS
The hypertensive patients included in the intervention version 16) using appropriate statistical methods.
group (G1) were given educational sessions to improve Frequencies, means and standard deviation were used to
knowledge and attitude of the patient toward DASH: summarize the data. Categorical data were compared by
Definition of dietary approach to stop hypertension, using chi square test. MC 'Nemar test was used to compare
importance of DASH diet, DASH eating plan and other life pre and post test. Student t test was used to compare two
style modification needed to control hypertension. The independent quantitative data. Paired t- test was used to
educational message was conducted by the researcher compare paired quantitative data. Probability was considered
through personal interview in health education sessions. Each significant if P. value is less than or equal to 0.05.
session took about 20 minutes and was held three times
weekly in the cardiology outpatient clinic. The message was 3. Results
facilitated by uses of posters and booklets which contain the
most important items in the health education message. As regard comparison between the two groups as regard
socio demographic characteristics (Table 1): there is no
2.2. Operational Design statistically significant difference between socio demographic
2.2.1. Pilot Study characteristics of both groups.
Before starting the actual field study, a pilot study was As regard Comparison between pre-tests of studied groups
carried on 10 hypertensive patients to estimate the level of about general knowledge of DASH (Table 2). It shows that
patient’s knowledge because of absence of Egyptian there is no statistical significant difference between pretests
reference and to test the questionnaire with the most of studied groups about general knowledge of DASH.
appropriate terms. It also helped to estimate time needed for
509 Eman E. Orabi: Effect of an Educational Intervention About Dietary Approach to Stop Hypertension (DASH) on Changing
Knowledge, Attitude and Blood Pressure of Hypertensive Patients Attending Zagazig University Hospitals

Table 1. Comparison between the two groups as regard socio demographic characteristics.

group (1) group (2)

Variables X2 P
No (66) % No (66) %
Age
45 - <60 35 53.0 29 43.9 1.095 0.295
60-75 31 47.0 37 56.1
Sex
Male 25 37.9 33 50.0 1.107 0.293
Female 41 62.1 33 50.0
Education of husband
Illiterate 19 28.8 26 39.4
Read and write 15 22.7 21 31.8
8.093 0.088
Essential education 4 6.1 0 0.0
Secondary 26 39.4 17 25.8
High 2 3.0 2 3.0
Education of wife
Illiterate 21 31.8 30 45.5
Read and write 27 40.9 29 43.9
8.604 0.072
Essential education 4 6.1 0 0.0
Secondary 12 18.2 5 7.6
High 2 3.0 2 3.0
Occupation of husband
Not working 27 40.9 21 31.8
Farmer 7 10.6 13 19.7
7.655 0.105
Worker 16 24.2 24 36.4
Clerk 14 21.2 8 12.1
Business man 2 3.0 0 0
Occupation of wife
Not working 59 89.4 63 95.5 1.467 0.226
Clerk 7 10.6 3 4.5
Residence
Urban 19 28.8 27 40.9 2.182 0.139
Rural 47 71.2 39 59.1
Social class
Low 55 83.3 62 93.9 3.308 0.068
Moderate 11 16.7 4 6.1
Smoking
Smoker 43 65.2 44 66.7
0.06 0.971
Ex-smoker 11 18.2 10 15.2
Non smoker 12 18.2 12 18.3

Table 2. Comparison between pre-tests of studied groups about general knowledge of DASH.

Pre-test G1 Pre-test G2
Variables X2 P
No (66) % No (66) %
Hearing about DASH
Yes 42 63.6 40 60.6 0.125 0.723
NO 24 36.4 26 39.4
Importance of having lots of fruits and vegetables
Yes 34 51.5 44 66.7 3.075 0.079
NO 32 48.5 22 33.3
Suitable type of dairy products
Full cream 40 60.6 30 45.5 3.030 0.082
Skimmed or low cream 26 39.4 36 54.5
Effect of excess salt and salty foods on blood pressure
Elevate 52 78.8 59 89.4 2.418 0.120
Lower 14 21.2 7 10.6
The best type of bread
White bread 26 39.4 17 25.8 2.948 0.086
Whole grain bread 40 60.6 49 74.2
Does excess fats and fatty foods effect blood pressure
yes 48 72.7 56 81.8 2.640 0.104
No 18 27.3 10 18.2
Suitable type of fats
Oil 44 63.6 45 68.2 0.03 0.853
Butter or margarine 22 36.4 21 31.8
The best type of oil
0.70 0.403
Olive 6 9.1 4 6.1
 Science Journal of Public Health 2016; 4(6): 506-516 510

