Self-Management Program for Hypertension and Its Behavioural

Outcomes: A Literature Review

Arfiza Ridwan

, Umaporn Boonyasopun

, Nurhasanah

Department of Community Nursing, Faculty of Nursing, Syiah Kuala University, Indonesia

Department of Public Health Nursing, Faculty of Nursing, Prince of Songkla University, Thailand

Keywords: Self-Management, Hypertension, Behaviour

Abstract: Hypertensive care in the community involves a non-pharmacologic treatment focusing on lifestyle

modification. To formulate the applicable, effective, and efficient program, it is important to gain a better

understanding about self-management program in changing behaviours. Systematic search methods were

utilized to identify intervention studies about self-management program for hypertension people living in

community. Several databases and universal case entry website are being used. The results of this study is

described in four sections; self-management concepts and related theory, components, outcomes, and

measurement of self-management program. Self-management concept is underpinned from the

psychological and behavioural science literature based on notion of an individual’s ability to control and

manage health effectively. There are numerous variation of the strategy and duration used in the programs.

Mostly, the outcome of the study that focused on the behavioural measured the changes of physical

activities, diet, and smoking. To assess those behavioural changes, various measurement were used. In

conclusion, self-management concept, components, outcomes, and measurement may have been different

between one study to another. However, it is revealed that the programs have a significant influence in

behavioural changes. It is expected that those programs can be applied by nurses as a strategy to manage

hypertension in community.

1 INTRODUCTION

The estimated prevalence of hypertension is

increasing globally in the last two decades. In long-

term projection, it is predicted that by year 2025,

29% of adults suffer from hypertension worlwide. In

other words, about 1.56 billion people would have

hypertention by next decade (Egan, 2018). The

prevalence of hypertension in Indonesia among

people over 35 years age is more than 15.6%

(Healthy Life Journal, 2010). In addition,

approximately 8 million deaths each year are blood

pressure related, with rates rising by 56.1% from

1994 to 2004 in the worldwide (Sood, Reinhart &

Baker, 2007).

The Seventh Report of the Joint National

Committee on Prevention, Detection, Evaluation,

and Treatment of High Blood Pressure (JNC 7)

describes the relationship between blood pressure

and cardiovascular disease as continues, consistent,

and independent of other risk factors. Beside, this

committee also identify blood pressure relationship

with myocardial infarct, heart failure, stoke, and

kidney disease. Risk of CKD (Chronic Kidney

Disease) increases with the extent and duration of

continuous high blood pressure (Eskridge, 2010).

Hypertension care involves having a structured

non-pharmacologic treatment plan including

counselling about behavioural changes (National

Institute for Health and Clinical Excellence, 2011 as

cited in Bradbury, Morton, Band, Woezik, Grist,

McManus, et al., 2018). In studies, the behaviours

that often related with hypertension are diet

modification, weight control, alcohol use, smoking,

and physical activity (Xue, Yao & Lewin, 2008;

Hall, Rodin, Vallis & Perkin, 2009; Park, Song,

Cho, Lim, Song & Kim, 2010; Matlock, Bosworth,

Giger, Strickland, Harrison. Coverson, et al. 2009).

Person with hypertension should be encouraged to

adopt these behaviours, especially for those who

have additional risk factors for cardiovascular

disease and diabetes mellitus.

Some reviews had been conducted, the result has

shown that counselling and education reduces risk

Ridwan, A., Boonyasopun, U. and Nurhasanah, .

Self-Management Program for Hypertension and Its Behavioural Outcomes: A Literature Review.

DOI: 10.5220/0008394600002442

In Proceedings of the Aceh International Nursing Conference (AINC 2018), pages 64-74

ISBN: 978-989-758-413-8

factors in high-risk hypertension, but lifestyle

changes are not easily achieved. Therefore, person

based approach is regarded as one way to help the

client in improving their rehabilitative behaviour

(Bradbury, et al., 2018). One of person based

approach that has been popular today is self

management. Self-management program have been

widely reported as one way to promote the ability in

managing behaviour and health outcome for several

chronic conditions. It emphasizes the clients’ role in

preventing and therapeutic health caring activities

that consists of organized learning experiences that

is designed to facilitate the health-promoting

behaviours.

2 METHODS

Several database were involved to meet the

objectives of this study; PubMed, CINAHL, Science

Direct, and ProQuest. Moreover, the authors also use

universal case entry website such as Google-scholar

and other official websites. The numbers of keyword

are used to obtain information for this study: self-

management program, behaviour, community,

hypertension, and self-management behaviour. The

research is limited to period 2000-2018, except for

the concept of self-management which the authors

take from earlier period.

