INTRODUCTION:

Health, often known as being well, is the state of having a healthy body and being free from illness¹. The key to living, existing, having a zest for life, feeling alive, and being happy is maintaining excellent health.

Health includes not only the absence of illness but also the existence of thoughts, attitudes, and actions that define various types of health. Achieving and sustaining health is a continuous process that is influenced by the advancement of medical knowledge and procedures as well as individual strategies and planned interventions for remaining healthy known as lifestyle management².

The World Health Statistics (2010) brought attention to the growing issues around non-communicable illnesses such as high blood pressure and diabetes. One in three persons worldwide have high blood pressure, which accounts for half of all stroke and heart disease fatalities³. Research conducted in 2019 attempts to evaluate global changes in the prevalence of hypertension and advancements in its management and control between 1990 and 2019: Despite stable global age-standardized prevalence, the number of people aged 30-79 years with hypertension doubled between 1990 and 2019, from 331(95% credible interval 306–359) million. Women and 317(292–344) million men in 1990 to 626(584–668) million women and 652(604–698) million men in 2019. This was revealed by a pooled analysis of 1201 population-representative studies with 104 million participants⁴.

Sleep experts recommend that Adults should sleep for 7 to 8 hours per night. It is well known that getting less sleep than six hours is hazardous for general health. Regular sleep deprivation can cause hypertension in both children and adults. Sleep is supposed to aid the body in managing the hormones needed to regulate stress and metabolism. Less than six hours of sleep every night may cause a more pronounced rise in blood pressure. Not getting enough sleep might exacerbate high blood pressure in people who already have it⁵.

A study was conducted in 2020 to assess the Prevalence and socio-demographic correlates of poor sleep quality among older adults in Hebei province, China. A large-scale cross-sectional epidemiological survey was conducted from April to August 2016. The study used a multistage, stratified, cluster random sampling method. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI). The sample size was 3,911.

The prevalence of poor sleep quality was 21.0% (95% CI 19.7–22.2%), with 22.3% (95% CI 20.9–23.8%) in rural areas and 15.9% (95% CI 13.4–18.4%) in urban areas. Multivariable logistic regression analyses found that female gender (P<0.001, OR 2.4, 95% CI 2.00–2.82), rural areas (P = 0.002, OR 1.5, 95% CI 1.14–1.86), Presence of major medical conditions (P<0.001, OR 2.4, 95% CI 2.02–2.96) and family history of psychiatric disorders (P<0.001, OR 2.7, 95% CI 1.60–4.39) were independently associated with higher risk of poor sleep quality. Poor sleep quality was common among older adults in the Hebei province of China⁶.

In 2023, A community-based cross-sectional research in both rural and urban parts of Delhi was done to evaluate the Sleep Quality Index among the older population in particular locations of the city. 115 people were included in each area's sample size using systematic random sampling. The data was gathered using a validated sleep quality indicator and a semi-structured questionnaire. The findings showed that only 41 people (17.8%) had good sleep quality, while 189 out of 230 had poor sleep quality, according to the data. Poor sleep quality was reported by 84(44.5%) people in the urban area and 105 (55.5%) people in the rural region. Depression and the use of sleeping medicines were shown to be substantially 14 correlated with higher scores on the sleep quality measure in the rural region. Eighty two percent of the senior participants reported having poor quality sleep, which was linked to living in a rural area, having depression, and not taking sleep aids⁷.

Both pharmaceutical and non-pharmacological approaches are used to treat HTN and sleep disturbance. The term complementary and alternative medicine (CAM) refers to a collection of various medical and health care practices, systems, and products that are not often seen as belonging to traditional medicine. It is believed that CAM treatments, particularly self-treatment for both healthy and unhealthy people, play a vital role in health care in the twenty-first century ⁸. Foot reflexology is one of the complementary therapies, linked to other treatments that are widely used in palliative care or to alleviate a problem without dealing with the underlying cause in order to improve a patient's emotional, physiological, and spiritual health and increase the value of their life.

As the prevalence of hypertension is increasing day year by year the health system has to incorporate non-pharmacologic measures in the treatment of hypertension with pharmacologic management. Aging is another problem that increases blood pressure levels due to changes in sleep patterns. Sleep and blood 6 pressure are inter-related. The researcher assumes that while improving the sleep pattern, the blood pressure level also tends to reduce. Hence the researcher is interested to find out the effect of foot reflexology in the reduction of blood pressure and Improvement in sleep patterns.