Pre-test G1 Pre-test G2
Variables X2 P
No (66) % No (66) %
Corn or sun flower 60 90.9 62 93.9
Effect of exercise on blood pressure
Lower 28 42.4 36 54.5 1.956 0.162
Elevate or does not effect 38 57.6 30 45.5
Effect of smoking on blood pressure
Elevate 26 39.4 34 51.5 1.985 0.159
Lower or does not effect 40 60.6 32 48.5

As regard Comparison between pre-tests of the studied groups about knowledge of serving size in DASH (Table 3). There is
no statistical significant difference between pretests of studied groups’ about serving size in DASH.

Table 3. Comparison between pre-tests of the studied groups about knowledge of serving size in DASH.

Pre-test G1 Pre-test G2
Variables X2 P
No (66) % No (66) %
Suitable serving size of vegetables
Adequate knowledge 27 40.9 26 39.4
0.03 0.859
Inadequate knowledge 39 59.1 40 60.6
Suitable serving size of fruits
Adequate knowledge 27 40.9 29 43.9
0.129 0.719
Inadequate knowledge 39 59.1 37 56.1
Suitable serving size of dairy products
Adequate knowledge 35 53.0 45 68.2 3.075 0.079
Inadequate knowledge 31 47.0 21 31.8
Suitable serving size of meat, poultry and fish
Adequate knowledge 45 68.2 53 80.3
2.296 0.129
Inadequate knowledge 21 31.8 13 19.7
Suitable serving size of seeds and dry beans
Adequate knowledge 15 22.7 13 19.7
0.218 0.640
Inadequate knowledge 51 77.3 53 80.3
Suitable serving size of grains
Adequate knowledge 34 51.5 27 40.9
1.128 0.288
Inadequate knowledge 32 48.5 39 59.1
Suitable serving size of sweets
Adequate knowledge 19 28.8 16 24.2
0.35 0.554
Inadequate knowledge 47 71.2 50 75.8

As regard Comparison between pre-test of studied group (1) and pre-test of studied group (2) about attitude towards DASH
(Table 4). There is no statistically significant difference between the two groups as regard attitude towards DASH.

Table 4. Comparison between pre-test of studied groups about attitude towards DASH.

Pre-test G1 Pre-test G2
Variables X2 P
No (66) % No (66) %
Following the DASH plan lower blood pressure.
Agree 14 21.2 16 24.2 0.121 0.728
Disagree 31 78.8 50 75.8
Limiting salt intake control blood pressure.
Agree 47 71.2 53 80.3 1.33 0.249
Disagree 19 28.8 13 19.7
Having fruits instead of sweets as a desert.
Agree 39 59.1 37 56.1 0.122 0.728
Disagree 27 40.9 29 43.9
Stop smoking and making exercise help to lower blood pressure.
Agree 16 24.2 17 25.8 0.192 0.662
Disagree 50 75.8 49 74.2
Total satisfactory attitude
satisfactory 15 22.7 13 19.7 0.257 0.612
not satisfactory 51 77.3 53 80.3

Regarding Changes of general knowledge about DASH among the studied group (1) & group (2) (table 5). It shows
statistically significant improvement in all items concerning general knowledge about DASH after health education especially
the best type of oil (olive oil) which was improved from 9.1% in pre test to 54.5% in post test followed by the importance of
having lots of fruits and vegetables which was improved from 51.5% in pre test to 92.4% in post test. While, there is no
statistically significant change in all items concerning general knowledge about DASH among studied group (2).
511 Eman E. Orabi: Effect of an Educational Intervention About Dietary Approach to Stop Hypertension (DASH) on Changing
Knowledge, Attitude and Blood Pressure of Hypertensive Patients Attending Zagazig University Hospitals