The selected studies needed to be aimed at

self management of hypertension and also describe

how to develop the program to achieve the objective

of each study. All articles and other sources that

relevant to the topic were retrieved. For article,

researcher only uses full text to be reviewed. Only

articles written in English were included. There was

no limit of setting of articles. Overall, more than

1000 artcles were found through those databases.

Howewer, most of those articles were exluded after

reading the title and abstract. The authors red

carefully the included articles and extracted the

given information. The data then was organized into

several items to be compared and described

systematically.

The results of this literature review are

described in four separate sections: self-management

concepts and its related theory, components of self-

management program for person with hypertension,

outcomes of self-management program for

hypertension, and measurement of behavioural

outcomes from self-management person with

hypertension

3 FINDINGS

3.1 Self Management Concept and

Related Theory

Self-management concept for chronic condition is

underpinned from the psychological and behavioural

science literature based on notion of an individual’s

ability to control and manage health and illness

effectively. Individual’s perception of own ability

affects their choices and behaviour, and it

consequently dictates them to achieved or avoid

desired goal (Bradbury, et al., 2018). Most of health

behaviour-change programs are based on Kanfer’s

Self-regulation and Bandura’s Social Cognitive

Theory (SCT). Self-regulation assumes that

behaviours of human in daily life consist of chain of

responses that built up previously; therefore a

response is automatically appearing. However, in

specific condition changes are required. When

changes are very important to be performed, self

regulation will be needed. The process focuses in

attention and continues decision making among new

changes future (Kanfer & Goldstein, 1991).

Meanwhile, social cognitive theory (SCT)

assumed that behaviour change is influenced by

several factors such as number of interacting

psychosocial, environment, and behavioural factors.

The process focuses on the importance of own

ability to control behaviours and how environment

or individual change can produce changes in

behaviours. The success in initiating and

maintaining changes is depends on own ability to

regulate behaviours and utilize the environment

toward the changes. Intervention based on this

theory is often related with self-efficacy that is

believed in enhancing/encouraging people to reach

their goals through changes (Pinto & Floyd, 2008).

From two theories above, we can conclude that

behaviour changes happen in human life in

particular situation. It requires own ability and the

process can be influenced by several factors, such as

interacting psychosocial, environment, and

behavioural factors. Therefore, self-management

program is regarded as one way to meet the

behaviour change of particular conditions in human

life such as chronic disease.

Self-management concept has been widely

defined in various meanings. It is different with

health education and promotion, because it assists

participant in self-efficacy and self-management

behaviour in managing diseases. This concept is

often promoted in chronic diseases including

hypertension, asthma, diabetes, etc. (Lorig &

Self-Management Program for Hypertension and Its Behavioural Outcomes: A Literature Review

Holman, 2003; Warsi, Wang, LaValley, Avorn, &

Solomon, 2004). Similarly, Lorig and colleagues

focused the self-management primarily on chronic

condition compared to risk and protective factors of

a disease (Ryan & Sawin, 2009). Self-management

emphasizes the importance of the clients’

responsibility by encouraging rehabilitative

experiences to increase responsibility for their

behaviour, deal with the environment, and plan for

the future (Kanfer& Goldstein, 1991). Self-

management is a process of changing several aspect

of own behaviours. The process consists of goal

selection, information collection, information

processing and evaluation, decision making, action,

and self-reaction (Creer, 2000).

Self-management refers to the ability of a person

in chronic condition to manage the symptoms,

treatment, physical and psychosocial consequences,

and lifestyle changes. Its efficacy is including the

ability to monitor one’s condition and to affect the

cognitive, behaviour, and emotional responses which

is important to maintain the quality of life (Sol, Bijl,

Banga, and Visseren, 2005).

Nodhturft (2000) as cited in Embrey (2006)

stated that the objectives of self-management are

cognitive symptom management, problem solving,

decision making, and promoting healthy behaviour.

Meanwhile, Kanfer and Goldstein (1991) described

three outcomes of self-management: 1) to help the

client to get the more effective interpersonal

cognitive and emotional behaviour; 2) to change

clients’ perception and evaluative attitudes towards

problems; 3) to alter stressed or hostile environment,

or to cope by accepting it as inevitable things.

Kanfer and Goldstein (1991) initiated three

stages of self regulation in self-management; 1) self

monitoring, 2) self evaluation, and 3) self

reinforcement. Meanwhile, the self regulation that

proposed by Bandura that is regarded as Social

cognitive Theory as cited in Ryan & Sawin (2009)

includes goal setting, self-monitoring, reflective

thinking, decision making, planning and action, self

evaluation, and cognitive responses associated with

health behaviour change. Similarly, Creer (2000)

stated that the self-management process consists of

goal selection, information collection, information

processing and evaluation, decision making, action,

and self-reaction.

