|Year : 2019 | Volume
| Issue : 12 | Page : 4003-4009
Factors affecting self-management of hypertensive patients attending family medicine clinics in Riyadh, Saudi Arabia
Razan K AlHadlaq1, Mazin M Swarelzahab2, Samaher Z AlSaad3, Abdulrahman K AlHadlaq4, Saad M Almasari1, Saleh S Alsuwayt1, Naif A Alomari1
1 Department of Family Medicine at King Saud Medical City, Riyadh, Saudi Arabia
2 Department of Preventative Medicine at King Saud Medical City, Riyadh, Saudi Arabia
3 Department of Family Medicine at King Saud University Medical City, Riyadh, Saudi Arabia
4 College of Medicine at King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
|Date of Submission||09-Sep-2019|
|Date of Decision||16-Sep-2019|
|Date of Acceptance||14-Oct-2019|
|Date of Web Publication||10-Dec-2019|
Dr. Razan K AlHadlaq
Department of Family Madicine at King Saud Medical City
Source of Support: None, Conflict of Interest: None
Background/Aim: Hypertension (HBP) is a chronic disease that has become a public health problem, which has been attributed to numerous risk factors. However, despite numerous HBP management and behavioral treatment guidelines, HBP is poorly controlled among patients due to insufficient care. We conducted this study to identify the prevalence of self-management behaviors and to explore factors affecting self-management behaviors for controlling HBP among hypertensive patients. Methods: We conducted a survey using the Hypertension Self-Care Profile (HBP-SCP) and the Hill-Bone Adherence Scale among diagnosed HBP patients attending the Family Medicine clinics of King Saud Medical City in Riyadh, Saudi Arabia in January 2019. All patients of Saudi nationality aged 18 years and above were included in the study. Results: A total of 187 patients responded to the survey, 95 (50.8%) males and 92 (49.2%) females. Only 93 patients (49.7%) monitor their BP at home, and 68 (36.4%) always measure their BP. Ninety-one patients (48.7%) said that measuring their BP is not important. The most common reason for not taking the anti-HBP medications is they forget to take the medications in 87 (46.5%) of patients. Seventy-two patients (38.5%) did not restrict salt intake, and 51 patients (27.3%) had no time for exercise. More than half of the patients (51.3%) were not motivated to regularly exercise and 56.7% were motivated to limit salt-intake. Confidence to exercise, check BP at home, and eat low-salt foods were also low at 52.4–53.5%. Significant factors including gender, age, BMI, duration of HBP, and presence of cardiac disease were found to be related toward behavior, motivation, and confidence to self-care. Conclusion: Compliance, behavior, motivation, and self-care among hypertensive patients visiting the primary care clinics in our representative population are low. Various factors were found to be related to poor behavior, poor motivation, and less confidence to do home BP monitoring, to exercise more, restrict salt intake, and value the control of HBP. There is a need for health practitioners to assess self-care activities and blood pressure control, and educate patients the importance of HBP monitoring and teaching practical techniques to boost their confidence and motivation to achieve a better behavior, self-care, and compliance to management.
Keywords: Factors, family medicine, hypertension, self-management, self-medication
|How to cite this article:|
AlHadlaq RK, Swarelzahab MM, AlSaad SZ, AlHadlaq AK, Almasari SM, Alsuwayt SS, Alomari NA. Factors affecting self-management of hypertensive patients attending family medicine clinics in Riyadh, Saudi Arabia. J Family Med Prim Care 2019;8:4003-9
|How to cite this URL:|
AlHadlaq RK, Swarelzahab MM, AlSaad SZ, AlHadlaq AK, Almasari SM, Alsuwayt SS, Alomari NA. Factors affecting self-management of hypertensive patients attending family medicine clinics in Riyadh, Saudi Arabia. J Family Med Prim Care [serial online] 2019 [cited 2020 Jan 17];8:4003-9. Available from: http://www.jfmpc.com/text.asp?2019/8/12/4003/272490
| Introduction|| |
Hypertension (HBP) is a chronic disease that has become a public health problem, which has been attributed to numerous risk factors, such as population growth, aging, and behavioral factors including poor nutrition, drinking alcohol, physical inactivity, overweight, and being exposed to ongoing stress. In 2008, worldwide, approximately 40% of adults aged 25 and above had been diagnosed with HBP, the number of people with the condition rose from 600 million in 1980 to 1 billion in 2008. It is a risk factor for heart disease, stroke, kidney failure, early death, and disability which burdens the patients, their families, and the society.,, It is responsible for at least 45% of deaths due to heart disease, 51% of deaths due to stroke, and accounts for 9.4 million deaths worldwide every year. Extensive research has shown that HPB is poorly controlled, and that treatment is a question of preventive behavior and risk-factor management. The World Health Organization (WHO) recommends the involvement of patients through their own self-management surveillance with cessation of smoking, weight management, low-sodium and low-fat diet, physical activity, regular doctor visits, and stress reduction to better control HPB.,,,,
