Exploration of plant-based diet in non-communicable disease management based on agro nursing†

2.1. Study design and setting

This study used a qualitative approach that was carried out in Patemon and Banjarsengon Village in Jember Regency. The selection of research areas is based on the percentage of most farmers who have hypertension in the area. From the population of farmers in the research area, 25 informants were selected using the maximum variation sampling method for focus group discussions (FGDs). The variations considered in this study included farmers’ consumption patterns of vegetables and fruits as well as their health conditions. We applied the Theory of Planned Behavior to explore farmers’ consumption patterns and to examine their health conditions related to hypertension. The study was conducted from August to October 2021. Data were collected through FGDs, covering aspects such as dietary patterns, food processing methods, sources of food ingredients, types of food consumed, health-seeking behaviors, and daily activity routines. Information on the quantity and frequency of vegetable and fruit consumption was also obtained, reflecting the integration of plant-based diets into farmers’ daily menus.

2.2. Ethical consideration

Ethics committee of Universitas Jember in Indonesia approved this study. All informants interviewed had given their written consent prior to their participation in our research.

2.3. Data collection

Data were collected through participant observation (PO) in the community and FGDs. Both emic and etic perspectives were examined to maintain objectivity and capture relevant patterns.¹¹ The study was conducted in 2 selected areas, Banjarsengon and Patemon villages. This area was selected because of the high prevalence of hypertension among farmers in these communities. Participants included farmers and community health workers (CHW). The objectives of the study were explained to all participants, and they provided informed consent voluntarily. The FGDs were initiated with the guiding question: “What are your thoughts on food and fruit consumption in relation to hypertension prevention?”(Figure 1).

Figure 1.

2.4. PO

We used PO to capture the authentic picture of farmers’ food consumption in relation to hypertension. We observed farmers’ dietary practices, particularly their plant-based diet. Since the researchers were residents of the community, we easily gained access and trust from the farmers and the community. Finally, the farmers described their consumption patterns to improve their health status and to maintain their hypertension at a manageable level.

We applied Leininger’s PO phase, which includes observation, participation, and reflection enablers,¹² which were performed as protocols for PO in this study. The protocols in the PO activities were as follows: preparing, determining the focus, setting, recording, and maintaining observations. In the preparatory activities, we collected information related to the procedures for caring for adolescents by farmers with hypertension and their plant-based consumption. Because the research team all have the same cultural background, we searched for key informants consisting of farmers who have hypertension and used to work in the morning. The next stage was determining the focus of observation, which consisted of the following steps: the descriptive (describing the problem of farmers), focus (focusing on the food consumption model and their relation to a plant-based diet) and choosing phases (deepening the farmers’ understanding about the importance of consuming vegetables and fruits). Furthermore, the researchers recorded observations through observational field notes, including participant activities, interactions, and routines.

2.5. Data analysis

The records of FGD’s and PO results were transcribed. Then, we read them to obtain a thematic view of the farmers’ patterns of consumption of vegetables and fruits, their behavior that may contribute to their hypertension. We used Leininger’s 4 phases of analysis for qualitative data¹¹ to obtain a thematic view in this study.

First, we pursued an emic focus and paid attention to etic data as well as the purposes of the survey form recorded. We transcribed data from the FGD, PO, and field notes. Furthermore, we coded all the data described. Then, the codes were classified according to Domains of Inquiry (DOI), and we analyzed meaning in context. Third, we ranked data that were repeatedly reviewed to discover recurrent patterns, similarities, and different meanings in context. In this phase, we confirmed the saturation of data. Data were analyzed to show patterns of the meaning of findings, taking into account further credibility and confirmation of results. In this phase, we described the meaning of the text as categories. In the last phase, we unified and interpreted data and settled the formulation of new discoveries in this study as a pattern of plant-based diet in farmers and their routine about their consumption and what vegetables and fruits they often consume. We conducted a literature data analysis process in which we went back and forth between each step, confirming data with the key informants and informants. Then, we reviewed each step, confirming data with the key informants at all stages.

3.1. Theme I: Actual behavior control

The behavior of the farmers in this village is based on the local culture that has existed from generation to generation. Farmers have the mindset that when they go to work, the most important thing for them to consume is a cup of coffee and a cigarette. The consumption of vegetables and fruits typically occurred as side dishes during lunch or upon returning home.

Theme 1 has 3 categories; the first is a dietary pattern related to hypertension. This category emerged from data citations, such as “we eat too often salty foods such as salted fish, shrimp paste and other foods that contain a high amount of salt” (P2 and P4). For the consumption of fruits and vegetables, participants noted: “I often eat fruit if there is fruit from the tree itself, such as papaya and bananas.” (P6 and P8). Regarding health-seeking behavior toward hypertension, the following statements were obtained: “I follow the habits of my parents, usually I use grated raw cucumber and drink the water” (P7 and P8) and “I buy it from the pharmacy, since I usually have to prepare it for myself.” (P10 and P11).