3.2 Components of Self-Management

Program

Each study has different contents, duration, and

strategies of intervention to be applied in the self-

management program. It depends on the framework

that they used and the objectives of the study. In this

part, reviewer presents content, duration and strategy

in detail.

The standardized chronic disease self-

management program (CDSMP) was done in a study

in China population, Victoria and Queensland,

Australia. The content of the program consists of

diet, exercise, medications, fitness, emotion

management, problem-solving skills, and

communication with health professionals, which are

the keys to a better quality of life in persons with

chronic illness (Siu, Chan, Poon, Chui, and Chan,

2005; Swerisson, Belfrage, Weeks, Jordan, Walker,

Furler, et al. 2006; Kendall, Catalano, Kuipers,

Posner, Buys & Charker, 2007). Almost similarly,

the contents of the program of self-management are

physical activity, DASH diet, salt, alcohol, smoking,

and medication management (Xue, Yao, & Lewin,

2008; Bosworth, Olsen, Grubber, Neary, Orr,

Powers, et al., 2009). In addition, Bosworth, Olsen,

Grubber, Neary, Orr, Powers, et al. also focus on

home blood pressure monitoring. Differently, the

contents of program in Netherland are maintaining

physical condition, recognizing symptoms, taking

action, coping with negative emotions, and giving

and seeking social support from partners, neighbors,

and colleagues (Scheurs, Colland, Kuijer, Ridder &

Elderen, 2003). A self-management program for

diabetes mellitus patient has different content in the

intervention. In a study about DM, the self

management content is anxious temperament, self-

management behaviour, and quality of life (Hall,

Rodin, Vallis & Perkin, 2009).

Several study focus on one behaviour as the

outcome. In as study about the use of self-

management strategies, the content of the program

focused on promoting physical activity (Saelens,

Gehrman, Sallis, Calfas, Sarkin & Caparosa, 2000).

Self-management knowledge and skill was also

applied in a program about health improvement and

prevention study. The content of the program

covered individual lifestyle that consists of diet,

physical activity; and group lifestyle that consists of

educational and physical activity practice based on

self-management strategies (Fanaian, Laws, Passey,

McKenzie, Wan, Davies, et al., 2010).

Strategy of intervention is important thing to be

discussed, because it can draw how researchers run

the program from the beginning until the end. The

information that is contained in this part can be

useful for those who need to know what strategy can

be used in further research. One of strategy that was

used in a program of health improvement and

AINC 2018 - Aceh International Nursing Conference

prevention study is self-management knowledge and

skills. This program offered sessions for individual

and lifestyle education for group. The self-

management strategy was applied in the group

session, which consists of goal setting, self-

monitoring, developing practical skills, and problem

solving to promote positive dietary and physical

activity changes and weight loss. The total session

counted for six sessions during nine months period

(Fanaian, Laws, Passey, McKenzie, Wan, Davies, et

al., 2010).

In a study that conducted in a cardiac patient

club in Shanghai, the participants attended group

treatment session. The participants were delivered

into six small groups with 10-12 patients per group.

There are four sessions where the participants need

to be attended. In the first session, each group were

given educational talk, in accordance with a self-

management manual for hypertension, introduction

of goal setting, and the exercise of using digital

blood pressure metre. Moreover, in the end of the

session they were given booklets about

hypertension, lifestyle change, compliance of

medication, diary to record their daily blood

pressure, and action plan (a set of goal sheets which

the patient set out and record the success with

weekly goals).

The second session was conducted one week

after the first one. The meeting was opened by doing

the feedback from practice of the goal from previous

week. After that, the participants got explanation

about physical activity, DASH diet, salt, alcohol,

and smoking. Further, they were invited to do

patient led exercise session, followed by explanation

about calculating body mass index (BMI). At the

end of the session, participants set new goals for the

one following week. The third session was done one

week after second session. The contents were about

managing the medication and food energy

calculation. The last session was conducted two

weeks after the third one. The content is about

giving feedback from the previous goals and

encourages maintaining change (Xue, Yao, &

Lewin, 2008).

Differently, in a study about Chonic Disease Self

Management Program (CDSMP) that was conducted

in Chinese population, Victoria and Queensland,

Australia, the procedure of the program took time

for six weeks. The program was done by a trained

professional leader and a trained lay leader. They

acted as the role models in the sessions. During the

sessions, participants were helped to tell their

experience and master self-management behaviours.

The session spent time for 2.5 hours once a week.

They learned how to set goals that they belief and

confident that they will complete. After that, the

progresses of fulfilling the goal were monitored by

peers in weekly timeframe. It was used further for

reviewing, sharing, and group problem solving (Siu,

Chan, Poon, Chui, and Chan, 2005; Swerisson,

Belfrage, Weeks, Jordan, Walker, Furler, et al. 2006;

Kendall, Catalano, Kuipers, Posner, Buys &

Charker, 2007).

