Post on 11-Jun-2020
FACTORS RELATED TO HEALTH PROMOTING BEHAVIORS AMONG
HYPERTENSIVE PATIENTS IN BHUTAN
HEM KUMAR NEPAL
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE MASTER DEGREE OF NURSING SCIENCE
(INTERNATIONAL PROGRAM)
FACULTY OF NURSING
BURAPHA UNIVERSITY
JULY 2015
COPYRIGHT OF BURAPHA UNIVERSITY
ACKNOWLEDGEMENT
I would like to express my sincere gratitude and deep appreciation to my
major advisor Assistant Professor Dr.Wanlapa Kunsongkeit and co-advisor
Dr. Khemaradee Masingboon for their continued guidance, support, encouragement,
and their time and effort during the entire period of this study. Without their help,
I would not have accomplished my goal.
I would like to send my great appreciation and heartfelt thanks to Thailand
International Development Cooperation Agency (TICA) and the Royal Government
of Bhutan for awarding me this scholarship to study Master of Nursing Science in
Burapha University. I would like to express my gratitude to the Dean, Faculty of
Nursing, Burapha University, and the Chairperson of Master of Nursing Science
(International Program) for giving me an opportunity to study Master of Nursing
Science Program in Burapha University. I am also thankful to all my lectures and
staff of Faculty of Nursing for rendering all possible support and assistance during my
study in Burapha University. I would like to express my gratitude to the experts, who
were involved in validating the research instrument, without their time and effort
I would not have completed my study.
I would like to express my gratitude to the Medical Director, Nursing
Superintendent, and nurses working in the Outpatient Department, Jigme Dorji
Wangchuck National Referral Hospital for rendering all possible help during my data
collection. Similarly, I would like to thank all the participants who participated in this
study. Gratitude remains in my heart for my parents, relatives and friends who have
always supported, encouraged and believed in me. Appreciation is especially
extended to my wife and two daughters for their patience and understanding for
the times I could not be with them. I am deeply sorry for the time we were apart.
Finally, I would like to extend my appreciations to all those who were
involved in accomplishing this project.
Hem Kumar Nepal
iv
56910102: MAJOR: NURSING SCIENCE, M. N. S.
KEY WORDS: PERCEIVED SELF-EFFICACY/ PERCEIVED
BENEFITS/ PERCEIVED BARRIERS/ PERCEIVED SOCIAL
SUPPORT/ HEALTH PROMOTING BEHAVIORS
HEM KUMAR NEPAL: FACTORS RELATED TO HEALTH
PROMOTING BEHAVIORS AMONG HYPERTENSIVE PATIENTS IN BHUTAN.
ADVISORY COMMITTEE: WANLAPA KUNSONGKEIT, Ph.D., KHEMARADEE
MASINGBOON, D.S.N. 96 P. 2015.
This descriptive correlational study aimed to describe health promoting
behaviors and to examine relationships among perceived self-efficacy, perceived
benefits, perceived barriers, perceived social support, and health promoting behaviors
in Bhutanese patients with hypertension. Conceptual framework of this study was
based on had Pender’s health promotion model. Simple random sampling technique
was used to recruit 123 primary hypertension patients visiting Jigme Dorji
Wangchuck National Referral Hospital, Thimphu, Bhutan. Data were collected by
self-report questionnaires. Which included demographic questionnaires, Health
Promoting Behaviors Questionnaires, Self-Rated Abilities for Health Practice Scale,
Benefits Assessment Scale, Barriers to Health Promoting Activities Scale, and Personal
Resource Questionnaire. Data were analyzed by descriptive statistics and Pearson’s
product moment correlation.
Findings revealed that participants had high level of health promoting
behaviors (M = 81.07, SD = 11.85). Health promotion behaviors had a high positive
correlation with perceived self-efficacy (r = .55, p < .01), had low positive correlation
with perceived benefits (r = .26, p < .01) and perceived social support (r = .27, p <
.05), and had moderate negative correlation with perceived barriers (r = -.47, p < .01).
From the results, health promotion behaviors could be enhanced by findings
of the study suggested that nurse can design nursing intervention to promote health
behaviors of hypertensive patients by focusing on strengthening self-efficacy and
decreasing perceived barriers.
CONTENTS
Page
ABSTRACT ............................................................................................................ iv
CONTENTS ............................................................................................................ v
LIST OF TABLES .................................................................................................. vii
LIST OF FIGURES ................................................................................................ viii
CHAPTERS
1 INTRODUCTION ...................................................................................... 1
Background and significance ................................................................ 1
Objectives of the study.......................................................................... 8
Research hypotheses ............................................................................. 9
Scope of the study ................................................................................. 9
Conceptual framework .......................................................................... 9
Definition of terms ................................................................................ 11
2 LITERATURE REVIEW ........................................................................... 13
Overview of hypertension ..................................................................... 13
The health promotion model ................................................................. 28
Factors related to health promotion behaviors of patients with
hypertension .......................................................................................... 30
Health promoting behaviors of Bhutanese patients with hypertension 33
3 RESEARCH METHODOLOGY ................................................................ 36
Research design .................................................................................... 36
Research setting .................................................................................... 36
Population and sample .......................................................................... 37
Research instruments ............................................................................ 38
Quality of instruments........................................................................... 40
Protection of human subjects ................................................................ 41
Data collection procedure ..................................................................... 42
Data analysis ......................................................................................... 43
vii
CONTENTS (CONTINUED)
CHAPTER Page
4 RESULTS ..................................................................................................... 44
Part 1 Description of demographic characteristics and medical
information of the participants .............................................................. 44
Part 2 Description of perceived self-efficacy, perceived benefits,
perceived barriers and perceived social support ................................... 48
Part 3 Description of health promoting behaviors of the participants .. 48
Part 4 Relationships between perceived self-efficacy, perceived
benefits, perceived barriers, perceived social support and health
promoting behaviors ............................................................................. 50
5 CONCLUSION AND DISCUSSION .......................................................... 51
Summary of the study ........................................................................... 51
Results of the study ............................................................................... 52
Discussion ............................................................................................. 53
Implications........................................................................................... 59
Recommendations for future research .................................................. 60
Conclusion ............................................................................................ 60
REFERENCES ....................................................................................................... 61
APPENDICES ........................................................................................................ 70
APPENDIX A ................................................................................................... 71
APPENDIX B ................................................................................................... 83
APPENDIX C ................................................................................................... 87
APPENDIX D ................................................................................................... 90
APPENDIX E ................................................................................................... 92
BIOGRAPHY ......................................................................................................... 96
viii
LIST OF TABLES
Tables Page
1 Frequency, percentage, mean, standard deviation of demographic
characteristics of the participants ............................................................... 45
2 Frequency, percentage, mean, standard deviation of medical information
of the participants ....................................................................................... 46
3 Mean, standard deviation, range of perceived self-efficacy, perceived
benefits, perceived barriers, and perceived social support ........................ 48
4 Mean, standard deviation, range of health promoting behaviors ............... 49
5 Pearson’s product moment correlation coefficient between health
promoting behaviors and related factors .................................................... 50
viiii
LIST OF FIGURES
Figures Page
1 Research framework of the study ............................................................... 11
2 Health promotion model ............................................................................. 29
CHAPTER 1
INTRODUCTION
Background and significance
Hypertension, also known as high or raised blood pressure, is a preventable
chronic disease affecting millions of people worldwide. Due to its increased
prevalence, morbidity, and mortality, hypertension is a global health problem.