Table 5. Changes of general knowledge about DASH among the studied groups after two months from intervention among group (1) and from pre test among
group (2).

group (1) group (2)

Variables Pre-test Post- test Pre-test Post- test
P* P*
No (66) % No (66) % No (66) % No (66) %
Importance of having lots of fruits and vegetables
Yes 34 51.5 61 92.4 <0.001 44 66.7 46 69.7 0.708
No 32 48.5 5 7.6 22 33.3 20 30.3
Suitable type of dairy products
Full cream 40 60.6 18 27.3 <0.001 30 45.5 23 34.8 0.629
Skimmed or low cream 26 39.4 48 62.7 36 54.5 43 65.2
Effect of excess salt and salty foods on blood pressure
Elevate 52 78.8 65 98.5 59 89.4 61 92.4 0.508
0.001
Lower 14 21.2 1 1.5 7 10.6 5 7.6
The best type of bread
White bread 26 39.4 10 15.2 <0.001 17 25.8 15 22.7 0.685
Whole grain bread 40 60.6 56 84.8 49 74.2 51 77.3
does excess fats and fatty foods Effect blood pressure
yes 48 72.7 64 97.0 56 81.8 57 86.3 0. 687
<0.001
No 18 27.3 2 3.0 10 18.2 9 15.2
Suitable type of fats
Oil 44 63.6 62 93.9 <0.001 45 68.2 46 69.7 0.851
Butter or margarine 22 36.4 4 6.1 21 31.8 20 30.3
The best type of oil
Olive 6 9.1 36 54.5 <0.001 4 6.1 5 7.6 0.729
Corn or sun flower 60 90.9 30 45.5 62 93.9 61 92.4
Effect of exercise on blood pressure
Lower 28 42.4 48 62.7 <0.001 36 54.5 34 51.5 0.727
Elevate or does not effect 38 57.6 18 37.3 30 45.5 32 48.5
Effect of smoking on blood pressure
Elevate 26 39.4 44 66.7 <0.001 34 51.5 33 50.0 0.862
Lower or does not effect 40 60.6 22 33.3 32 48.5 33 50.0

*N.B: McNemar test of significance.

As regard Changes of knowledge about serving size in DASH among group 1& group 2 (Table 6). There is statistically
significant improvement in all items concerning knowledge about serving size in DASH after application of health education
sessions among the studied group 1 especially adequate knowledge about suitable serving size of seeds and dry beans which
was improved from 22.7% in pre test to 60.6% in post. While, there is no statistically significant change in all items concerning
knowledge about serving size in DASH among the studied group (2).

Table 6. Changes of knowledge about serving size in DASH among studied groups after two months from intervention among group (1) and from pre test
among group (2).

group (1) group (2)

Variables Pre-test Post- test Pre-test Post- test
P* P*
No (66) % No (66) % No (66) % No (66) %
Suitable serving size of vegetables
Adequate knowledge 27 40.9 44 66.7 < 0.001 26 39.4 27 40.9 0.859
Inadequate knowledge 39 59.1 22 33.3 40 60.6 39 59.1
Suitable serving size of fruits
Adequate knowledge 27 40.9 46 69.7 < 0.001 29 43.9 30 45.5 0.861
Inadequate knowledge 39 59.1 20 30.3 37 56.1 36 54.5
Suitable serving size of dairy products
Adequate knowledge 35 53.0 52 78.8 45 68.2 43 65.2 0.711
< 0.001
Inadequate knowledge 31 47.0 14 21.2 21 31.8 23 34.8
Suitable serving size of meat, poultry and fish
Adequate knowledge 45 68.2 60 90.9 53 80.3 52 78.8 0.681
< 0.001
inadequate knowledge 21 31.8 6 9.1 13 19.7 14 21.2
Suitable serving size of seeds and dry beans
0.754
Adequate knowledge 15 22.7 40 60.6 < 0.001 13 19.7 12 18.2
 Science Journal of Public Health 2016; 4(6): 506-516 512

group (1) group (2)

Variables Pre-test Post- test Pre-test Post- test
P* P*
No (66) % No (66) % No (66) % No (66) %
Inadequate knowledge 51 77.3 26 39.4 53 80.3 54 81.8
Suitable serving size of grains
Adequate knowledge 34 51.5 52 78.8 < 0.001 27 40.9 26 39.4 0.500
Inadequate knowledge 32 48.5 14 21.2 39 59.1 40 60.6
Suitable serving size of sweets
Adequate knowledge 19 28.8 38 57.6 < 0.001 16 24.2 18 27.3 0.727
Inadequate knowledge 47 71.2 28 42.4 50 75.8 48 72.7

N.B: McNemar test of significance.