There is also a study that compares the outcome

for group who received different interventions. The

first group received tailored behaviour self-

management intervention two times a month, the

second group received home blood pressure

monitoring intervention three times a week, and the

third received combined intervention of first and

second group. The first group focuses on adherence,

dietary pattern, weight loss, reduce sodium intake,

physical activity, smoking cessation, and moderation

of alcohol intake. The monitoring is delivered by a

single nurse during bi-monthly telephone calls. The

second group records their blood pressure that they

take three times a week in a log. Meanwhile, the

third group did both interventions (Bosworth, Olsen,

Grubber, Neary, Orr, Powers, et al, 2009).

Meanwhile, a study by Scheurs, Colland, Kuijer,

Ridder & Elderen (2003) conducted 5 weeks

program that contained 5 sessions. Each session

spent time for two hours. It provides several steps:

introduction the self-management tasks; sharing

beliefs, emotions, experience, and barriers; action

plans; and goal attainment. The intervention is for

group which consists of 6-8 participants. The

sessions were conducted two times a week.

From the result above, we can see that there are

various strategies were used to run the self-

management programs. Mostly, the programs were

separated into several sessions in a period of time.

Each session contains different content and methods

one another. We cannot assume which strategy is

better, because each study have different outcome to

be achieved and it also depends on the framework

that conceptualized the studies.

Several studies that used the standardized

Chronic Disease Self-Management Program

(CDSMP), spent time of six week for intervention

(Siu, Chan, Poon, Chui& Chan, 2005; Swerisson,

Belfrage, Weeks, Jordan, Walker, Furler, et al. 2006;

Kendall, Catalano, Kuipers, Posner, Buys &

Charker, 2007). However, each study has different

timeframe of follow up. Study by Siu, Chan, Poon,

Chui, and Chan followed up the measurement in one

week following the intervention. Differently, study

by Swerisson, Belfrage, Weeks, Jordan, Walker,

Self-Management Program for Hypertension and Its Behavioural Outcomes: A Literature Review

Furler, et al. conducted the follow up on the six

months after the program. Meanwhile, study by

Kendall, Catalano, Kuipers, Posner, Buys & Charker

did the follow up four times in 12 months period; at

3,6,9, and 12 months. Similarly with a study by

Swerisson, et al., the follow up of study by Hall,

Rodin, Vallis & Perkin (2009) was held on the 6 six

months after the treatment.

A study about health improvement and

prevention study which used self management

knowledge and skills did the follow up on the nine

months counted from the beginning of the program.

During the nine months, there were 6 time group

session done (Fanaian, Laws, Passey, McKenzie,

Wan, Davies, et al., 2010). Meanwhile, in a

randomized trial of self-management program, the

intervention was conducted for 5 weeks that

contained of 4 group treatment sessions. The follow

up was held on 1 month and 4 months after ending

the treatment (Xue, Yao, & Lewin, 2008). Similar in

duration of intervention, a study by Scheurs,

Colland, Kuijer, Ridder & Elderen (2003) also took

time for 5 weeks. Differently, a randomized control

trial about self-management intervention took time

for 24 months. The evaluation of blood pressure was

held every 6 months over 24 months. There were

four groups attended the program. Each group

received different intervention and duration of

intervention. The tailored behaviour self-

management group accept the intervention two times

a month, home blood pressure monitoring group did

the monitoring of blood pressure three times a week,

and combined group did both of intervention that

first and second group did (Bosworth, Olsen,

Grubber, Neary, Orr, Powers, et al., 2009). Similar

duration of intervention, study by Saelens, Gehrman,

Sallis, Calfas, Sarkin & Caparosa (2000) also

completed the assessment after 24 months. The

follow up was held twice; 1 year and 2 year after

ending the intervention.

3.3 Outcomes of Self-Management

Program

Studies about self management in various kinds of

disease have various outcomes to meet the

objectives of the study. Most of the outcomes tend to

be clinical/physical outcome, the others tend to be

behavioural, psychological, social outcome, and

some also have for the quality of life.

In detail, the primary outcomes of self-

management in chronic condition are; 1) health

status ; including self-related health, health-related

quality of life, disability, pain, fatigue, shortness of

breath, and psychological well being, 2) health

behaviour; including exercise, cognitive symptom

management, adherence, 3) health care use, and 4)

self-efficacy (confidence) to self-care (Foster,

Taylor, Eldridge, Ramsay & Griffiths, 2009).

