Effects of the self-management training program on self-management behavior and

Swanee Bumrungsuk

Faculty of Nursing, Rattana Bundit University, Sam Khok, Pathum Thani 12160, Thailand

Abstract: Objective: To determine the effects of the Self-Management Training Program on self-management behavior and blood pressure (BP) levels among elderly people with hypertension (HT).Methods: This study was based on a quasi-experimental design using sampling groups composed of elderly residents of Pathum Thani Province with HT. Simple random sampling was applied to two sampling groups, an experimental group and a control group. However, the experimental group had been on the Self-Management Training Program based on the Creer concept. The Program’s contents included small-group health-education sessions and the patients’ manual, Self-Management Training Skills for Self-Management Behavior. Small group discussions were held for self-reflection, to stimulate follow-up for self-management behavior training during home visits. The Self-Management Training Program was compared with programs involving the more usual care. Data were collected using the Self-Management Behavior for Hypertension Control Questionnaire and BP assessment tests. Data were analyzed using a descriptive statistic, chi-square test, pair t-test, repeated-measures Analysis of Variance (ANOVA), and repeated-measures Analysis Covariance (ANCOVA).Results: It was found that at 13 weeks after entering the program, the experimental group demonstrated a significantly lower systolic and diastolic BP with a baseline statistical significance (P ＜ 0.005), and that at the 4th week and the 13th week, there was a decrease in BP in the experimental group. The experimental group also had above-baseline self-management behavior scores that were higher than in the control group (P ＜ 0.01).Conclusions: Results from this study show that the Self-Management Program was useful for BP control and promoted sustainable self-management behavior.

Keywords: hypertension · self-management behavior · blood pressure levels · elderly people © Shanxi Medical Periodical Press.

1. Introduction

Hypertension (HT) is a chronic disease mostly found in elderly people. It is found in 55% of those at least 60 years of age and in 65% of those at least 70 years of age.1In addition, HT is a public health problem that has increased rapidly. It has been forecasted that by the year 2025, HT will have increased to 60% of the world’s population, and it will affect the world’s population of 1.6 million people.2

For Thailand, HT is a crucial national public health problem. The number of senior patients with HT has steadily risen during the period 2007-2015.3Furthermore, HT is a significant risk factor for cardiovascular disease (CVD), which results in coronary heart disease, congestive heart failure (CHF), stroke, renal failure, and peripheral arterial disease.4An essential problem arising from HT in the elderly is the danger of complications that can easily lead to their death. There is also confirmed information that the majority of the Thai elderly with HT cannot effectively control their blood pressure (BP).5

From the results of a survey in Thanyaburi District, Pathum Thani Province, it was found that HT is found mostly in elderly people. A total of 27 people were found to have HT, which is equal to 44.30% of the elderly living in the District. Furthermore, 50% of the elderly cannot control their BP levels following the prescribed criteria of the Thai Hypertension Society.

The significant factor that caused HT in the elderly is the increase of the peripheral vascular resistance caused by blood coagulation, which affects blood vessel flexibility and resulted in a decrease of baroreceptor speed and the effective functioning of hormone rennin. It increased the reaction of the sympathetic nervous system and hormone norepinephrine, which leads to more blood vessel contraction and minimizes the presence of nitric oxide (a substance that helps the blood vessels to expand).6This reaction affects the HT levels of the elderly. If there is no proper control, it will destroy and harden the blood vessels and create complications, such as CVD, stroke, nephropathy, or kidney disease. Thus, if the HT-stricken elderly receive no medical treatment, their condition could lead to death from heart failure, stroke, and nephropathy at an average rate of 50%, 30%, and 15%, respectively.7Moreover, HT is a disease that cannot be cured. It can increase the stress levels imposed on the elderly, especially in cases with complications leading to longterm disabilities.

Consequently, these elderly people may become dependent on someone, which will add burden to their families financially. Therefore, controlling BP levels is necessary.

This research included the study of a report in which it was found that most HT patients cannot control BP levels according to specified criteria, because they find it difficult to change their behaviors such as having control over their diet.8Maintaining BP levels means maintaining them at 130/90 mmHg9through medical and non-medical applications. Even though one can control HT by taking the prescribed medicines and prevent complications, the use of medicines among the elderly has always caused residual side effects, which is always harmful. On the other hand, HT can be controlled without the use of drugs, such as by reducing salty and fatty foods, limiting alcohol consumption, quitting smoking, practicing stress management techniques, and exercising. The control of HT without medicinal applications and by changing day-to-day behaviors can reduce the systolic pressure down to 5.2-7.8 mmHg (millimeters of mercury), and the diastolic pressure down to 8.4-9.6 mmHg.10However, the critical factor that HT patients should realize and prioritize is the regulation of their behaviors to control their BP levels. Their priority should be to prevent risk and reduce various complications within their own persons. Therefore, it is necessary to change daily behaviors, together with the discreet use of medicines, to promote the patients’ understanding of the causes of any problem that may emerge and to enable them able to manage themselves properly so that they may prevent any of the various risks or complications that could arise.