The use of self-care management strategies is key to adequate blood pressure control and the reduction of cardiovascular events. Studies have shown that problems with these self-management behaviors are important elements in explaining the episodes of stroke and early death from HBP. Despite numerous published HBP management and behavioral treatment guidelines, less than 40% of Americans with HBP have adequate blood pressure control., HBP is poorly controlled among patients due to insufficient care, which could be attributed to many different barriers which are multifactorial.,,
The rate of adherence to medication, regular blood pressure monitoring, and physical exercise needs improvement especially for young male patients with shorter history of HPB since their results showed lower self-care behaviors. Studies have shown that healthcare providers' actions improve patients' adherence in terms of diet, medication intake, weight management, and physical activity, of which some were affected by age, gender, socioeconomic status, BP monitoring device, and duration of HBP diagnosis. Another study showed that patients with HBP and their family members perceived barriers (including competing health priorities, lack of knowledge about HBP, and poor access to community resources) to HPB self-management.
A study conducted in Saudi Arabia revealed that hypertensive patients received insufficient care, which to patient compliance with appointment, coordination with hospitals, lack of diagnostic facilities, and weak documentation. Another study showed that the overall prevalence of HPB among Saudis was 25.5%, of which only 37.0% were controlled. This translates to the fact that HBP is still poorly controlled among a significant percentage of Saudi patients due to insufficient self-care, which could be attributed to many different barriers.
To better understand the various factors that affect HBP control and self-management behaviors for medical practitioners and health experts to control high blood pressure and also allow policy makers to better support these patients, we identify the prevalence of self-management behaviors and to explore factors affecting self-management behaviors for controlling HPB among hypertensive patients.
| Methods|| |
We conducted a survey among diagnosed HBP patients attending the Family Medicine clinics of King Saud Medical City in Riyadh, Saudi Arabia in January 2019. All patients of Saudi nationality aged 18 years and above were included in the study. Patients less than 18 years old, recently diagnosed hypertensive (less than 1 year), pregnant, and non-Saudi patients were excluded from the list.
There were approximately 365 HBP patients who were actively following up at the clinics for the study duration. Sample size was calculated based on the target population of 365, 5% confidence interval, 95% confidence level, and 80% power. The calculated sample size was 187 patients. Quota sampling technique was used to enroll participants to the study after securing formal consent.
We used two validated questionnaires in our survey; the Hypertension Self-Care Profile (HBP-SCP) which is a practical tool to measure HBP self-care which includes three scales: Behavior, Motivation and Self-Efficacy, and the Hill-Bone Adherence Scale. The item-total correlations and the internal consistency for the three scales for HBP-SCP and the Hill-Bone Adherence Scales were taken.
The questionnaires were distributed by trained family medicine residents and nurses. Sociodemographic characteristics, HPB-related information, and self-care behaviors to identify the factors affecting HBP self-management was also collected using some questions from another validated questionnaire by Hu et al. in 2013. Patients' anthropometric measurements were taken and recorded as height (measured to the nearest 0.5 cm), weight (measured to the nearest 0.1 kg), and blood pressure (measured in a sitting position after at least 5 minutes of rest). Body mass index (BMI) was calculated using the formula (weight (kg)/height (m)2). Calculated BMI (kg/m 2) was categorized as underweight (<18.5), normal weight (18.5 to 24.9), overweight (25 ≥to 29.9), and obese (BMI ≥30).
Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0 (SPSS Inc., Armonk, New York, USA). Results are expressed as numbers and percentages for categorical variables and mean and standard deviation for continuous variables. Chi-square test was performed to find out the significant association between categorical variables. Independent sample t-test/ANOVA was used to analyze any association between continuous variables (association between self-management and age, gender, duration of HPB, self-rated health status, marital status, education level, comorbidities, BMI, etc.). P values were considered to be statistically significant when P is ≤ 0.05. Ethical approval was obtained and granted by the Institutional Review Board of King Saud Medical City Research Center in Riyadh, Saudi Arabia. IRB Approval Obtained on 21-01-2019.
| Results|| |
A total of 187 patients responded to the survey. There were 95 (50.8%) males and 92 (49.2%) females. [Table 1] shows the demographic profile of the respondents. There were 93 patients (49.7%) who monitor their BP at home, 43 (23.0%) at primary care centers, and 51 (27.3%) at the hospital. Sixty-eight patients (36.4%) always measure their BP, 81 (43.3%) sometimes, and 38 (20.3%) rarely monitor their BP. Ninety-one patients (48.7%) said that measuring their BP is not important, 93 (49.7%) don't know how to use the BP monitor, and 3 (1.6%) patients said that financial problem is the reason why they do not measure their BP. Of the 93 patients who monitor their BP at home, 45 (48.4%) said they follow their doctor's advice, 14 (15.1%) said because of what they feel, and 34 (36.6%) because they wanted to record their BP.
[Table 2] shows the patients' responses to questions using the Hill-Bone Blood Pressure Compliance Scale. The most common reason for not taking the anti-HBP medications is they forget to take the meds in 87 (46.5%) of patients, followed by difficult to obtain a refill prescription in 27 (14.4%), fear of side effects in 16 (8.6%) patients, do not believe in western medication in 14 (7.5%) patients, and distance to the hospital or center in 4 (2.1%). Table salt intake restriction is by taste in 55 patients (29.4%), by salt spoon in 33 patients (17.6%) and visual in 32 patients (17.1%). Patients restrict salt intake because of doctor's advice (n = 70, 37.4%), for own health in 25 (13.4%) patients and family (n = 25, 13.4%). Sixty-five patients (34.8%) said that their BP feels better with salt restriction, whereas 38 (20.3%) felt no change in what they feel. Seventy-two patients did not restrict salt intake, 25 patients (13.4%) like high-salt diet, 20 (10.7%) were not motivated to restrict salt intake, 14 (7.5%) said that it is not important to restrict salt intake, and 13 (7.0%) do not know why they have to restrict salt intake. As to regular physical activity, 51 patients (27.3%) had no time for exercise, 37 (19.8%) were not motivated to exercise, 18 (9.6%) have health-related issue/s that restrict them to exercise, and 51 (27.3%) thought that exercise has to be in proper places.
[Table 3] shows the patients' responses to questions on the HBP-SCP Behavior Scale. Relatively fewer percentage of patients practice good behavior (always or frequently practice) particularly taking part in regular physical activity (12.8%), read nutrition facts (25.1%), replacing traditional high-salt foods (35.8%), eating less salty and fatty foods, limiting calorie intake, eating more fruits and vegetables, and losing weight. However, 71 patients (37.9%) check their BP at home, 122 (65.2%) does not smoke, and 159 (85.0%) see their doctor regularly.
|Table 3: Responses to questions on the Hypertension Self-Care Profile (HBP-SCP) Behavior Scale|
Click here to view
[Table 4] shows the patients' responses to questions on the HBP-SCP Motivation Scale. There were a larger percentage patients who were rarely and never motivated to regularly exercise (96, 51.3%), read nutrition facts on labels (83, 44.3%), eat less than 1 teaspoon of table salt per day (98, 52.4%), check BP at home (94, 50.3%), and practice self-relieving exercises (99, 52.9%). On the other hand, a larger number of patients feel always and frequently motivated to limit use of high-salt condiments (106, 56.7%), use broil, bake or steam instead of frying (114, 60.9%), practice nonsmoking (126, 67.4%), avoid stress (98, 52.4%), and see their doctor regularly (159, 85.0%).
|Table 4: Responses to questions on the Hypertension Self-Care Profile (HBP-SCP) Motivation Scale|
Click here to view
[Table 5] shows the patients' responses to questions on the HBP-SCP Self-Efficacy Scale. A larger percentage of patients rarely and never was confident to take part in regular physical exercise (100, 53.5%), to eat less than 1 teaspoon of table salt per day (98, 52.4%), checking blood pressure at home (98, 52.4%), and practice stress-relieving exercises (99, 52.9%). On the other hand, there were a larger number of patients who were always and frequently confident to limit use of high-salt condiments (102, 54.5%), broil, bake or steam instead of fry (114, 61.0%), practice nonsmoking (122, 65.2%), stay away from anything stressful (98, 52.4%), and see their doctor regularly (159, 85.0%).