3.3.1 Physiological Outcomes

A study by Xue, Yao, and Lewin (2008) presents

several outcome measurements, such as measure

blood pressure, weight, height, and waist

circumference, biochemical test, and health related

quality of life (HRQOL). Similarly, a study by Park,

Song, Cho, Lim, Song, and Kim (2010), also

measure health related quality of life (HRQOL) as

one of the outcomes of the study. Differently, one of

outcomes in a study measure self-reported health

status by assessing two components; Physical

Component Summary and Mental Health

Component Summary (Scheurs, Colland, Kuijer,

Ridder & Elderen, 2003). Health distress, disability,

illness intrusiveness, social role/activity limitation,

depression, pain severity, shortness of breath and

fatigue also also physiological outcome. These

outcome were measured by using self-rated

instrument (Swerisson, Belfrage, Weeks, Jordan,

Walker, Furler, et al. 2006)

Meanwhile, a study by Bosworth, Olsen,

Grubber, Neary, Orr, Powers, et al. (2009) only

measure blood pressure (BP) using a digital

sphygmomanometer digital (BPTRU automated

non-invasive BP monitor, Model BPM-100) to

obtain the outcome. The authors compared BP in

four group who accept different type of

interventions; usual care, behavioural intervention,

home BP monitoring, and combined home BP

monitoring and behavioural.

3.3.2 Psychological Outcomes

There are several kinds of psychological outcomes

are included in the self-management program.

Themost common of psychological outcomes is self

efficacy (Scheurs, Colland, Kuijer, Ridder &

Elderen, 2003; Kendall, Catalano, Kuipers, Posner,

Buys & Charker, 2007; Siu, Chan, Poon, Chui, and

Chan, 2007; Park, Song, Cho, Lim, Song, and Kim,

2010). It is believed that self-efficacy is the most

important condition where one’s confidence can

carry out behaviour that is needed to meet the goals

(Sol, Bijl, Banga, and Visseren, 2005). A study by

Kendall, Catalano, Kuipers, Posner, Buys & Charker

stated that besides self-efficacy there are three

domains for psychological outcome; mood,

AINC 2018 - Aceh International Nursing Conference

personality, and thinking, because these domains can

be affected by cardiovascular disease .

A different psychological outcome was measure

in a study. Besides measure self efficacy, the

researcher also added coping strategies as

psychological outcome. The coping strategies

measurement has six dimensions, they are diverting

attention, reinterpreting pain sensations,

catastrophizing, ignoring sensations, praying or

hoping, and making coping self-statements. This

strategies are important, because the change

mechanism of coping underlies adjustment to illness

and disability (Siu, Chan, Poon, Chui, and Chan,

2007).

3.3.3 Behavioural Outcomes

One of the most common behavioural outcomes of

hypertension program is physical activity. It is

believed that by doing physical activity, the persons

who suffer from hypertension may get controlled

blood pressure, get more energy, and feel fresh.

Consistency of physical activity is necessary to

obtain health benefits (Saelens, Gehrman, Sallis,

Calfas, Sarkin & Caparosa, 2000). Physical activity

is defined as activity that is performed intentionally

to raise the blood pulse for at least 30 minutes in

several choices of activity such as cycling, walking,

or swimming (Drevenhorn, Kjellgren & Bengston,

2007). Sometimes, physical activity also called

exercise. One of behavioural domains of a study in a

Chinese population is exercise. In this study, the

physical activity that is measured covered walking,

swimming, and relaxation (Siu, Chan, Poon, Chui &

Chan, 2007). Meanwhile, in a study in Sweden, the

researcher separated physical activity into three

levels; 1) no regular exercise, 2) intermediate, when

participants practice twice a week by

cycling/walking to work place ≥ 5 km; or once a

week by cycling/walking to work place ≥ 3 km, and

3) high, when participant practice a regular exercise

more than twice a week. These levels were measured

before and after the participants attending the

intervention to assess the effect of the program

(Drevenhorn, Kjellgren & Bengston, 2007).

Differently, in a study by Park, Song, Cho, Lim,

Song, and Kim (2010), the three kinds of physical

activity are walking, moderate, and vigorous

activity. The total weekly physical activity MET-

minutes/week was estimated from the reported

minutes within each kind of activities per week. The

higher level of physical activity was indicated by

higher score from the estimation. Similarly, the level

of the physical activity was estimated by computing

the physical activity MET-minutes/week that is the

sum of walking, moderate, and vigorous activity

(Xue, Yao & Lewin, 2008).

Physical activity is also one of outcomes of a

study in Australian. However, in the article there is

no explanation about it. There is only brief

information about how they get the data of physical

activity from clinic record audit (Fanaian, Laws,

Passey, McKenzie, Wan, Davies, et al., 2010).