According to World Health Organization [WHO] (2013), approximately 40 % of
adults aged 25 years and above were diagnosed with hypertension in 2008.
The number of people with hypertension has increased from 600 million in 1980 to
one billion in 2008, and it is projected to increase to 1.56 billion by 2025
(WHO, 2013). Bhutan, a country in South East Asia, with approximate population of
0.7 million people, is experiencing the double burden of communicable and
non-communicable diseases. Among the non-communicable diseases, hypertension is
the most important cause of an increasing number of strokes, heart attack and chronic
kidney diseases in Bhutanese adults (Wangdi, 2013). National Health Survey [NHS]
(2012) reported a 16 % prevalence of hypertension in Bhutan and the incidence of
hypertension has increased to 375/ 10,000 population in 2012 comparing to
303/ 10,000 population in the year 2008 (Annual Health Report, 2013).
Hypertension is defined as a Systolic Blood Pressure (SBP) more than
140 mmHg or a Diastolic Blood Pressure (DBP) more than 90 mmHg (WHO, 2013).
The major problem of hypertensive patients is inability to control their blood pressure
leading to devastating consequences. Hypertension that is not kept under control leads
to several complications like; stroke, myocardial infarction, hypertensive retinopathy,
hypertensive nephropathy and paralysis (American Heart Association [AHA], 2013;
Velagaleti & Vansan, 2007). Globally, cardiovascular disease accounts for
approximately 17 million deaths a year of which, complications of hypertension
account for 9.4 million deaths worldwide every year (WHO, 2013). Hypertension is
responsible for at least 45 % of deaths due to heart disease and 51 % of deaths due to
stroke (WHO, 2013). Beside, hypertension is responsible for increased number of
renal failure and other complications in patients. The prevalence of hypertension is
2
high in low and middle income countries, as a result many people are exposed to
dangerous complications of hypertension (Pereira, Lunet, Azevedo, & Barros, 2009;
Whitworth, 2003). The impact of hypertension leads to premature death, disability,
personal and family disruption, loss of income, and increased healthcare expenditure.
Further, families face catastrophic health expenditure and often push tens of millions
of people into poverty (World Health Organization [WHO], 2011).
Bhutan NHS (2012) reported 16 % prevalence of hypertension among adults
in Bhutan. Similarly, the non-communicable disease survey reported 26 % prevalence
of hypertension in the capital city Thimphu, Bhutan (Cowan, Dorji, & Pelzom, 2009).
Hypertension is responsible for a large number of strokes, heart attacks and chronic
kidney diseases. In 2014, the National Referral Hospital treated 105 cases with
complication of hypertension. The data from the National Referral Hospital shows an
overwhelming number of strokes and acute myocardial infarction with 89 patients
diagnosed with stroke and 12 patients with acute myocardial infarction in the year
2012 (Wangdi, 2013). Cardiovascular and cerebrovascular diseases account for
14.9 % of total morbidity and non-communicable diseases account for 50 % of
inpatient mortality (Giri, Sharma, Chapagai, & Pelzom, 2013). It shows that the risk
of complications among hypertensive population is increasing.
Hypertension is a chronic condition and cannot be control by medications
alone. According to Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure [JNC 7] (2003), the gold standard of treatment
for hypertension includes medication and life style modification, which are integral
part of treatment recommended by the physicians to prevent complications and in
enhancing quality of life. Lifestyle modifications are healthy activities that can
enhance ones quality of life and aid in the prevention of cardiovascular disease.
Effective lifestyle modifications are the most important part of management of
chronic disease including hypertension (WHO, 2013). Practicing healthy behaviors
and avoiding harmful habits promotes one’s health and wellbeing.
Health promoting behaviors, defined as self-initiated and enduring actions,
based on an active approach, that serve to maintain or enhance the level of personal
wellness (Walker, Sechrist, & Pender, 1987). Health promoting behaviors are integral
part of treatment for patients with hypertension and must be integrated as a regular
3
part of patient’s daily living (WHO, 2011). In terms of hypertension, health
promoting behaviors include; taking medication, physical activity, nutrition, stress
management, limiting alcohol consumption, weight management, and smoking
cessation (JNC 7, 2003; Lee et al., 2010). Engagement in health promoting behavior
is considered useful strategies to enhance functional capacity, prevent complications,
improve social networks and enhance quality of life (Pender, Murdaugh, & Parsons,
2006). Several studies have demonstrated positive effects of healthy behaviors on
hypertension control and in improving health of individuals with hypertension
(Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure [JNC 8], 2014). Research on the effects of diet and nutrition on
health, has demonstrated that by maintaining a diet with more fruits and vegetables,
low in sodium, and low in fat is effective in controlling blood pressure and preventing
cardiovascular disease (Appels et al., 2006; Huang, Duggan, & Harman, 2008).