Regarding changes of attitude towards DASH plan among group 1 and group 2 of the studied sample (Table 7). There is
statistically significant improvement in all items concerning attitude towards DASH in group (1) after application of health
education sessions especially their positive attitude toward stop smoking and making exercise help to lower blood pressure
which was improved from 22.7% in pre test to 62.1% in post test. While, there is no statistically significant change in all items
concerning attitude towards DASH in group (2).

Table 7. Changes of attitude towards DASH plan among studied groups after two months from intervention among group (1) and from pre test among group
(2).

group (1) group (2)

Variables Pre-test Post- test Pre-test Post- test
P* P*
No (66) % No (66) % No (66) % No (66) %
Following the DASH plan lower blood pressure.
Agree 14 21.2 55 83.3 < 0.001 16 24.2 18 27.3 0.861
Disagree 31 78.8 11 16.7 50 75.8 48 72.7
Limiting salt intake control blood pressure.
Agree 47 71.2 59 89.4 0.009 53 80.3 52 78.8 0.829
Disagree 19 28.8 7 10.6 13 19.7 14 21.2
Having fruits instead of sweets as a desert.
Agree 39 59.1 57 86.4 < 0.001 37 56.1 35 53.0 0.726
Disagree 27 40.9 9 13.6 29 43.9 31 47.0
Stop smoking and making exercise help to lower
blood pressure.
< 0.001 0.841
Agree 16 24.2 41 62.1 17 25.8 16 24.2
Disagree 50 75.8 25 37.9 49 74.2 50 75.8

As regard changes of total knowledge and attitude among the studied group (1) and group (2) (Figure 1). It shows
statistically significant improvement in both total knowledge scores from 40.9% in pre test to 72.7% in post test and total
attitude scores from 22.7% to 83.3% after application of health education sessions among the studied group (1). While, there is
no statistically significant difference in both total knowledge scores and total attitude scores among group (2) between pre and
post test.

Figure 1. Changes of total knowledge and attitude among studied groups after two months from intervention among group (1) and from pre test among group
(2).
513 Eman E. Orabi: Effect of an Educational Intervention About Dietary Approach to Stop Hypertension (DASH) on Changing
Knowledge, Attitude and Blood Pressure of Hypertensive Patients Attending Zagazig University Hospitals

Regarding Comparison between blood pressure levels of studied group (1) and studied group (2) before the intervention
Table (8). There is no statistical significant difference in both systolic and diastolic blood pressure between the two groups.

Table 8. Comparison between blood pressure levels of studied groups at the beginning of the study.

Blood pressure Group (1) Group (2) t test P

Systolic mean ±SD 144.7 ± 12.7 145.1 ± 12.2 0.7 0.485
Diastolic mean ±SD 93.8 ±7.9 94.2 ± 6.9 1.64 0.103

Figure 2. Changes of blood pressure among the studied groups after two months from intervention among group (1) and from pre test among group (2).