Similarly, there is also no explanation about physical

activity that is used to assess the effect of the

program in a study by Hall, Rodin, Vallis & Perkin

(2009).

In conclusion, from the studies above we can see

that physical activity is one of the most common

behavioural outcomes of hypertension program is

physical activity. There are various kinds of activity

were used to enhance the physical activity such as

cycling, walking, swimming, relaxation, and

vigorous activity. Several standards were used to

determine the level of this behaviour to examine the

effect of self-management programs .

Several studies about hypertension use dietary

behaviour to assess the effect of the intervention.

However, from the literature about self management

program, there is only few researches use it as

outcome. In a study in Shanghai, diet was assessed

by asking the intake of food items that participants

consumed in the last three months before

intervention, one month after intervention, and four

months after intervention. The food items that asked

consist of red meat, vegetables, and fruits. The

calculation is counted per day (Xue, Yao & Lewin,

2008). Differently, diet behaviour was assessed by

using Daily Living Diary by asking the participant to

fill out 3-4 days of their food intake for each week,

including weekend (Fanaian, Laws, Passey,

McKenzie, Wan, Davies, et al., 2010). There is also

a study which has diet as one of outcomes. The diet

habits were assessed before the program and 15

months after the program. The habits that was

assessed are reducing the intake of energy-rich food,

choosing light dairy products and low-fat cheese,

choosing cooking fat high in mono- and/or poly-

unsaturated fat (olive or rape oil), eating fish more

often, eating chicken rather than pork and beef,

choosing bread and cereals rich in fibers, cutting off

visible fat, choosing low-calorie delicatessen

products, eating more fruit, vegetables and root

vegetables and distinguishing between weekdays

and special occasions (Drevenhorn, Kjellgren &

Bengston, 2007).

Smoking has strong relationship with

cardiovascular problems, including hypertension. In

Self-Management Program for Hypertension and Its Behavioural Outcomes: A Literature Review

a 13 years cohort study in Mediterranean, Spain, the

researcher identified and estimated risk factors

which increase the risk of cardiovascular disease.

From the study it is known that smoking behaviour

is the leading risk for cardiovascular events such as

angina pectoris, stroke, and acute miocard infarc.

Therefore, it is important to promote healthy life by

avoiding smoking (Huerta, Tormo, Gavrila, &

Navarro, 2010).

Smoking is one of behavioural outcomes of self-

management program. However, only few articles of

self-management programs have this behaviour as

the outcome. In a study by Drevenhorn, Kjellgren &

Bengston (2007), the smoker and non smoker were

identified before the intervention and 15 months

after intervention. As the indicator of the effect of

intervention, the researcher compared and counted

the number of smokers who stop smoking in 15

months after intervention. Similarly, the number of

smokers who stop smoking is also the indicator of

the effect of intervention of a study in a cardiac

patient club in Shanghai. In the baseline, the

participants were asked if they had smoked in the

last four weeks. After attending the 5 weeks self-

management program, they were asked again in the

next four months follow up (Xue, Yao & Lewin,

2008).

A study Fanaian, Laws, Passey, McKenzie, Wan,

Davies, et al. (2010) also had the same indicator of

smoking. The difference thing compared to previous

study is the time frame of follow up. This study

conducted follow up after 12 months after the

intervention.

3.4 Measurement of Behavioural

Outcomes

To assess the effects of self-management programs,

several measurements were used in various studies.

Most of them used the measurement in the baseline

and in the end of the program or in the follow up in

particular time after finishing the program. The

explanations that are presented in this part are

measurements of physical activity, diet, and

smoking. Actually, physical activity is

interchangeable with exercise; and diet is related

with weight control and food modification.

Therefore, in this part, reviewer only presents these

three kinds of behavioural outcome.

3.4.1 Physical Activity

Several studies used International Physical Activity

Questionnaire (IPAQ) to measure it (Xue, Yao &

Lewin, 2008; Park, Song, Cho, Lim, Song, & Kim,

2010). This measurement is widely use in

surveillance and studies in the worldwide. IPAQ

short form is a tool that is designed primarily for

population surveillance and as an evaluation tool in

intervention studies for physical activity among

adults. It has been developed and tested for use in

adults (age range of 15-69 years). This tool assesses

physical activity that undertaken a comprehensive

set of domains including leisure time physical

activity, domestic and gardening (yard) activities,

work-related physical activity, and transport-related

physical activity. There are three levels of physical

activity are proposed; low, moderate, and high. The

questionnaire must cover these three levels to be

asked to the samples (IPAQ group, 2005).