OBJECTIVES:

1. To assess the level of blood pressure and quality of sleep among elderly with hypertension thin experimental and control groups.

2. To evaluate the effect of foot reflexology on blood pressure and quality of sleep among elderly with hypertension in the experimental group.

3. To associate pretest level of blood pressure and quality of sleep among elderly with hypertension with their selected demographic variables.

HYPOTHESIS:

H₁: There will be a difference in the level of blood pressure and quality of sleep among elderly with hypertension who is receiving foot reflexology.

MATERIALS AND METHODS:

Research approach: Quantitative approach

Research design: True experimental pre-test post-test control group design.

Setting: Selected old age homes

Population: Elderly with hypertension

Sample: Elderly with Hypertension in Selected Old age Homes.

Sample Size: 60 elderly people from selected old age homes in Kerala.

Sampling Technique:

Simple Random Sampling using lottery method Criteria

For sample selection:

Inclusion criteria:

Elderly with Hypertension who are,

· Inmates of selected old age homes

· Willing to participate in the study

· Having blood pressure range within 130/90 mmhg-180/100mm hg Exclusion criteria:

· Elderly with Hypertension who are,

· Following any other relaxation techniques

· Psychologically unstable

· Having foot ulcers

· Has neuropathies

· Taking sedatives

· Known case of memory problem

Development And Description of The Tool:

The tool consists of three parts.

TOOL 1:

Section A:

Demographic variables: Socio-demographic variables in this study include age, sex, marital status, education type of family, place of living, diet pattern, habits & physical activity.

Section B:

Clinical variables: Clinical variables in this study include Duration of hypertension, Family history of hypertension, Treatment for hypertension, and duration of medication.

TOOL 2:

Tool 2 consists of a BP chart. The researcher assessed the BP before and after the intervention and recorded it in the BP chart for each day of foot reflexology.

TOOL 3:

The Pittsburgh Sleep Quality Index (PSQI) is a self-rated questionnaire that assesses sleep quality and disturbances over a 1-month time interval. The PSQI was developed by Daniel J. Buysse and collaborators in 1989 at the University of Pittsburgh to measure the quality of sleep and to help discriminate between individuals who experience poor sleep versus individuals who sleep well ⁹.

Description of Intervention:

Foot reflexology:

Total duration of foot reflexology: 20 minutes

(10 minutes for each foot) Pre-procedure.

· Explain the procedure to the client

· Ask the client to lie in a supine position with toes pointing upward.

· Clean both the foot with a clean towel or tissue paper. During the procedure

· Hold the left foot with both thumb finger and the remaining fingers supporting the dorsal area.

· Make the foot warm using thumb walking method from toes to heal

· Apply 2-3 drops of coconut oil for smoothening.

· Start the massage from toes to heal and go back to the big toe apply pressure in the

· Points for heal, heart, neck, pituitary gland, cranial nerves, calf muscle and spinal nerves with the help of tools or fingers for 10 minutes.

· Repeat the procedure for right foot also the same procedure has to be repeated for twice weekly for one month.

Post procedure:

· Wash hands.

· Record the blood pressure with date.

Validity and Reliability of the Tool:

Content validity of the tool was established by requesting six experts to go through the developed tool and give their valuable suggestions. The suggestions of experts were incorporated in the tool. Pittsburgh sleep quality index is a standardized tool.

The reliability of the scale is considered good with Cronbach’s alpha of 0.83 for the total score. Test–retest reliability is also considered good. The validity of PSQI has been described by the authors as good with a sensitivity of 89.6% and a specificity of 86.5% of patients versus control subjects.

Ethical Consideration:

I undertake to ensure the following guidelines:

· Permission obtained from the authority of selected old age homes.

· Ethical clearance obtained from the institute ethics committee.

· Formal administrative permission obtained from Principal College of Nursing PIMS.

· Informed consent obtained from the participants after explaining the purpose of the study.

Pilot Study:

A pilot study was conducted to test the feasibility and practicality of a larger study. The pilot study involved 10 participants who were residents at selected old age homes, and took place from June 11th to June 19th, 2023, for four alternate days.

Formal permission was obtained from the in-charge of each old age home, and the nature and purpose of the study were explained to the residents. Written consent was obtained from those who met the inclusion criteria, and they were randomly assigned to either the experimental or control group using the lottery method. Demographic and clinical variables were assessed prior to the study using a pre-designed interview schedule, as well as pre-test quality of sleep using the Pittsburgh Sleep Quality Index. The experimental group received 20 minutes of foot reflexology, while the control group received routine care. The pilot study revealed no issues and confirmed that the study was feasible. Additionally, it allowed the investigator to estimate the total time required for the larger study.