|Table 5: Responses to questions on the Hypertension Self-Care Profile (HBP-SCP) Self-Efficacy Scale|
Click here to view
There were significant correlations between behavior and gender (P < 0.001), BMI (P < 0.001), age (P < 0.001), status (P < 0.001), duration of HBP (P = 0.022), presence of cardiac disease (P < 0.001), and dyslipidemia (P = 0.011). Motivation was significantly correlated with gender (P = 0.003), BMI (P < 0.001), age (P < 0.001), status (P < 0.001), duration of HBP (P = 0.005), smoking (P < 0.001), and presence of cardiac disease (P < 0.001). Self-efficacy was significantly correlated with gender (P < 0.001), BMI (P < 0.001), age (P < 0.001), status (P < 0.001), duration of HBP (P = 0.008), smoking (P < 0.001), presence of cardiac disease (P < 0.001), and dyslipidemia (P = 0.023). Compliance was significantly correlated to age (P = 0.003), occupation (P = 0.002), duration of HBP (P < 0.001), the number of anti-HBP medications (P < 0.001), and stroke (P = 0.017).
Multivariate regression analysis showed that female patients, patients with lower BMI, patients who are married, and patients without cardiac disease tend to have a good behavior toward HBP control (P = 0.033, P < 0.001, P = 0.031 and P = 0.024 respectively). Patients who have low BMI, nonsmokers, and patients without cardiac disease tend to be more motivated to control HBP (P < 0.001, P < 0.001 and P < 0.001, respectively). On the other hand, female patients, patients who are married, patients with low BMI, and patients who are nonsmokers tend to have better confidence toward self-care. Compliance tend to be significantly better among patients on multiple anti-HBP medications (P = 0.002) and patients who had stroke (P = 0.033).
The Cronbach's alpha for the HBP-SCP behavior scale was 0.902, for HBP-SCP Motivation scale was 0.906, for HBP-SCP Self-Efficacy Scale was 0.898, and for the Hill-Bone Scale was 0.70.
| Discussion|| |
This study showed that among HBP patients, less than half of the patients practice BP self-monitoring. In fact, almost half of the patients said the measuring BP is not that important. This is very crucial to the effective control of HBP, since self-measurement of BP leads to less medication use and more effective control of HBP, as shown by previous studies. Furthermore, patient reported BP monitoring leads to adjustment of anti-HBP treatment, and is more economical, absence of white-coat syndrome, and increases compliance of the patient to HBP management. To further this, “patients' management based on home BP measurement leads to better control of ambulatory BP than with the usual care” as suggested by Parati et al. in 2009.
The problem seemed to be compounding since not only patients do not monitor their BP at home, there are other reasons why do not measure their BP, from nonimportance, to unfamiliarity on use of a BP monitor, to financial problems. The reasons for these “reasons” are not clear. But, taking into account the feasibility of home BP monitoring and its great contribution to the well-being of the patient, these can be easily addressed by information-dissemination and education of patients not only in tertiary care centers but also in primary care centers.
Based on the Hill-Bone Blood Pressure Compliance Scale, many of our patients were noncompliant to medication either forgetting to take their medicine or other reasons including difficulty in obtaining a refill and fear of side effects. And compliance was related to age, occupation, duration of HBP, number of anti-HBP medications, and stroke. It was suggested that elderly patients have a higher compliance rate to medication and that compliance increases with increasing age., Older patients may become noncompliant to treatment because of difficulty to understand instructions or having physical problems like swallowing of the tablets. On the other hand, middle-aged and younger patients tend to be noncompliant because they might have other priorities in their daily life, work, and other commitments and may not give much priority spending or going to the clinic to monitor their disease. What was surprising in this study is that gender was not related to compliance in contrast to other previous studies. In contrast to this, there were studies have shown that female patients were found to have better compliance to medication compared to male patients.,
The HBP-SCP scales showed that a lot of our patients practice good behavior, were less motivated, and less confident to take part in measures to control HBP. In fact, only 1 or 2 patients regularly exercise and 3 to 4 patients watch what they eat particularly in the control of salty and oily foods, and women have a better behavior compared to men. This finding is similar to a study conducted among Koreans where women were more likely to have controlled BP since they cut down more on salt, exercise more, and take their medicines regularly. Poor behavior toward treatment leads to poor motivation, and this is what happened in most of our participants. Patients' lack of motivation to hypertensive therapy and follow-up were attributed to difficulties to accept being hypertensive and undergo a life-long treatment, a careless attitude and the feeling of “hopelessness”, and these are very common among hypertensive patients visiting the primary healthcare clinics. Others may have felt frustrated with life-long treatment and this could have also affected their motivation and behavior toward HBP therapy, particularly among patients who have been diagnosed with HBP for a longer duration. In one study, higher self-efficacy was helpful in smoking reduction and increasing physical activity, but the problem of low-salt diet remains an issue. Again, factors including being “too busy” and the “love” for high-sodium diets also remained a problem.