The self-management concept was developed by Creer200011as a strategy to help patients change their behaviors on their own. This concept was focused on the control of chronic diseases and reducing the effects of a disease on the bodies and minds of elderly patients and on their societies. It consisted of these six steps:

(1) Goal setting took place between patients and health teams to control or reduce the effects of diseases. Thus, patients needed to be knowledgeable about diseases and cures and have the skills needed to manage the disease.

(2) Information collection took place by noticing patients’ symptoms and recording information from the symptoms. Thus, these data collections were useful for specifying guidelines for self-management and self-surveillance and helping to achieve the goal.

(3) The information process consisted of compiling the collected information for analysis and checking whether the most recent behaviors were proper by comparing them with the criteria specified for use in the procedures.

(4) Decision-making involved decisions that were made on self-management behavior.

(5) Action was the application of skills to self-management by following guidelines specified by the healthcare team.

(6) Self-reflection evaluates one’s own performance by comparing it with preset goals.

From the literature reviews, it was found that many people applied the self-management concept as a guideline in developing patient behavioral-change programs, which involved many methods, such as exercise by fast walking or aerobic dancing, or exercise by the Tai Chi style, all of which can reduce BP levels.10However, stress management could also include the less physically active approaches, such as myofascial treatment therapy or meditation, either of which can also reduce BP.12For the nutrition control aspect, the eating of low-cholesterol foods like vegetables and fruits can reduce systolic pressure down to 8-14 mmHg with significance.13The aforementioned procedures consist of activities that HT patients should perform on their own. By changing their lifestyles and following the specified criteria for proper behaviors, diseases like HT can be controlled.

However, even though there are studies of many useful methods, the elderly people with HT are still unable to maintain their BP control behaviors, or, at most, they can control them for only short periods. The elderly should therefore learn self-management and acquire the skills to act properly and correctly to cover all aspects that will continually affect their HT control. Self-management is one way to encourage the elderly to realize what they can do and to be responsible for themselves. They must learn to adhere to the treatment regimen required to treat whatever diseases they may have contracted.14Thus, the development of a multidimensional program to promote self-management for HT control in all dimensions should be given top priority.

The self-management concept of Creer was developed as a program for HT control of the elderly. The researcher believed that the program could improve the control of BP in the elderly and reduce complications. The program was intended to continue as a form of sustainable self-management.

1.1. Research Objectives

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

1. A comparison of the self-management behaviortraining 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)

1.2. Concept/Theory

This research is based on Creer’s concept of self-management,1which 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 selfmanagement 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:

1. Small-groupeducation 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.

2. The Small-group self-management training skills start from(1) the establishment of the two principal goals in self-management to control BP, (2) data collection by BP symptom surveillance and symptoms observation by recording BP symptoms, (3) daily evaluation by one’s own self, (4) the decision to start pursuing the specified goals, (5) exercise behaviors in the form of the Dao De Xin Xi dance and choosing the proper food for the elderly who are afflicted with HT, and (6) an evaluation of self-management by the elderly by monitoring their BP levels for comparison with the specified goals of lowered BP, followed by the necessary behavioral adjustments to achieve the planned results.

3. Small-group discussionsare arranged by encouraging the sampling groups to exchange their self-management experiences in controlling BP. Thus, participants may be partitioned into groups of no more than seven people each. The sampling groups can then evaluate their results after performing the assigned activities to see if they have been pursuing the established goals. Researchers would continue to urge the sampling groups to realize the importance of their self-management training. In addition, opportunities are opened up for the patients to reflect on their ideas and evaluate their self-management behavior-training skills by comparing them with their specified goals.

4. Following up and continually urging self-management behavior by visits at the patients’ homesmeant monitoring the patient’s progress in self-behavior-management and encouraging the patients to continue with their self-management regularly as a means of controlling their BP levels. Thus, the right choices of food and exercising with the Dao De Xin Xi dance routine need to be maintained. They must then follow up by using their HT medicines correctly. Researchers should continuously talk to the patients and encourage them to ask any questions they may have. They should feel free to discuss any obstacles in BP control they may be having. They may need further guidance in solving their BP issues. However, the visiting of houses will start after the completion of the first month of the research process. There will then be two visits per home.