Dietary approaches to stop hypertension (DASH) diet is effective in lowering on an
average 11 mmHg systolic blood pressure and 5.5 mmHg diastolic blood pressure in
hypertensive patients (Appel et al., 1997; Appel et al., 2006). Similarly, reducing
dietary intake of sodium to 2.4 grams per day can lower systolic blood pressure by
4-5 mmHg in hypertensive individuals and 2 mmHg in normotensive individuals
(Huang et al., 2008).
The impact of physical activity is associated with improving health in people
of all ages. Regular physical activity has many health benefits including decreasing
the risk of cardiovascular diseases, obesity, and diabetes. According to research and
recommendation from the Centers for Disease Control and Prevention [CDC] (2011),
it is suggested that people with hypertension perform moderately intense exercise
30 minutes a day, most days of the week. Research has shown that 30 minutes of
exercise a day can lower systolic blood pressure by 4-9 mmHg (Chobanian et al.,
2003). For those who drink alcohol, reduction in drinking can reduce systolic blood
pressure by 4 mmHg and diastolic blood pressure by 2.5 mmHg (Centers for Disease
Control and prevention, National Institute of Health, 2000; Chobanian et al., 2003).
Research has proven that all types of tobacco have negative effects on the body.
Smoking increases the risk of cardiovascular diseases, and is damaging to one’s
health. Similarly, research has shown that, weight reduction of 5-10 kg and
4
maintaining a normal Body Mass Index (BMI) under 25 can decrease systolic blood
pressure by 5-20 mmHg (American Heart Association, 2005; Chobanian et al., 2003).
Furthermore, taking regular medications and appropriate stress management helps
individual to control blood pressure (Sharma, Kulkarni, Mishra, & Srivastava., 2013).
Although health promoting behaviors are widely accepted to benefit
individuals with hypertension, the practice is limited in people with hypertension
(Lee et al., 2010; Viera, Kshirsagar, & Hinderliter, 2008; Warren-Findlow, Seymour,
& Huber, 2012). Studies suggested that long-term reduction of 5-6 mmHg in blood
pressure is associated with 35-40 % fewer strokes and 20-25 % less coronary heart
diseases (Collins et al., 1990). The JNC 7 report showed that a decrease of systolic
blood pressure by 5 mmHg would result in a 14 % reduction in mortality due to
stroke, 9 % reduction in mortality due to coronary heart diseases, and a 7 %
decrease in all-cause mortality (Chobanian et al., 2003). However, despite known
benefits, many people do not comply with suggested recommendations and often fails
to improve their behavior, to control their blood pressure (Chobanian et al., 2003).
A study by Warren-Findlow et al. (2012), found only 52.2 % of people with
hypertension adhered to prescribed physical activities recommendation. Practices
related to weight management was less frequent, (30.1 %) and adherence to low-salt
diet recommendations was also low (22.0 %). In Bhutan, according to the report on
Survey for Risk Factors and Prevalence of Non-communicable Diseases in Thimphu,
two third of the population (66.6 %) were not eating enough fruits and vegetables, and
58.6 % do not attain a minimum requirement of health enhancing physical activities
(Cowan et al., 2009). Thus, one of the most important roles for nurses is to help
individuals with hypertension to improve their health promoting behaviors and
improve quality of life.
Health promoting behaviors are one of the integral parts of therapy to
control hypertension and prevent complications (Chobanian et al., 2003). In order to
help patients improve their ability to control blood pressure, nurses need to
understand the theory and the associated factors related to health promoting
behaviors. The health promotion model (Pender, Murdaugh, & Parsons, 2011), has
been used as a framework for research aimed at examining health-promoting lifestyle
behaviors. Within health promotion model, health promoting behavior is
5
an expression of the human tendency to actualize and is directed at elevating
the individual’s level of well-being, enhancing self-actualization, and maximizing
personal fulfillment (Pender et al., 2006). There are three major concepts in Pender’s
health promotion model. The major concepts are individual characteristics and
experiences, behavior-specific cognitions and affect, and behavioral outcome.
According to Pender et al. (2011), the model proposed that performing health
behaviors can be achieved through the direct and indirect effects of factors. Perceived
self-efficacy is the judgment of personal capability to organize and execute
a particular health behavior; perceived benefits of action are the positive perception of
individual to undertake or reinforce a health behavior; perceived barriers to action are
perceptions of blocks, hurdles, personal costs of undertaking a specific health
behavior; interpersonal influences includes norms, social support, role models
perceptions concerning the behaviors, beliefs, or attitudes of relevant others in regard
to engaging in a specific health behavior; and health promoting behavior is identified
as the ultimate outcome of the model. Perceived self-efficacy, perceived benefits,
perceived barriers, and perceived social support, were chosen as variables for
the study based on the literature review.
Number of studies indicated that these factors affect health promotion
behaviors of hypertensive patients (Ho, Pathumarak, & Hengudomsub, 2012;
Kemppainen et al., 2011; Kwong & Kwan, 2007). However, factors studied in other
countries may not be generalized to the Bhutanese population, with diverse and
unique cultural and traditional values. In Bhutan, traditional Bhutanese dietary
behavior is more likely unhealthy including fat-rich and spicy. Rice forms the staple
diet with meat, poultry, cheese, chilies, and is often salty and spicy. People also prefer
rice with locally made pickle with added salt and butter tea locally called as suja and
is widely taken as breakfast. Further, Bhutan being a mountainous country,
geographical barrier and climatic condition may indicate some restrain in practicing
health promoting behaviors (Cowan et al., 2009). People often face difficulty in
getting recommended food items primarily due to unavailability of resources. An
extreme weather condition like cold winters and rainy summer seasons also inhibits
people from practicing health promoting behaviors. Cold winter months are usually
considered as inactive months during which people are inactive and often use alcohol
6
as a source of warmth exposing them to unhealthy behaviors. Further, Bhutan has four
seasons and finding suitable foods like fruits and vegetables is limited. Therefore, it is
necessary to understand the behavior and identify factors related to health promotion
in patients with hypertension in Bhutan.
