Effects of the self-management training program on self-management behavior and blood pressure levels among elderly people with hypertension

To study the results of the Self-Management Behavior-Training Program and the HT BP levels in the elderly

A comparison of the self-management behavior-training scores between the experimental group and the control group receiving the more usual care (at the 4th week and the 13th week after entering the program)

A comparison of the systolic BP and diastolic BP of the experimental group with the corresponding BP of the control group (at the 4th week and the 13th week after entering program)

This research is based on Creer's concept of self-management,¹ which was formulated to develop a program of self-management behavior training and to control BP levels in elderly citizens with HT. Creer stated that anyone who would like to perform any of the actions must know and understand the effects of the illness and believe that self-management can control symptoms or the impact of that sickness. Therefore, this action could be undertaken with the cooperation of patients and health teams by promoting an appropriate self-management scheme and providing information to promote sustainable self-management, leading to good health results. Furthermore, Creer quoted that the self-management process consisted of six significant steps. The first step is to set goals for both patients and healthcare teams to control or reduce the disease's effect. The second step is the information process and evaluation by self-observation and self-recorded data to be kept as guidelines for self-management specification. The information process and assessment constitute an analysis performed by observing the collected information and determining whether the contents are proper. Decision making is a behavioral process of applying skills in self-management as specified in the guidelines. It functions together with the health teams and with self-management by comparing the specified goals for this research study, and the researcher has presented the aforementioned concepts as guidelines in developing the Self-Management Training Program, which consisted of the following components:

Small-group education activities: This component is concerned with the causes of HT. It deals with its symptoms, complications, and treatments, as well as food choices, exercise, and self-management principles, for the effective control of BP by focusing on proper nutrition for the elderly with HT. The exercising of the body and mind with the Dao De Xin Xi dance routine, the dance mixture of exercise, meditation, relaxation, and principle in self-management all help to correct the causes of HT. Thus, the distribution of a manual or booklet called “Elderly-with-Hypertension Self-Management Promotion” brings home a program and reviews for self-management skill training designed to control BP.

It will first be necessary to determine that the elderly have proper knowledge and understanding of self-management skills and can manage on their own to control their BP levels. It will helpful for the elderly to participate in the Self-Management Behavior Program, as they will then finally be able to control their BP levels.

Descriptive statistics using the SPSS 17.0 software package was used for statistical analyses. The reliability of the instrument used was assessed using Cronbach's alpha coefficient.

The comparability of the intervention- and control-group participant characteristics and clinical characteristics at baseline was analyzed by using the frequency, percentage, mean and standard deviation (SD) of the compiled data, followed by a Chi-square test check of similarity between the groups.

A p-value below 0.05 was considered significant.

The Chi-square test was conducted at 4 and 13 weeks after the intervention to compare the proportion of participants achieving acceptable BP levels and self-management behaviors in each arm of the study at baseline.

Assumption of T-test normality of the BP level and self-management behavior scores found that most of them had a normal distribution.

The hypothesis used an independent t-test to compare the BP levels of the groups and a repeated measure ANCOVA for comparability of self-management behavior between the interventions.

Thus, the sampling group consisted of elderly citizens with HT from Thanyaburi District, Pathum-Thani Province, who had been diagnosed with HT without causes. They were entirely conscious and could communicate by speaking, listening, and understanding Thai, and they had been cured by HT medical control. Thus, they were able to participate in activities according to the specified Program and were willing to join the research. They had no severe complications that would have prevented them from entering the Program's activities, such as stroke or other diseases, for which they would have had to be admitted to hospitals during the research. The sample group had a calculated specified reliability level of 0.05, a prediction power of 0.80, and an interrelationship-study evaluation of 0.50. Because of the number of studied variables, the nursing-research interrelationship value was leveled to 0.40–0.60.¹⁵ It was therefore used in calculating the size of the sampling group by applying the G Power 3.1 Program. Each sampling group contained 51 people for a total of 102 elderly citizens. The related literature review found that the studied sampling group had similar average values of disappearance of about 4.38%.¹⁶ However, the researcher prevented the sampling group's disappearance by increasing the size by 6.37%. Therefore, the sampling group's chance of disappearance was within the total of 106, which was then sub-divided into two groups of 53 people each – 53 people for the experimental group and the other 53 people for the control group. The research commenced with 106 people in sample groups subdivided into an experimental group of 53 participants and a control group of 53 participants. After the study, only 91 people were remaining, of whom 44 were in the experimental group and 47 in the control group. A total of 15 people dropped out from the program (at a drop-out rate of 13.65%) because of absences.

Bring questionnaire forms to determine the reliability levels of similar sampling groups at the Lumpakgood Sub-District, Thanyaburi District, Pathum Thani Province, for 10 cases.

Cronbach's alpha coefficiency of self-management for HT-behavior control was found to be 0.83. Consequently, when the program concluded, the self-management for the HT-behavior control tool responded to the reliability test with an outcome of 0.85.