The validity and reliability of IPAQ already

tested in several studies. In a study that has purpose

to test the validity and reliability of IPAQ, the result

show Spearman's rho clustered around 0.8, and

Criterion validity had a median rho of about 0.30

(Craig, Marshall, Sjostrom, Bauman, Booth,

Ainsworth, et al., 2003). Moreover, a study in a

Spanish population shows the IPAQ has a good

reliability coefficient for total physical activity

(r=0.82, P<0.05), vigorous activity (r=0.79,

P<0.05), moderate activity (r=0.83, P<0.05), and

time spent walking (r=0.73, P<0.05). Total time

spent on work-related physical activities (r=0.92,

P<0.05), on household-related activities (r=0.86,

P<0.05), and leisure-time physical activities

(excluding walking) (r=0.82, P<0.05) showed good

reliability coefficients (Vinas, Majem, Hagstromer,

Barba, Sjostrom, & Cordona, 2010).

IPAQ is not the only one measurement that was

used to measure physical activity. Several study

used self-administered questionnaire that developed

according to the conceptual framework that they

used. For example, in a study about evaluation of the

chronic disease self-management program in a

Chinese population, the physical activity is one part

of self management behaviour. The researcher

measured the physical activity by using an

instrument of the self-management course devised

by Lorig, et al. (1996). The instrument covers four

domains of behaviour; exercise, cognitive symptom

management, use of community services, and

communication with physician. The questionnaire

has 26 items using 4-5 point scale, where the

samples were asked to indicate their behaviours.

This questionnaire demonstrated acceptable to high

internal consistency (α = .72-.91) and acceptable

test-retest reliability (r =.65-.80). These values were

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obtained from the pilot study (Siu, Chan, Poon,

Chui, and Chan, 2005).

There is also a study in Sweden that used a

simple measurement for physical activity. They

measure the level of exercise in the baseline and in

the follow-up after 15 month, and then compared it,

whether there is significant shift or not. The three

levels of exercise consist of no regular exercise,

intermediate vigorous exercise, and high vigorous

exercise. However, in the article the authors did not

mention the details of the tools that they used; its

validity and reliability (Drevernhorn, Kjellgren, &

Bengston, 2007). Differently, in a study about health

improvement and prevention study (HIPS) for

preventing vascular disease that used self-

management knowledge and skill in the program,

the physical activity was measured by using clinical

record audit in the hospital during 12 months.

Similarly as the study in Sweden that explained

before, the article of this study there is no detail

explanations about the tool that was used, its validity

and reliability (Fanaian, Laws, Passey, McKenzie,

Wan, Davies, et al., 2010).

In a study conducted in Canada, physical activity

was measured by using The Physical Activity Scale

for the Elderly (PASE). This instrument was

developed and validated specifically to measure

physical activity in older adult. The. It had good test-

retest reliability over 3 to 7 weeks period (Hall,

Rodin, Vallis & Perkin, 2009). Actually, PASE is

used for the elderly, but the study by Hall, Rodin,

Vallis & Perkin used it participants of this study

ranged from 29 to 79 years. There is no explanation

why they chosen it as the tool. Moreover, in the

article the author did not mention the value of

instrument validity and reliability.

3.4.2 Diet

From the articles that are reviewed, some of studies

have diet as the behavioural outcome. Similarly with

physical activity, diet is also measured by various

kinds of measurements. The instrument for diet as

behavioural outcome that was used in a study in

Sweden is food habit. The limit of satisfactory blood

lipid was set for the study as the indicator of the

program. In the intervention, the sample were given

simple advice about distributing food throughout the

day, reducing the intake of energy-rich food,

choosing light dairy products and low-fat cheese,

choosing cooking fat high in mono- and/or poly-

unsaturated fat (olive or rape oil), eating fish more

often, eating chicken rather than pork and beef,

choosing bread and cereals rich in fibers, cutting off

visible fat, choosing low-calorie delicatessen

products, eating more fruit, vegetables and root

vegetables and distinguishing between weekdays

and special occasions. Then, the follow up were held

to assess whether the satisfactory effect on blood

lipid is achieved or not (Drevernhorn, Kjellgren, &

Bengston, 2007).

Differently, in a study about HIPS program for

preventing vascular disease, the diet behaviour was

measured by using daily living diary. However, the

authors did not mention clearly how the use the tool

and the validity and reliability of the tool (Fanaian,

Laws, Passey, McKenzie, Wan, Davies, et al., 2010).

Meanwhile, diet behaviour was measure using

validated food frequency questionnaire (FFQ). In

this study, the samples were asked about their diet in

the last three months, and then it was compared in

two times of follow up. The first follow up was in 1

month after ending the treatment, and the second

follow up was in 4 months after ending the treatment

(Xue, Yao & Lewin, 2008).