A number of studies found that perceived self-efficacy is associated in
initiating behavior change and to develop healthy behavioral practice among patients
with hypertension. Perceived self-efficacy, the confidence of individuals in
performing a specific behavior is one of the most important factors influencing health
promotion behaviors in people with hypertension. Self-efficacy provides
the confidence to overcome barriers, whereas outcome expectations provide
the motivation for behavior (Bandura, 1997). In a study of older Chinese perceived
self-efficacy was positively related (r = .57, p < .001) to health promoting behavior
(Kwong & Kwan, 2007). Jaiyungyuen, Suwonnaroop, Priyatruk, and Moonpayak
(2008) found similar result, where self-efficacy had positive relationship (r = .59, p <
.01) with health promoting behaviors in population of Thai people with hypertension.
In study of 445 middle aged Korean Americans with hypertension, self-efficacy
contributed significantly and was the highest predictor (β = .25) of physical activity
and diet (Lee et al., 2010). Similarly, in the study of the association between
perceived self-efficacy and health behaviors of 190 African-American adults with
hypertension, the result demonstrated that people with high perceived self-efficacy
had higher prevalence of engaging in physical activities and eating low salt diet
(Warren-Findlow et al., 2012). Perceived self-efficacy has shown to be the strongest
factor associated to health promotion behaviors in hypertensive patients.
Understanding the relationship of health promoting behaviors and perceived self-
efficacy in Bhutanese patients with hypertension is not yet available. Therefore, to
understand and confirm relationship between self-efficacy and health promoting
behavior in Bhutanese population is necessary.
Perceived benefits are mental representations of positive or reinforcing
consequences of a behavior (Pender et al., 2011). Individual’s expectations to engage
in a particular behavior depend on the anticipated benefits. Perceived benefits directly
and indirectly motivate behavior through determining the extent of commitment to
a plan of action to engage in behaviors. Hypertensive patients get benefits from health
7
promoting behaviors because it reduces blood pressure and prevent complications.
In a study of 198 hypertensive patients, the result indicated that perceived benefits
significantly related (r = .27, p < .01) to health promoting behaviors (Nangyaem,
Deenan, & Chunlestskul, 2007). The benefits hypertensive patients get from health
promotion behavior are reduced blood pressure, loss weight, being healthy and
improved quality of life. Preventing complications, improving quality of life,
controlling weight, being fit and live longer are some of the benefits acquired from
health promoting behaviors.
Perceived barriers are viewed as blockages, hurdles, and personal costs to
perform a specific type of behaviors. When individuals come across difficulties, they
are confronted with doubts about their ability to perform a specific behavior (Pender,
et al., 2006). Lucas, Orshan, and Cook (2000), as cited in Kwong and Kwan (2007)
have identified several barriers such as, fear of harming oneself, lack of self-
motivation, lack of knowledge, the cost and require effort of activities, and lack of
support from family and significant others. There are wide range of barriers to health
promoting behaviors. The individual knowledge and beliefs that hypertension runs in
the family and nothing could be done are some of the common examples cited in the
literature (AHA, 2013). In several studies it was found that, the common barriers in
health promotion to control hypertension were time and budgetary constraints, lack of
motivation, and social influences (Khatib et al., 2014). The above studies show
relationship between perceived barriers and health promoting behaviors. However, in
Bhutanese context, there is still no information and study done. Thus, it is necessary
to understand and find the relationship.
Perceived social support play a very significant role in health promotion
behavior. Perceived social support acts as a protective mechanism of health promoting
behaviors. Loss of social support exposed individuals to variety of diseases and
reduce individuals ability to engage in health promoting behaviors to manage diseases
and improve health (Pender et al., 2011). Social influence is critical, as individuals
consider engaging in health promoting behaviors. Previous studies showed that
perceived social support was the determinant to enhance health promoting behaviors
among patients with hypertension. Jaiyungyuen et al. (2008) in study of older people
with hypertension found that social support was positively related to health promotion
8
behavior in hypertensive patients (r = .38, p < .01). Similar study found that social
support was significant predictor of health promotion behavior (β = .27, p < .01) in
adult patients with hypertension (Ho et al., 2012). Further, similar study in low
income women with hypertension found that social support had positive relation
(r = .44, p < .001) with health behaviors (Yang, Jeong, Kim, & Lee, 2014).
Furthermore, understanding the role of social support and health promoting behaviors
among Bhutanese people with hypertension still needs to be explored.
In conclusion, health promoting behaviors are crucial to optimize health of
hypertensive patients by identifying factors affecting health promotion behaviors.
Although perceived self-efficacy, perceived benefits, perceived barriers and perceived
social support, are widely studied, and discussed in the literature, little or no
information is available in context to the Bhutanese population with hypertension.
In fact, no study has been carried out till date in Bhutan to understand the factors
related to health promoting behaviors in hypertensive patients. Further, with
difference in culture, values, beliefs, physical, and social characteristics of Bhutanese
population with hypertension, the findings from other studies may not be same with
Bhutanese population. This lack of information in relation to hypertensive population
suggested investigation, in order to develop effective nursing intervention.
Understanding the relationships of factors to health promoting behaviors would
provide a deeper insight for the nursing professionals and other health care providers
to develop effective nursing strategies to help individuals with hypertension to engage
in health promotion to control hypertension and prevent complications.