Another highlight of this study is that female patients, patients who are married, patients with low BMI, and patients who are nonsmokers tend to have better self-efficacy. Patients with good self-efficacy have increased prevalence of adherence to medication, salt restriction, nonsmoking, exercising, and weight management. Again, the cycle of good behavior, proper motivation, and good practice of self-care are all interrelated and each one will not work without the other. This suggests that self-care alone may be insufficient to overcome the salient barriers to address the issue of increasing morbidity and mortality brought about by HBP.
Several implications relevant to the practice of primary care and family medicine can be drawn from this paper such as: 1. Primary care physicians with the participation of the community should take initiatives to effectively achieve target BP control of patients and the population as a whole, as described by Hadate et al. (2019). 2. There is a need for primary care physicians and health educators to educate and promote patients' self-monitoring of blood pressure control, and educate patients on the importance of HBP monitoring. This has been shown to greatly impact the patients' knowledge and skills in self-monitoring of BP, and thus lead to better control of HBP. 3. There is a need for family and primary care physicians to address factors related to poor behavior and poor motivation of patients with HBP to actively participate in the control of BP. This aspects (patients' behavior and motivation) were less addressed by primary care physicians, but should be included in the treatment protocols as soon as HPB is diagnosed, and 4. There is also a need for primary care physicians to urge patients to have a lifestyle modification and proper nutrition that will aid the patients in the control of their HBP.
| Conclusion|| |
Compliance, behavior, motivation, and self-care among hypertensive patients visiting the primary care clinics in our representative population are low. Various factors were found to be related to poor behavior, poor motivation, and less confidence to do home BP monitoring, to exercise more, restrict salt intake, and value the control of HBP. There is a need for health practitioners to assess self-care activities and blood pressure control, and educate patients the importance of HBP monitoring and teaching practical techniques to boost their confidence and motivation to achieve a better behavior, self-care, and compliance to management.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Motlagh SFZ, Chaman R, Sadeghi E, Eslami AA. Self-care behaviors and related factors in hypertensive patients. Iran Red Crescent Med J 2016;18:e35805.
World Health Organization. A global brief on hypertension: Silent killer, global public health crisis: World Health Day 2013 (No. WHO/DCO/WHD/2013.2). World Health Organization. 2013.
Koh YLE, Lua YHA, Hong L, Bong HSS, Yeo LSJ, Tsang LPM, et al
. Using a web-based approach to assess test–retest reliability of the “hypertension selfcare profile” tool in an Asian population: A validation study. Medicine (Baltimore) 2016;95:e2955.
Han HR, Lee H, Commodore-Mensah Y, Kim M. Development and validation of the hypertension self-care profile: A practical tool to measure hypertension self-care. Eur J Cardiovasc Nurs 2014;29:E11.
Hallberg I, Ranerup A, Kjellgren K. Supporting the self-management of hypertension: Patients' experiences of using a mobile phone-based system. J Hum Hypertens 2016;30:141.
Bosworth HB, Olsen MK, Grubber JM, Neary AM, Orr MM, Powers BJ, et al
. Two self-management interventions to improve hypertension control: A randomized trial. Ann Intern Med 2009;151:687-95.
Flynn SJ, Ameling JM, Hill-Briggs F, Wolff JL, Bone LR, Levine DM, et al
. Facilitators and barriers to hypertension self-management in urban African Americans: Perspectives of patients and family members. Patient Prefer Adherence 2013;7:741.
Abel WM, Joyner JS, Cornelius JB, Greer DB. Self-care management strategies used by black women who self-report consistent adherence to antihypertensive medication. Patient Prefer Adherence 2017;11:1401-12.
Al-Saleem SA, Al-Shahrani A, Al-Khaldi YM. Hypertension care in Aseer region, Saudi Arabia: Barriers and solutions. Saudi J Kidney Dis Transpl 2014;25:1328.
] [Full text]
Hu H, Li G, Arao T. Prevalence rates of self-care behaviors and related factors in a rural hypertension population: A questionnaire survey. Int J Hypertens 2013; 2013:526949.