Food Frequency Questionnaire (FFQ) is

commonly used for assessing diet and health in large

epidemiologic studies. In the application, this

instrument asks participants to report the size and

portion of consumption in particular period (Fred

Hutchinson Cancer Research Center, 2011). There is

one study which assessed the validity and reliability

of FFQ for hypertension. In the result, it shows that

it has good relialibility (Kappa coefficients ranged

from .79-.98) and validity (correlation coefficients

varying from .19 (general sample)-.31 (female sub-

sample)) (Ferreira-Sae, Gallani, Nadruz, Rodrigues,

Franchini, Cabral, et al. 2009).

3.4.3 Smoking Cessation

Smoking is considered as one behaviour that has

strong relationship with hypertension. Smoking

cessation is the process of discontinuing or stopping

the practice of inhaling a smoked substance. Based

on the articles about self-management program for

hypertension that are reviewed, there is no specific

measurement is used to measure the smoking

behaviour. In a study at 30 general practices in New

South Wales, Australia, the smoking behaviour

together with diet and exercise was measured using

clinical record audit. The researcher counted how

many sample stop smoking after getting the

intervention (Drevernhorn, Kjellgren, & Bengston,

2007; Fanaian, Laws, Passey, McKenzie, Wan,

Davies, et al., 2010). Similarly, a study in cardiac

patient club in Shanghai also counted how many

samples stop smoking after the intervention ending

Self-Management Program for Hypertension and Its Behavioural Outcomes: A Literature Review

and compared it to the baseline data about smoking

habit in the last four weeks before intervention (Xue,

Yao & Lewin, 2008).

Reviewer concluded that only few studies that

focus on smoking as the behavioural outcome of

self-management program for hypertension.

Moreover, they only used smoking cessation as the

measurement to see the effect of self-management

on smoking behaviour. Therefore, it is necessary to

do further research to improving the better care and

treatment of hypertension by focusing on smoking

behaviour.

4 DISCUSSION

This review presented an overlook of studies

measuring the effectivity of self management

program for people with hypertension. It is shown

that self management progam for people with

hypertension include a large diversity of concept,

components, outcomes, and measurement.

Self-management has many definitions and

concepts. This concept usually use to a research that

focus on chronic illness person including

hypertension. The concept emphasize clients

responsibility in experiencing their health behaviour

by dealing with environment, coping, and planning

the future. To be succeeding in self-management,

persons must be able to monitor the targeted

behaviours, use objective measurement, and see

clearly about the time period. In the process, self

management has three stage; self monitoring, self-

evaluation, and self-reinforcement.

In many studies, there are various contents,

strategies, and duration of self-management

program. It depends on the framework that used and

the objectives of the study. Some of those were for

individual, while some for group or community. It

may take a long and short period of time.

Self-management program has shown good

result in physiological, psychological, and

behavioural outcomes. The outcomes may have

different outcomes between one study to another.

Some of them mixed physiological, psychological,

and behavioural as the outcomes. The common

physiological outcome including blood pressure,

weight, biochemical, and quality of life.

Psychological outcome including self-efficacy,

mood, personality, thinking, and coping strategies.

Meanwhile, the behavioural outcomes of self-

management program consists of physical activity,

smoking cessation, alcohol consumption, diet

management.

The various measurements were used to assess

the effects of the program. This review focuses only

to the measurement of behavioural program. There

are three most common behavioural outcomes that

are used in studies; physical activity, diet, and

smoking cessation. For physical activity, the

measurement that have been used are the Physical

Activity Questionnaire (IPAQ), comparison of the

level from baseline and follow up, clinical record

audit, and the Physical Activity Scale for the Elderly

(PASE). For diet, there are blood lipid check, clinic

record audit, and Food Frequency Questionnaire

(FFQ). Meanwhile, for smoking cessation there is no

specific instrument. Researcher only count and

compare the number of smoker that stop smoking

after attending the self-management program.

Moreover, only few studies focus on smoking

behaviour even though this behaviour has strong

relationship with hypertension.

Hypertension is considered as one of diseases

that must be prevented and treated. The care of it

involves non-pharmacologic treatment especially

related to behaviours. Smoking, alcohol

consumption, weight, diet, physical activity and

stress management are behaviours that have strong

relationship with hypertension. However, it is not

easy to change behaviour. Sometimes changes are

not acceptable by people surrounding the

hypertension person. In addition, to change

behaviour itself is difficult.

Based on studies, self-management is one

effective way to change behaviour in chronic disease

including hypertension. It emphasizes own

responsibility to manage their behaviours to meet the

set goals. Therefore, providers and community must

be alert and recognize about this strategy in order to

help persons with hypertension in improving their

health and quality of life. Moreover, this review can

be used for those who want to develop a self-

management program for hypertension in any setting

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