Objectives of the study
The objectives of this study were:
1. To describe the health promoting behaviors of patients with hypertension
in Bhutan.
2. To examine the relationships of perceived self-efficacy, perceived
benefits, perceived barriers, and perceived social support on health promoting
behaviors of Bhutanese patients with hypertension.
9
Research hypotheses
Health Promotion Model of Pender et al. (2011) was used as a theoretical
base for this study, and the hypotheses were as follows:
Hypotheses 1 There is a positive relationship between perceived self-
efficacy and health promoting behaviors among Bhutanese patients with hypertension.
Hypotheses 2 There is a positive relationship between perceived benefits and
health promoting behaviors among Bhutanese patients with hypertension.
Hypotheses 3 There is a negative relationship between perceived barriers
and health promoting behaviors among Bhutanese patients with hypertension.
Hypotheses 4 There is a positive relationship between perceived social
support and health promoting behaviors among Bhutanese patients with hypertension.
Scope of the study
The proposes of the study were to describe the health promoting behaviors
of hypertensive patients in Bhutan, and to examine the relationships of perceived
self-efficacy, perceived benefits of action, perceived barriers to action, and perceived
social support on health promoting behaviors of Bhutanese patients with
hypertension. The population of this study included 123 patients with hypertension
visiting medical outpatient department at Jigme Dorji Wangchuck National Referral
Hospital (JDWNRH), Thimphu, Bhutan. The study was conducted in February and
March 2015. Variables for the study include perceived self-efficacy, perceived
benefits of action, perceived barriers to action, perceived social support, and health
promoting behaviors.
Conceptual framework
Pender’s Health Promotion Model (2011) was used to guide this research.
The Health Promotion Model has been used as a framework for research aimed at
examining health promoting behaviors. In this study, health promoting behaviors of
hypertensive patients include taking medication, physical activity, nutrition, stress
management, limiting alcohol consumption, weight management, and smoking
10
cessation. These behaviors are viewed as health promoting behaviors and must be
integrated into daily living.
According to Health Promotion Model (Pender et al., 2011), the success of
motivating individuals to maintain and enhance health promoting behaviors depends
on numerous factors through the direct and indirect effects of factors. Perceived
self-efficacy, perceived benefits of action, perceived barriers to action, and perceived
social support are variables within the concept of behavior specific cognition and
affect and are considered to have major motivational influence on health promoting
behaviors. Perceived self-efficacy is one of the variables in behavior-specific
cognition that affects the health promotion model and is considered the major
motivation for performing health behaviors. Perceived benefits are proposed to
directly and indirectly motivate behavior through determining the extent of
commitment to a plan of action to engage in health promoting behaviors. Perceived
barriers are obstacles that inhibit involvement of an individual in health promoting
behaviors. Anticipated barriers have been found to affect intentions to engage in
particular behavior. Similarly, social environments are known to affect health
promoting practices in people with hypertension and include support from significant
others. These variables have major motivational significance within the health
promotion model and are considered modifiable through interventions.
The relationship between perceived self-efficacy, perceived benefits, perceived
barriers, and interpersonal influences on hypertension and health promoting behaviors
in Bhutanese patients may be demonstrated by using the health promotion model.
Therefore in this study, the researcher used the Pender’s health promotion
model (2011) as a research framework to examine the relationships between
perceived self-efficacy, perceived benefits of action, perceived barriers to action, and
perceived social support as independent variables and health promoting behaviors as
dependent variable. The research framework for this study is shown in Figure 1.
11
Figure 1 Research framework of the study
Definition of terms
Hypertensive patient
Hypertensive patient is defined as individual with primary hypertension as
diagnosed by physician with a systolic blood pressure of more than 140 mmHg or
a diastolic blood pressure of more than 90 mmHg, or taking antihypertensive
medication.
Health promoting behaviors
Health promoting behaviors were defined as enduring activities that
hypertensive patients performed to manage hypertension and enhance the level of
personal wellness. Health promoting behaviors included; taking medication, physical
activity, nutrition, stress management, weight management, smoking cessation, and
limiting alcohol consumption. Health promoting behaviors were measured by health
promoting behaviors questionnaires which were developed by the researcher.
Perceived self-efficacy
Perceived self-efficacy referred to the confidence in ability of hypertensive
patients to perform specific health promoting behaviors to manage hypertension.
Specific health promoting behaviors referred to nutrition, psychological well-being,
exercise and health responsibility. Perceived self-efficacy was measured by Self
Rated Abilities for Health Practice Scale developed by Becker, Stuifbergen, Oh, and
Hall (1993).
Health Promoting Behaviors
Perceived self-efficacy
Perceived barriers to action
Perceived social support
Perceived benefits of action
12
Perceived benefits of action
Perceived benefits of action were perceptions of hypertensive patient that
performing health promoting behaviors would help them to control blood pressure
and prevent complications. Perceived benefit of action was measured by the Benefits
Assessment Scale developed by Murdaugh and Verran (1987).
Perceived barriers to action
Perceived barriers were hypertensive patient’s perceptions of obstacles that
inhibit them to practice health promoting behaviors. Perceived barriers to health
promotion include inconvenience, lack of time, expensive, and lack of support.
Perceived barriers were measured by Barriers to Health Promoting Activities Scale
developed by Becker et al. (1993).
Perceived Social support
Perceived social support was defined as hypertensive patient’s perception of
attachment, social integration, nurturance, reassurance of worth, and availability of
assistance from others in managing hypertension. Perceived social support was
measured by Personal Resource Questionnaire (PRQ 2000) developed by Weinert
(2003).
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CHAPTER 2
LITERATURE REVIEW
In this chapter, the researcher reviewed literature covering hypertension,
health promoting behaviors and factors related to health promoting behaviors.