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.

2. Methods

2.1. Statistical analysis

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 controlgroup 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.

Ap-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 ofT-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.

2.2. Material and Method

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 0.40-0.60.15It 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%.16However, 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.

2.3. Research tools included were as follows:

1. Data collection

1.1 Personal information record book

1.2 Self-management behavior measurements in HT control __ This tool was developed by Wattana17and consists of 20 questionnaires that the researcher has been permitted to use.

1.3 BP record book

1.4 3M stethoscope

1.5 Spirit Model ERKA 300 mercury standard BP measurement

2. Intervention study

2.1 The Self-Management Training Program for elderly citizens with HT

2.2 The Self-Management Promotion Program for Hypertensive Elderly

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.

3. Results

3.1. Participant Characteristics

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).

3.2. BP Levels

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 andP＜ 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 ofP＜ 0.05 (t= 2.08,P= 0.04) (Table 3).

Table 1. Participant characteristic.

Table 2. Clinical characteristics.

Table 3. Comparisons of decreases in systolic and diastolic BP levels between the experimental and control groups (at week 4).

Table 4. Comparison of BP levels within experimental group and control group before - after entering the Program (at the 13th week).

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 guideline18that 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 ofP＜ 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.

3.3. The self-management behaviors

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 ofP＜ 0.001 andP＜ 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.

Table 5. Comparison of mean differences of self-management behaviors before - after program participation (at week 4, at week 13).

Table 6. Comparison of mean differences in self-management behavior scores before and after entering the Program (at the 4th & 13th weeks within each group).

Figure 1. The present study showed a mean difference in selfmanagement program scores between the experimental and control groups at the fourth week after entering the Program.

The experimental group had a mean difference in self-management behavior scores that were significantly higher than before entering the program (P＜ 0.001 andP＜ 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).

4. Discussion

The effectiveness of a self-management training program was quite evident. Results showed that at the 13th week, the experimental group had acquired a selfmanagement behavior score greater than it had before entering the program and higher than the control group. The initial intervention started with small-group healtheducation seminars. Setting goals for changing behavior was the next step and was followed by information collection. The Program continued with self-monitoring in the form of self-observation and the self-recording of any symptoms of HT, such as headaches or high daily BP readings. Physical activity like Dao De Xin Xi dance training is an important workout routine to make healthy changes in one’s behavior and can be very effective in providing the appropriate actions for the experimental group. Self-reflection is a component of self-management that can help the patients to learn to monitor their own BP and symptoms of HT in comparison with the specified goals and to adjust their behaviors to achieve the results as planned. The six steps that have been proposed are effective in improving goal achievement.18The results revealed the strong points of self-management, particularly in the extensive implementation of goal setting for BP control and encouraging program participants to change their behaviors through small-group discussions, self-management, and reinforcement by the home-visit approach.

The control group, at the 13th week following program entry, had a mean difference of self-management behavior scores that were significantly lower than it had before entering the program. It may be concluded, therefore, that the self-management training program is conducive toward effective change in health behaviors and BP control.

From the results of this study, it was found that at 13 weeks after entering the program, the experimental group had lower average values of systolic and diastolic pressure than it had before joining the program, but without statistical significance (P＜ 0.001 andP＜ 0.001, respectively). Before entering the program, participants in both the experimental and control groups had normal BP levels.

Following program entry, the decreasing levels of BP showed a change in the number of participants who reached their BP goals, as recommended by the JNC-7.18Such change was also significant in the intervention group at the 13th week. Accordingly, the self-management training program effectively changed the patients’ health behaviors and was significant in improving their BP levels.19

5. Conclusions

For sustainability and continuity, this program, which was the subject of this study, should be implemented in hospitals and communities for other people with chronic diseases, such as diabetes or obesity. Some changes in the program model of self-management training may be appropriate to suit each community, age group, and disease group.

Acknowledgments

The author extends special thanks to Dr. Chodchoi Wattana, research program advisor, for her encouragement, insightful guidance, and invaluable advice, Center for Nursing Research and Innovation (CNRI), and The Faculty of Nursing, Thammasat University for research recommendation.

Ethical approval

Approval was granted to this study by the Institutional Review Board of the Eastern Asia University (EAU), with the ID number: SN 2556/4, and by the Ethics Committee of the Pathum Thani Province Public Health Office.

Conflicts of interest

There are no conflicts of interest.