Saeed AA, Al-Hamdan NA, Bahnassy AA, Abdalla AM, Abbas MA, Abuzaid LZ. Prevalence, awareness, treatment, and control of hypertension among Saudi adult population: A national survey. Int J Hypertens 2011.;2011:174135.
Han HR, Lee H, Commodore-Mensah Y, Kim M. Development and validation of the hypertension self-care profile: A practical tool to measure hypertension self-care. J Cardiovasc Nurs 2014:29:E11-20.
Kim MT, Hill MN. Bone LR, Levine DM. Development and testing of the hill-bone compliance to high blood pressure therapy scale. Prog Cardiovasc Nurs 2000;15:90-6.
Warren-Findlow J, Seymour RB. Prevalence rates of hypertension self-care activities among African Americans. J Natl Med Assoc 2011;103:503-12.
World Health Organization. Obesity: Preventing and managing the global epidemic (No. 894). World Health Organization. 2000.
Verberk WJ, Kroon AA, Lenders JW, Kessels AG, van Montfrans GA, Smit AJ, et al
. Self-measurement of blood pressure at home reduces the need for antihypertensive drugs: A randomized, controlled trial. Hypertension 2007;50:1019-25.
Staessen JA, Den Hond E, Celis H, Fagard R, Keary L, Vandenhoven G, et al
. Treatment of hypertension based on home or office blood pressure (THOP) trial investigators. Antihypertensive treatment based on blood pressure measurement at home or in the physician's office: A randomized controlled trial. JAMA 2004;291:955-64.
Parati G, Omboni S, Albini F, Piantoni L, Giuliano A, Revera M, et al
. TeleBPCare Study Group. Home blood pressure telemonitoring improves hypertension control in general practice. The TeleBPCare study. J Hypertens 2009;27:198-203.
Caspard H, Chan AK, Walker AM. Compliance with a statin treatment in a usual-care setting: Retrospective database analysis over 3 years after treatment initiation in health maintenance organization enrollees with dyslipidemia. Clin Ther 2005;27:1639-46.
Lacasse Y, Archibald H, Ernst P, Boulet LP. Patterns and determinants of compliance with inhaled steroids in adults with asthma. Can Respir J 2005;12:211-7.
Cooper C, Carpenter I, Katona C, Schroll M, Wagner C, Fialova D, et al
. The AdHOC study of older adults' adherence to medication in 11 countries. Am J Geriatr Psychiatry 2005;13:1067-76.
Iihara N, Tsukamoto T, Morita S, Miyoshi C, Takabatake K, Kurosaki Y. Beliefs of chronically ill Japanese patients that lead to intentional non-adherence to medication. J Clin Pharm Ther 2004;29:417-24.
Choi-Kwon S, Kwon SU, Kim JS. Compliance with risk factor modification: Early-onset versus late-onset stroke patients. Eur Neurol 2005;54:204-11.
Fodor GJ, Kotrec M, Bacskai K, Dorner T, Lietava J, Sonkodi S, et al
. Is interview a reliable method to verify the compliance with antihypertensive therapy? An international central-European study. J Hypertens 2005;23:1261-6.
Han HR, Kim KB, Kang J, Jeong S, Kim EY, Kim MT. Knowledge, beliefs, and behaviors about hypertension control among middle-aged Korean Americans with hypertension. J Community Health 2007;32:324-42.
Jokisalo E, Kumpusalo E, Enlund H, Takala J. Patients' perceived problems with hypertension and attitudes towards medical treatment. J Hum Hypertens 2001;15:755.
Lahdenperä TS, Kyngäs HA. Levels of compliance shown by hypertensive patients and their attitude toward their illness. J Adv Nurs 2001;34:189-95.
Mansyur CL, Pavlik VN, Hyman DJ, Taylor WC, Goodrick GK. Self-efficacy and barriers to multiple behavior change in low-income African Americans with hypertension. J Behav Med 2013;36:75-85.
Hadaye R, Kale V, Manapurath RM. Strategic implications of changing rule of halves inhypertension: A cross-sectional observational study. J Family Med Prim Care 209;8:1049-53.
Dymek J, Golda A, Polak W, Lisowski B, Skowron A. Effect of education for hypertensive patients with correctly performed self-blood pressure monitoring (SBPM). Pharmacy (Basel) 2019;7:.pii. E75.
Frieden TR, Varghese CV, Kishore SP, Campbell NRC, Moran AE, Padwal R, et al
. Scaling up effective treatment of hypertension – A pathfinder for universal health coverage. J Clin Hypertens 2019. doi: 10.1111/jch. 13655. [Epub ahead of print]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]