Data Collection Process:

The study was conducted with permission from the relevant authority and took place between June 2023 and August 2023 at selected old-age homes in Kerala. Samples were selected using a simple random sampling method through a lottery. The investigator obtained written consent from each of the 60 participants and explained the nature and purpose of the study to them.

Demographic and clinical variables were collected, and a pre-assessment of the Pittsburgh Sleep Quality Index was conducted through a previously planned interview schedule. Foot reflexology was provided twice weekly, excluding Sundays, with BP monitoring using a digital BP apparatus. On the 29th day, a post-assessment of sleep quality with the Sleep Quality Index was conducted.

Data Analysis:

The data analysis involved the use of descriptive and inferential statistics to evaluate the blood pressure and quality of sleep among elderly individuals with hypertension. To analyze the demographic data, we calculated frequency and percentage distribution. For the effect of the intervention-foot reflexology on blood pressure and quality of sleep, we used paired and unpaired t-tests, the Wilcoxon Sign Ranking test, and the Mann-Whitney U test. We also analyzed the association between the pre-test level of blood pressure and quality of sleep among elderly with hypertension with selected demographic variables by using Fisher's exact test and chi-square test.

MAJOR FINDINGS AND DISCUSSION:

Findings Based on The Objectives:

Objective 1: To assess the level of blood pressure and quality of sleep among elderly with hypertension in experimental and control groups:

Experimental group consisted of 30 participants, among whom 2(6.7%) were pre-hypertensive, 22(73.3%) were in stage 1 hypertension, and 6(20%) were in stage 2 hypertension. In the control group, 30 Participants were included, with 3(10%) being pre-hypertensive, 13(43.3%) in stage 1 hypertension, and 14 (46.7%) in stage 2 hypertension. The study found that poor sleep was prevalent in nearly all participants, with 22(73.75%) in the experimental group and 23(76.7%) in the control group reporting poor sleep. Meanwhile, 8 (26.7%) participants in the experimental group and 7 (23.3%) in the control group reported good sleep.

Objective 2: To determine the effect of foot reflexology on blood pressure and quality of sleep among elderly with hypertension in the experimental group. N=30

Fig.1 Pre and Post Test Level of Blood Pressure Among Elderly with Hypertension in Experimental Group

Figure 1 shows that in experimental group pre-test stage 1 hypertension (73.3%) decreased to (20%) in post-test and pre-test stage 2 hypertension (20%) decreased to (6.7%) in post-test.13.3% of participants in experimental group attained normal range of blood pressure.

N=30

Fig.2 Pre-Test and Post-Test Level of Quality of Sleep Among Elderly with Hypertension in Experimental Group

Table 5 shows that there is a significant difference in post-test quality of sleep between experimental and control group. In post-test quality of sleep mean 3.23± 1.92 and median 2.50 with inter quartile range 2.00-5.00 in experimental group and mean 8.17±3.27 and median 9.00 with inter quartile range 5.00-10.00 in control group at p value < 0.001 (Mann-Whitney ‘U’ 95.50).

Objective 3: To associate pre-test level of blood pressure and quality of sleep among elderly with hypertension with their selected demographic variables

Fisher‟s exact test is used to find out the association between pre-test level of blood pressure among elderly with hypertension with selected demographic variables. There is no significant association between pre- test level of blood pressure among elderly with hypertension with selected demographic variables like age, marital status, education, type of family, place of residence, diet, and physical activity and with selected clinical variables like duration of hypertension, family history of hypertension, and duration of treatment at p value > There is no significant association between the pre-test level of quality of sleep among elderly with hypertension with selected demographic variables like age, marital status, education, type of family, place of residence, diet, and physical activity at p-value > 0.05.

Fisher 's exact test or Chi-square test is used to find out the association between pre-test level of quality of sleep among elderly with hypertension with selected clinical variables. There is borderline association between pre-test level of quality of sleep among elderly with hypertension with selected clinical variables like duration of hypertension, and duration of treatment for hypertension. No significant difference for family history of hypertension.

RECOMMENDATIONS:

The report suggests the following topics for more study. Large samples might be included in the study to allow for the generalization of the results. Comparative research between various alternative modalities can be carried out in a variety of therapeutic contexts, for example, comparing foot reflexology with reiki. It is possible to conduct gender-based comparative research. The same study may be carried out with a longer length of intervention in community settings where family members can be educated about foot reflexology.