The results of PO showed that the habit of consuming too salty food is still commonplace and is done by the community. However, people continue to consume fruits and vegetables, especially those they can get from their own fields. And when they are sick, the initial treatment is self-medicating either traditionally or using drugs.

3.2. Theme II: Behavioral intention

Behavioral intention is a desire that turns into a form of behavior that is determined by 3 factors, namely attitude toward behavior, subjective norm, and perceived behavioral control. For attitude toward dietary habits, this was reflected in the statement: “Food is too salty, it can make me feel unwell” (P2). The quote indicates that farmers’ behavior can change due to the effects caused by consuming excessively salty food. For subjective norms, which refer to external influences shaping an individual’s perception of behavior, one participant expressed: Yes, it’s an economic factor, you know, especially during this time (laughs). This suggests that economic conditions are among the factors that can influence an individual’s willingness to change behavior.

For the category of perceived behavior, which relates to the individual’s self-perception or ability regarding the individual’s control over a behavior, a respondent stated: Yes, if you already know that, then it is not healthy (laughs). This indicates that respondents are able to recognize and perceive appropriate health-related behaviors, which can support efforts to improve health status, particularly in relation to hypertension.

PO indicated that the behavior of farmers with hypertension actually also have a desire to change their behavior, but indeed several factors can influence this, such as economic factors and local culture that do not like to eat breakfast with vegetables and fruit.

4.1. Actual behavioral control for plant-based diet in NCD management

The farmers in this area have controlled behavior when it comes to eating patterns by maintaining a menu of vegetables and fruits associated with NCDs. The pattern of fruit and vegetable intake that has been internalized into daily life is one of the keys for farmers and families to be able to overcome problems related to the management of NCDs, especially hypertension suffered by farmers. This can happen because this activity has been going on for decades in the area. They also believe that a healthy lifestyle, apart from lifestyle and diet, can also be obtained from the prayers they have been praying, because the majority of farmers in Patemon and Banjarsengon villages are Muslim.¹³ For this reason, the essential value for actual behavioral control is that farmers can carry out a plant-based diet by consuming vegetables and fruits that are already available in their own backyard.

4.2. Behavioral intention for plant-based diet in NCD management

Our findings of behavioral intention were described as attitude toward, subjective form, and perceived behavior. The results showed that the farmers change their behavioral intention by forming a new intention about health that occurs due to hypertension problems, any changes from outside themselves can also change the behavior or desires of farmers in health management, especially for hypertension where this is indicated by increasing the intake of plant-based diets, so that the condition of blood pressure which is one of the determinants of hypertension can be controlled properly. These findings may be explained by the fact that farmers cannot play their own role without the participation of their families and health workers to achieve the ultimate goal of improving health status. This illustration also illustrates that the plant-based diet presented cannot be separated from the role of the family, such as the selection of vegetables, processing, and serving.

The results of the study showed that the management of NCDs can be achieved by changing behavior in the consumption of plant-based diets, both vegetables and fruits; in addition, reducing the consumption of salty foods is also something that needs to be followed up to be able to do a good pattern of hypertension management. The regulation of other factors that can influence the behavior of farmers also needs to be monitored and modified, such as increasing the amount of consumption of vegetables and fruit that can be obtained, either from their own gardens or by buying them. A plant-based diet is also necessary, without leaving the rules in terms of content and benefits of the type of vegetable diet taken. This indicated that every family needs to define they plant based diet based on capability of family and farmers himself, and make a norms that are structured as a standard reference for each family member to set their diet for daily used so that the roles and responsibilities will be done to achieve the good management of NCD and plant based diet in development tasks based on local wisdom of the Indonesian context.

4.3. Limitations

First, conducting exploratory research was hindered by challenges in gaining access and building trust with farmers and the community. In addition, supervision and observation required a high level of rigor, particularly in relation to observing Madurese culture. However, the research team minimized these challenges through a thorough PO approach. This process was further supported by the team’s background, as several members were indigenous to the Pandalungan cultural research area.

Second, there is a potential for bias on the part of researchers, which can distort the data and insights gained from it. Due to the intimate nature of research, there is potential for ethical and interpersonal issues to emerge. Finally, the storytelling nature of an exploratory research approach may disrupt the interpretation of the data, although the research team has maintained trustworthiness through the data collection methods of FGD and PO.

The results indicated that farmers’ existing dietary habits already incorporate plant-based foods; however, this qualitative exploration did not measure direct changes in blood pressure values following dietary intake. Previous studies have demonstrated that higher consumption of vegetables and fruits is associated with lower blood pressure.^14,15,16 Thus, while our findings do not provide quantitative proof of blood pressure control, they underscore the relevance of culturally grounded dietary practices that can be further developed into nursing interventions for hypertension management.