The researcher reviewed concepts of hypertension and impacts of hypertension to
individuals, family, and community. The order of presentation is as follows:
1. Overview of hypertension
1.1 Definition of hypertension
1.2 Classification of hypertension
1.3 Pathophysiology of hypertension
1.4 Complications of hypertension
1.5 Impact of hypertension
1.6 Management of hypertension
2. Pender’s health promotion model
3. Factors related to health promoting behaviors of patients with
hypertension
3.1 Perceived self-efficacy
3.2 Perceived benefits of action
3.3 Perceived barriers to action
3.4 Perceived social support
4. Health promoting behaviors of Bhutanese patients with hypertension
Overview of hypertension
Hypertension is a global health problem. According to WHO (2013),
approximately 40 % of adults aged 25 years and above were diagnosed with
hypertension in 2008. The number of people with hypertension has increased from
600 million in 1980 to one billion in 2008, and it is projected to increase to
1.56 billion by 2025 (WHO, 2013). Hypertension is a major problem responsible for
at least 45 % of deaths due to heart disease and 51 % of deaths due to stroke (WHO,
2013).
14
1. Definition
Hypertension or high blood pressure is understood as the force exerted by
the blood on the walls of the arteries, when the heart pumps the blood from the left
ventricle (AHA, 2007 as cited in Philips, 2014). The Seventh Report of the Joint
National Committee on Prevention and Detection of High Blood Pressure (JNC 7,
2003), and the WHO provides appropriate definitions to understand hypertension
which are popularly used all over the world. According to the JCN 7 (2003) report,
classification of hypertension is based on the mean of two or more seated blood
pressure readings, on two or more consecutive office visits (AHA, 2013; CDC, 2011;
Chobanian et al., 2003). According to WHO (2013), hypertension is defined as
a Systolic Blood Pressure (SBP) of 140 mmHg or more, Diastolic Blood Pressure of
(DBP) of 90 mmHg or more or taking antihypertensive medication. The definition
provided by the JNC 7 (2003) report provides clear information as it is represented
with the classification of hypertension based on the blood pressure reading for adults
older than 18 years and is classified according to the stage as:
Normal: Systolic lower than 120 mmHg, diastolic lower than 80 mmHg.
Pre-hypertension: Systolic 120-139 mmHg, diastolic 80-89 mmHg.
Stage 1: Systolic 140-159 mmHg, diastolic 90-99 mmHg.
Stage 2: Systolic 160 mmHg or greater, diastolic 100 mmHg or greater.
Therefore, hypertension among adult is a sustained systolic or diastolic
blood pressure greater than 139/89 mmHg. The systolic reading between
120-139 mmHg and diastolic blood pressure between 80-89 mmHg is termed as
pre-hypertension, as this reading usually provides the opportunity to involve
individuals in health promotion to improve blood pressure control (JNC 7, 2003).
As per the JNC 7 guidelines, Stage 1 hypertension is now a systolic blood pressure
between 140-159 mmHg and diastolic between 90-99 mmHg. Stage 2 hypertension is
a systolic blood pressure greater than 160 mmHg or diastolic greater than
100 mmHg. Treatments at each stage depend on compelling indications. These
include heart failure, post-myocardial infraction, diabetes, chronic kidney disease,
high coronary disease risk, or recurrent stroke prevention (Chobanian et al., 2003).
It is important to note that the JNC 7 has introduce the term pre-hypertension, which
is used to classify individuals with systolic blood pressure of 120-139 mmHg and
15
diastolic blood pressure of 80-89 mmHg. The goal of the new classification is to
identify individuals at risk to be hypertensive and provide an opportunity for health
care providers for early interventions by promoting their behaviors (JNC 7, 2003).
2. Classification of hypertension
Hypertension is classified as primary hypertension and secondary
hypertension. Primary hypertension is the most common type of hypertension and
represents 90-95 % of all cases of hypertension (Chobanian et al., 2003; Eckman &
Kirk, 2013; Hajjar & Kotchen, 2003). The specific cause to explain primary
hypertension is unknown and yet no single specific cause has been identified.
However, several genetic and environmental factors could contribute to this
phenomenon. Its pathogenesis is believed to be the interaction between genetic and
environmental or lifestyle factors (Fagard, 2005). Further, environmental and lifestyle
factors have been identified to explain an elevated blood pressure and include
increased consumption of sodium, alcohol and caloric intake, stress and physical
inactivity (Adeniyi, Idowu, Ogwumike, & Adeniyi, 2012; CDC, 2011). Primary
hypertension has no definite cause, or clear identifiable etiology, which differentiates
it from the secondary hypertension, in which the blood pressure elevation occur
secondary to identifiable cause.
Approximately 5-10 percent hypertension cases are due to identifiable
causes with renal diseases being the most common contributor to 2.5- 6 % of all
causes of secondary hypertension (Catala-Lopez, Sanfelex- Gimeno, Garcia-Torris,
Ridao, & Periso, 2012; O'Brien, Beevers, & Lip, 2007). Other causes of secondary
hypertension include; endocrine conditions, such as Cushing’s syndrome,
hyperthyroidism, hypothyroidism, acromegaly, hyperaldosteronism,
hyperparathyroidism and pheochromocytoma (O’Brien et al., 2007). Other causes
contributing to secondary hypertension include obesity, sleep apnea, and pregnancy,
certain prescription medicines, herbal remedies and illegal drugs (Eckman & Kirk,
2013).