IMPLICATIONS:

The findings of the study have implications in different aspects ofnursing profession such as nursing practice, nursing education, nursing research and nursing administration.

Nursing Practice:

In the battle against non-communicable diseases (NCD), nurses are crucial. The incidence, prevalence, and issues related to hypertension are all rising each year. Focusing on methods that will decrease the burden of illness is therefore essential. Foot reflexology can be a valuable addition to routine nursing care, as it has been proven to lower high blood pressure and improve sleep quality. The nursing staff should inform the public about foot reflexology benefits as adjunctive treatment for hypertension, decreased sleep and mitigating side effects.

Nursing Education:

As nursing educators, we must emphasize non-pharmacological methods to lower blood pressure and improve sleep, and teach these methods in nursing curricula. As part of nursing school, future nurses should be trained in a variety of treatment methods, including complementary and alternative medicine, And encouraged to stay up-to-date with all relevant fields of study. This study will help nursing students learn about foot reflexology, its role in regulating blood pressure and improving sleep. To incorporate foot reflexology into nursing care, student nurses should receive training in the practice.

Nursing Administration:

Nurse administrators should set up several staff development initiatives to inform nurses of the value of foot reflexology as a supplement to managing hypertension. Nurse Managers should encourage their staff to learn about numerous alternative treatments for hypertension and sleep disturbances and use them while providing care for patients.

CONCLUSION:

The study was done to evaluate the effect of foot reflexology on level of blood pressure and quality of sleep among patients with hypertension at selected old age homes Kerala. When compared to the pre-test, the statistical analysis of the study revealed a reduction in the raised blood pressure level in hypertensive individuals receiving foot reflexology. Additionally, there was a difference between the experimental and control groups' post-test blood pressure results. Thus, this study demonstrated the positive effects of foot reflexology on hypertensive patients' blood pressure levels and quality of sleep.

CONFLICT OF INTEREST:

NIL

REFERENCES:

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2. Http://repository-tnmgrmu.ac.in/10076/1/300132016silambarasan.pdf

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6. Indian journal of continuing nursing education [internet]. Ijcne.org. [cited 2023 sep 27]. Available from: https://www.ijcne.org/article.asp?Issn=2230- 7354; year=2022; volume=23; issue=2; spage=190; epage=195; aulast=ann

7. George S, Paul G, Paul N. Study on sleep quality and associated psychosocial factors among elderly in a rural population of Kerala, India. Int J Community Med Public Health [Internet]. 2018 [cited 2023 Nov 6]; 5(2): 526. Available from: https://www.ijcmph.com/index.php/ijcmph/article/view/2475

8. Hassan II, Abd Hadi NH, Soon LK. Complementary and alternative medicine (CAM): A comparative study between nursing and medical students. Educ Med J [Internet].2012;4(2).

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Received on 03.01.2024 Modified on 23.02.2024

Int. J. of Advances in Nur. Management. 2024; 12(2):53-59.

DOI: 10.52711/2454-2652.2024.00013

Blood Pressure	Pre-test			Post-test			‘Z’ Value	P Value
Blood Pressure	Mean	SD	Median (IQR)	Mean	SD	Median (IQR)	‘Z’ Value	P Value
Systolic Blood Pressure	150.73	14.51	150.00 (140.00-159.00)	132.57	13.17	128.50	-4.793	< 0.001*
Diastolic Blood Pressure	87.10	3.73	88.00 (84.00-90.25)	74.83	4.33	76.00 (70.00-79.00)	-4.790	< 0.001*

Test	Mean	SD	Median (IQR)	‘Z’ Value	P Value
PRE-TEST	7.03	2.88	6.50 (5.00-10.00)	-4.243	< 0.001*
POST-TEST	3.23	1.92	2.50 (2.00-5.00)	-4.243	< 0.001*

Group	Post Test				Mann- Whitney U value	P value
	Mean	SD	Median	IQR
Experimental Group	132.57	13.17	128.50	122.00-142.75	76.50	< 0.001*
Control Group	161.73	15.29	162.00	155.25-175.00

Group	Post Test				Mann- Whitney ‘U’ value	P value
	Mean	SD	Median	IQR
Experimental Group	74.83	4.33	76.00	70.00-79.00	40.00	< 0.001*
Control Group	84.50	4.27	84.00	80.75-88.00