As regard Changes of blood pressure among the studied

group (1) & group (2) (Figure 2). There is statistically 4.2. Effect of Health Education on Patient’s Knowledge
significant reduction in both systolic and diastolic blood Knowledge plays an important role in the nutrition of
pressure in group (1) after application of health education hypertension patients. (Ford et al, 2009). It is well known
intervention. The mean systolic blood pressure had decreased that health education can result in lifestyle modifications and
from 144.7 before intervention to 137.4 after intervention and improve blood pressure control in hypertensive patients
mean diastolic blood pressure had decreased from 93.8 (Shaw and Bosworth, 2012).
before intervention to 87.4 after intervention. While there is In the present study the application of nutritional education
no statistical significant change in both systolic and diastolic in the intervention group (1) led to significant improvement
blood pressure among group (2). in all items of general knowledge, knowledge about serving
size and total knowledge about DASH diet (table 5, 6 figure
4. Discussion 1).
These results were consistent with the results of the study
4.1. Assessment of the Patient’s Knowledge by Magadza et al., (2009), Jeng, (2011) and the study by
In the present study there was no significant difference Pandey et al., (2013) which indicated a significant increase in
between the intervention and the control group neither in nutritional knowledge of the patients after the intervention.
general knowledge about DASH nor in knowledge about the This result also agreed with Harrison, (2014) who tested
serving size in DASH before the intervention (table 2 and the efficacy of educational intervention about DASH in
table 3). This may be due to most of patients were of classrooms versus internet education. Seung-Hye and Choi-
relatively the same social class and there was no significant Kwon (2014) also reported that one educational session
difference in their educational level. increased dietary knowledge but dietary self-efficacy and
This result was consistent with Jeng, (2011) Al-Weedy et DASH diet compliance did not increase significantly. Also,
al., (2014) and Kamran et al., (2015) who studied the effect this study was consistent with result of Habib et al., 2016
of DASH educational intervention on knowledge, self- who revealed significant improvement of knowledge of
efficacy and dietary practice, there was no significant interventional group regarding general knowledge about
difference in knowledge between intervention and control DASH and knowledge about the serving size of DASH after
group before the intervention. Also, it was consistent with the the intervention done on hypertensive Patients Attending
results of Habib et al., (2016) who revealed no significant Dierb Negm hospital.
difference between the intervention and the control group Assessment of knowledge of the control group (2) after
neither in general knowledge about DASH nor in knowledge two months of application of the pretest revealed that there
about the serving size in DASH before the intervention. was no significant change neither in general knowledge about
 Science Journal of Public Health 2016; 4(6): 506-516 514