3. Pathophysiology of hypertension
In the present study, pathophysiology of hypertension was focused on
primary hypertension. The pathogenesis of primary hypertension is multifactorial and
highly complex (Gandhi et al., 2001). Multiple factors modulate the blood pressure
16
for adequate tissue perfusion and include humeral mediators, vascular reactivity,
circulating blood volume, vascular caliber, blood viscosity, cardiac output, blood
vessel elasticity, and neural stimulation. A possible pathogenesis of essential
hypertension has been proposed in which multiple factors, including genetic
predisposition, excess dietary salt intake, and adrenergic tone, may interact to cause
hypertension. Although genetics appears to contribute to essential hypertension,
the exact mechanism has not been established. The pathophysiology mechanisms of
hypertension are as follows:
3.1 Genetic factors
Primary hypertension is a complex, multifactorial, with genetically
determined characteristics contributing to between 30 % and 50 % of the variation in
blood pressure among individuals (Ward, 1990 as cited in Dominiczak, Negrin, Clark,
Brosnan, & Alexander, 1999). About 50 % of the patients with family history of high
blood pressure or history of premature death in the family are at greater risk of
developing hypertension (O’Brien et al., 2007). The exact identification of
hypertension and genes has not been clear because of the multifactorial nature of the
disease and the presence of many major pathogenetic pathways. Major genes that
cause primary hypertension are yet to establish. Although a number of individual
genes and genetic factors have been linked to the development of primary
hypertension, it is likely that multiple genes contribute to the development of the
disease in any given individual. It is extremely difficult to accurately determine the
relative contributions of each of these genes. However, genetic factors probably play a
role in the alterations of various physiologic parameters that have been identified in
hypertensive patients (Rana et al., 2007).
3.2 Cardiac output and peripheral resistance
Regulation of normal blood pressure is a complex process and is
a product of cardiac output and peripheral vascular resistance. The balance between
the cardiac output and peripheral vascular resistance is essential to maintain normal
blood pressure. Cardiac output is the volume of blood flowing through systemic or
pulmonary circulation in a minute. An increase in cardiac output without a decrease in
peripheral resistance will cause both arterial volume and arterial pressure to increase
(Huether & McCance, 2012). Peripheral resistance is determined by both large
17
arteries and the capillaries and small arterioles and found in some young individuals
with borderline hypertension. Most patients with primary hypertension have increased
peripheral vascular resistance and a normal cardiac output. The cardiac output may be
increased in the early stages of primary hypertension, where peripheral resistance
slowly increases in order to maintain normal tissue perfusion. As the hypertension
progress, the left ventricular function diminishes, as a result the cardiac output is
decreased and the blood pressure is maintained by the increase in peripheral vascular
resistance (Beevers, Lip, & O’ Brien, 2007).
3.3 Renin-angiotensin-aldosterone
The renin-angiotensin-aldosterone system is the main systems that affect
the blood pressure control. Renin is secreted from the juxtaglomerular apparatus of
the kidneys in response to glomerular hypo-perfusion as a result of reduce salt intake
or due to stimulation from the sympathetic nervous system. Renin is responsible for
converting angiotensinogen to angiotensin I. Angiotensin I then is transformed into
angiotensin II by Angiotensin Converting Enzymes (ACE). Angiotensin II is a potent
vasoconstrictor and thus, causes a raise in blood pressure. It may also cause some of
the manifestation of hypertensive target organ damage, like left ventricular
hypertrophy and atherosclerotic vascular disease. In addition it stimulates the release
of aldosterone from the zona glomerulosa of the adrenal gland, which further results
in raised blood pressure related to sodium retention (Beevers et al., 2007). However,
the renin- angiotensin system is not responsible directly for the increase in blood
pressure in patients with primary hypertension. Many patients with hypertension have
low levels of circulating endocrine renin and angiotensin II. In these patients the drugs
that block the renin-angiotensin-aldosterone system is less effective (Beevers et al.,
2007).
3.4 Autonomic nervous system
Autonomic nervous system is another factor contributing to development
of hypertension. It has an important role in maintaining a normal blood pressure
because its stimulation causes both arteriolar constriction and dilatation.
The autonomic nervous system mediates the short term changes in blood pressure in
response to stress and physical activity (Beevers et al., 2007). Thus, has an important
role in maintaining a normal blood pressure.
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4. Complications of hypertension
Complication of hypertension are the outcome of persistent elevation of
blood pressure and is a major risk factor for various complications to vital organs like;
heart, brain, kidney, blood vessels and eyes (White, 2009). The major complications
includes
4.1 Cardiac complication of hypertension
Hypertension is the most important risk factor for premature
cardiovascular disease and accounts for 47 % of all ischemic heart disease globally
(Lawes, Vander, & Rodgers, 2008). Uncontrolled and prolonged blood pressure
elevation can lead to changes in the myocardial structure, coronary vasculature, and
conduction system of the heart, leading to the development of Left Ventricular
Hypertrophy (LVH). Other complications include coronary artery disease, and
systolic and diastolic dysfunction of the myocardium, which manifest clinically
as angina or myocardial infarction. In addition, the increased size of heart muscle
increases the oxygen demand and impaired the contractibility of the heart, resulting in
systolic heart failure (Huether & McCance, 2012).
Atherosclerotic coronary artery or micro vascular disorder, or cardiac
arrhythmias are often seen as cardiac complications of hypertension. Left ventricular
hypertrophy in patients with hypertension could be the result of sudden death and
manifestation of stroke in patients with hypertension. In hypertensive patients,
abnormalities of diastolic function, which range from asymptomatic heart disease to
heart failure, are commonly seen (Verma & Solomon, 2009). Diastolic dysfunction is
an early consequence of hypertension related heart disease and is exacerbated by left
ventricular hypertrophy and ischemia (Fukuta & Little, 2007).
4.2 Cerebral complication of hypertension
Blood pressure is a powerful determinant of risk for ischemic stroke and
intracranial hemorrhage. In fact, long-standing hypertension may manifest as
hemorrhagic and atheroembolic stroke or encephalopathy. Both the high systolic and
diastolic pressures are harmful; a diastolic pressure of more than 100 mmHg and
a systolic pressure of more than 160 mmHg are associated with a significant incidence
of strokes (AHA, 2013). Hypertension accounts for an estimated 54 % of all strokes
events globally (Lawes et al., 2008). The stroke events increase with raising systolic
19
blood pressure levels in individuals more than 65 years. Development of
atherosclerosis and hypertension affects the arteries whereby, decreasing the flow of
blood or ruptured of weak blood vessels within the brain resulting in stroke. The risk
for transient ischemic attacks and the incidence of any type of stroke including
ischemic stroke and intracerebral hemorrhage are greater in person with hypertension
comparing to individuals with normal or borderline hypertension (Rigaud, Seux,
Staessen, Birkenhager, & Forette, 2000). Further, hemorrhagic stroke results in
increased morbidity and mortality.