This research passed scrutiny and was certified by the Research Ethics Committees. The research process of self-management training took place from September to November of 2018. The experimental group was informed and divided into small groups of eight people each. (The time spent during the first week was between 30 min and 40 min per group.) The small groups training in self-management skills participated in one training session per group, with no more than eight people per group. (The time spent during the first week was 30 min per group.) There were small-group discussions and reflections on the concept of self-management. (The time spent during the second week was one hour per group.) Self-management behaviors were assessed and BP levels were measured, together with stimulation and self-management follow-up (during the 4th and 13th weeks). On the contrary, the control group received standard care for improving BP.

The research studied a total of 91 people, who were subdivided into an experimental group of 44 people and a control group of 47 people. Four people (at a drop-out rate of 5%) dropped out from the Program because they were chronically absent.

The study found that the ages of participants in both the experimental and control groups were mostly between 56 years and 65 years old (40.90% and 55.30%). Most were married (61.40% and 59.60%), had graduated from school at the elementary level (65.90% and 68.10%), and were unemployed (52.30% and 70.20%) (Table 1).

In terms of clinical characteristics, it was found that participants in both the experimental and control groups had symptoms of HT for periods of fewer than 5 years (56.8% and 68.10%) and that most had no record of smoking (93.20% and 97.90%) and had not consumed alcohol (93.20% and 83%). When comparing the general characteristics between the experimental and control groups before starting the Program, it was found that they had no differences whatever (P > 0.05). Furthermore, they had no other congenital diseases (54.50% and 57.40%) but did have excessive weights or body-mass indices ≥ 23 (70.50% and 61.70%). A comparison of test results from both the experimental and control groups before starting the program found that most had no differences in their clinical characteristics and the factors that related to their BP levels (P > 0.05) (Table 2).

From the results of this study, it was found that at 13 weeks after entering the program, the experimental group had systolic and diastolic pressure levels lower than before joining the program. These levels did not significantly (P < 0.001 and P < 0.001, respectively), because before participating in the program, participants in the experimental group had already lowered their BP, and most had been seeing their doctors regularly. Meanwhile, they continued to take their prescribed medicines. As they participated in the Program, they acquired an even better understanding of self-care and managing their HT, and were able to see how these actions could reduce their BP down to the specified levels. Before entering the Program, however, their BP levels were not higher than the specified criteria. Program participation did affect the reduction of their BP after entering the Program, but without statistical significance up to week 13. The effectiveness of the programs was shown in the fourth week. The resulting systolic decrease at the fourth week between the groups was significantly different at a level of P < 0.05 (t = 2.08, P = 0.04) (Table 3).

Although in the 13th week after entering the Program, BP levels did not differ significantly, it was found that the experimental group was successfully controlling their BP following the criteria of the Thai Hypertension Society. The systolic BP can decrease to levels lower than before participating in the Program, while the diastolic BP does not change. It has been recommended by the JCN-7 guideline¹⁸ that the systolic BP be ≤140 mmHg and diastolic BP be ≤90 mmHg. In general, HT is a chronic disease of BP, which should be below 130/80 mmHg (Table 4).

Applying Levene's test for systolic BP and diastolic BP showed that equal variances had been assumed. The resulting systolic decrease at the fourth week was significantly different between the two groups at a level of P < 0.05 (t = 2.08, P = 0.04). The diastolic decrease did not differ significantly between the two groups. In addition, the diastolic decrease did not differ in the groups between their entry into the programs and their departure from the programs.

The average values of self-management behavior scores can be applied to compare outcomes in both the experimental and control groups. From these outcomes, it was found that before entering the program, the groups had no differences in self-management behavior scores (P > 0.05). At 4 weeks and 13 weeks after entering the program, the experimental group had a higher average value of self-management scores than did the control group (with significance levels of P < 0.001 and P < 0.001, respectively) (Table 5).

The comparative mean differences in self-management behavior before and after entering the Program (at the 4th &13th weeks after program entry) were analyzed by the one-way repeated-measures ANCOVA. At the 4th and 13th weeks after entering into the Program, the self-management training program had affected self-management behaviors, as signified by the effective mid-size length (F [1, 89] = 1.094, P < 0.001, η² = 0.983). After entering the program, the experimental group had a self-management behavior score that differed from the control group. Also, the time of entering the Program affected the self-management behavior scores significantly in terms of effective mid-size length (F [1,89] = 1.094, P < 0.001, η² = 0.092). It was shown that at the 4th and 13th weeks after entering into the program, the experimental group had self-management behavior scores that were significantly different from what they had been prior to participation (Table 5).

The results of comparing the mean differences in self-management behavior scores within the experimental group at the 4th and 13th weeks before and after entering the program were analyzed by the oneway repeated-measures ANCOVA. These results were found at the 4th and 13th weeks after program entry.

Figure 1

The experimental group had a mean difference in self-management behavior scores that were significantly higher than before entering the program (P < 0.001 and P < 0.001). At the 13th week after entering the program, the experimental group had a self-management behavior score that was not significantly different from the 4th week following program entry (P > 0.05).

At the fourth week following program entry, the control group had a mean difference in self-management behavior scores that were significantly higher than before entering the program (P = 0.001). At the third week after entering the program, the control group had a mean difference in its self-management behavior scores that was significantly lower than before entering the program (Table 6).