DASH nor in knowledge about serving size and total important in hypertension management (table 4). This result
knowledge (table 5, 6 figure 1). These results may be was consistent with Mahajan et al (2012) and Habib et al.,
explained by 2016. Parmar et al (2014) and Rakumakoe (2011) reported
They were not given health education sessions about better attitude (45.2%, 82% respectively). This discrepancy is
DASH by their doctors. due to lake of knowledge about the importance of exercise
Absence of mass media campaigns about DASH during and stop smoking in controlling hypertension, old age of the
the period of the study. patients and lack of facilities to exercise.
The studies of Jeng, (2011), Al-Wehedyet et al., (2014) and
Habib et al., 2016 also reported that there was no significant 4.4. Effect of Health Education on Patient’s Attitude
change in knowledge of the control group. In the present study the application of nutritional education
4.3. Assessment of the Patient’s Attitude in the intervention group, lead to significant improvement in
patient’s positive attitude (table 7 and figure 1). This result
This study found that only (22.7%) had satisfactory may be attributed to improvement of patient’s knowledge
attitude among group (1) and (19.7%) among group (2) (table after health education sessions.
4). This result may be attributed to lack of awareness in This result was consistent with Mahajan et al (2012),
hypertensive patients about healthy life style. The low level Sabouhi et al (2011) and Habib et al., 2016.
of awareness may be explained by: There was no significant change in attitude of patients in
Lack of mass media campaigns about DASH eating the control group two months after application of the pretest
plan and other life style modifications. (table 7 and figure 1) because there was no change in
Doctors ignore nutritional education as a part of patient’s knowledge. This result was consistent with Habib et
hypertension management. al., 2016.
Doctors don’t educate patients how to follow the DASH
eating plan. 4.5. Changes of Blood Pressure in Intervention and Control
In India, Mahajan et al (2012) revealed that the majority of Group
hypertensive patients had unsatisfactory attitude. Also, it was In this study there was no significant difference in the
relatively consistant with results of Habib et al., 2016 who mean of systolic and diastolic blood pressure between the
revealed that 13.6% of studied population had satisfactory two groups before the intervention (table 8) because of the
attitude before health education intervention. homogeneity of the sample in socio demographic characters
On the contrary Sabouhi et al (2011) reported that patient’s and the level of knowledge.
attitude was good (58.2%). After the intervention, there was significant difference in
The present study revealed that there was no significant the mean of systolic and diastolic blood pressure in the
difference in patient’s attitude between the two groups before intervention group (G1) (figure 2). The mean systolic blood
intervention (table 4). This may be attributed to homogeneity pressure had decreased from 144.7 before intervention to
of the studied sample in socio demographic characters and 137.4 after intervention and mean diastolic blood pressure
level of knowledge. had decreased from 93.8 before intervention to 87.4 after
This study showed that 21.2 % of the patients agreed that intervention. These results were consistent with Appel et al
DASH diet is important in hypertension management (table (1997) and Al-Wehedyet al (2014). Also, it was consistent
4). This result was going with Mahajan et al (2012) stated with Habib et al., 2016 who revealed decrease of mean
that only 5% of patients agreed that DASH diet is important systolic blood pressure from 142.7 before intervention to
in hypertension management. While, it was in contrary with 139.2 after intervention and mean diastolic blood pressure
Sabouhi et al (2011). Tadevosyan (2013) and Rakumakoe had decreased from 91.2 before intervention to 89.2 after
(2011) reported better attitude (70% and 96% respectively) intervention.
and Habib et al., 2016 revealed 50 % of the patients agreed Burke et al (2007) observed the benefits of the lifestyle
that DASH diet is important in hypertension management. modification program provided to hypertensive patients and
About 71.2% of the participants agreed that reducing salt found that89% of the studied subjects reported healthy
is important in controlling blood pressure (table 4). This behaviors as decrease dietary fat, increased physical activity,
result may be attributed to good knowledge of patients about decrease weight, and increase fish and vegetable in diet.
salt effect on blood pressure. This result was consistent with The DASH diet lowered systolic blood pressure by an
Mahajan et al (2012) and Habib et al., 2016 who revealed average of about 6 mm Hg and diastolic pressure by about 3
71% of the participants agreed that reducing salt is important mm Hg. The diet that was merely higher in fruits and
in controlling blood pressure. Other studies conducted by vegetables also lowered blood pressure, but by a lesser
Parmar et al (2014) and Tadevosyan (2013)reported that amount: about 3 mm Hg systolic and 2 mmHg diastolic
(40% and 51%respectively) of patients agreed that reducing (Appel et al., 1997).
salt is important in controlling blood pressure. On the contrary the study of Seung-Hye, (2014) there was
The present study showed that 59.1% of the patients no significant change in blood pressure in both experimental
agreed that fruits are better than sweets as a desert and 24.2% and control groups.
of the sample agreed that exercise and stop smoking are
515 Eman E. Orabi: Effect of an Educational Intervention About Dietary Approach to Stop Hypertension (DASH) on Changing
Knowledge, Attitude and Blood Pressure of Hypertensive Patients Attending Zagazig University Hospitals

In this study there was no significant change in blood Effect of an educational intervention about Dietary Approach
pressure in the control group (G2) (figure 2) because there To Stop Hypertension (DASH) on Changing knowledge and
Attitude of hypertensive Patients Attending Dierb negm
was no change in knowledge nor in attitude of the patients. It hospital. Master thesis in Community Medicine Zagazig
was consistent with Habib et al., 2016. University

[10] Harrison A (2014): "Web-based Nutrition Education in

5. Conclusion and Recommendations Georgia Senior Centers: Pilot Test of a Dietary Approaches to
Stopping Hypertension (DASH) Diet Website Prototype."
We conclude from the results of the present study that the Thesis, Georgia State University.
educational program for hypertensive patients about DASH http://scholarworks.gsu.edu/nutrition_theses/54
diet proved its success in improving patient’s knowledge,
[11] Heller M., (2016): What Is the DASH Diet? Available at
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recommend the following:
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about importance of DASH diet and other life style intervention on nutritional knowledge, dietary practice, self
efficacy and blood pressure in hypertensive individual.
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Continuous training of physicians and providing them medical university.
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Shekarchi L., (2015): Evaluating Dietary Perceptions
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