4.3 Renal complication of hypertension
Hypertension is responsible for renal complications in people with
hypertension and is related to systolic blood pressure (Marín, Gorostidi, Fernández-
Vega, & AlvarezNavascués, 2005). The complications of hypertension include
parenchymal damage, nephron sclerosis, renal arteriosclerosis and renal insufficiency
or failure. The early signs of renal complication include micro albuminuria, in
10-15 % of individuals with primary hypertension. The artherosclerotic, hypertension
related vascular lesions, in the kidneys primarily affects the pre-glomerular arterioles,
resulting in ischemic changes in the glomeruli and post glomerular structures.
Damage to glomerulus allows large molecules of protein to pass through to the urine
in presence of proteinuria and is reflective of increased glomerular permeability and
an early sign of hypertensive renal injury. If intervention for blood pressure control is
not initiated, it leads to renal impairment and finally to end stage renal disease (Marín
et al., 2005).
4.4 Retinal complication of hypertension
Hypertensive retinopathy is complication associated with loss of vision,
and is characterized by retinal vascular changes including alteration of light reflexes,
retinal hemorrhage, retinal edema, and blurred disc margin (Wong & Mitchell, 2004).
When the blood pressure increases, the retinal circulation responds by changing
pathophysiology. Vasospasm and increased retinal arteriolar tone owing to local
auto-regulation is seen in the beginning. Persistent elevation of blood pressure
disrupts blood-retina barrier leading to necrosis of smooth muscles and retinal
ischemia. These changes are manifested in the retina as micro aneurysms,
hemorrhage, and cotton-wool spots (Wong & Mitchell, 2004). Atherosclerosis also
20
contributes to the retinal injury produce by hypertension, resulting in retinal
detachment leading to blindness (Eckman & Kirk, 2013).
Complication of hypertension, such as heart failure, strokes, renal failure
and hypertensive retinopathy leads to serious impact on the individual patients, their
families and the community.
5. Impacts of hypertension
Hypertension is the most important risk factors for premature cardiovascular
diseases and accounts for approximately 54 % of all strokes and 47 % of all ischemic
heart disease events globally (Lawes et al., 2008). Complications of hypertension
account for 9.4 million deaths worldwide every year (WHO, 2013). Hypertension is
responsible for at least 45 % of deaths due to heart disease and 51 % of deaths due to
stroke (WHO, 2013). In the United States, 77.9 million that is, 1 in every 3 adults
have hypertension and contributes nearly 1000 deaths per day which are preventable
and the number is more in developing countries (AHA, 2013; Philips, 2014).
These devastating consequences of hypertension have several impacts on individual,
family, health care system and nation as a whole.
5.1 Impact of hypertension on individual
Since there are no symptoms associated with hypertension and is
considered as a “silent killer” (AHA, 2013). People often do not seek medical care,
leaving it undetected and untreated. Further, it is recognized only when complications
has already occurred. The presence of hypertension causes serious problems affecting
the quality of life of individuals with hypertension. The major complications
associated with hypertension include; coronary heart disease, stroke, heart failure,
chronic kidney disease, visual problems and peripheral vascular diseases. The risk of
coronary disease and stroke increases with age above 60 years and is significant factor
for mortality (JNC 7, 2003). Mild to moderate hypertension, if left untreated, is
associated with a risk of atherosclerotic disease in 30 % of people and organ damage
in 50 % of people within 8-10 years after onset. Death from ischemic heart disease
and stroke increases progressively as BP increases. For every 20 mmHg systolic or
10 mmHg diastolic increase in BP above 115/ 75 mmHg, the mortality rate for both
ischemic heart disease and stroke doubles (Chobanian et al., 2003). Hypertension
21
affects individual’s work, their activities of daily living, and quality of life resulting in
poor income and low socioeconomic status.
5.2 Impact on family
Hypertension is responsible for increased number of renal failure and
other complications in patients with hypertension. Treatment for the complication of
hypertension usually are costly and requires long term therapy like dialysis to
sustained living with decreased quality of life. Prolonged and costly treatment results
in draining individual and government budgets. The impact of hypertension leads to
premature death, disability, personal and family disruption, loss of income, and
increased healthcare expenditure. Further, families face catastrophic health
expenditure and often push tens of millions of people into poverty (WHO, 2011).
Hypertension as a chronic illness requires prolonged care resulting in increased health
care expenditure affecting the entire family. Further caring patient with complication
of hypertension will impose a greater burden to the family, as they are constantly
exposed to stress and other health related behaviors, risking their own health.
5.3 Impact on health system
Managing hypertension and its resultant complications constitutes
a great financial burden on individual patient, family, and the health system in many
countries. These costs are usually borne by the individuals, governments, and
the private sector (Gaziano, 2008). Further, hypertension often is associated with
other co-morbid conditions, where it further increases the costs of managing
the disease. The direct and indirect costs of hypertension in the United States is
estimated to be more than $93.5 billion per year, and that cardiovascular disease and
stroke account for 17 % of the total health expenditures annually (Heidenreich,
Trogdon, & Khavjou, 2011). The impact of hypertension to each individual, family
and the community are large. It costs a lot of financial implications at every stage of
disease progression and treatment. Therefore, early management of high blood
pressure by participating in health promotion becomes an important step in preventing
complications. Thus, reducing the burden and negative impact to individual, family
and the community.
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6. Management of hypertension
Not all patients diagnosed with hypertension needs medication. Individuals
with medium to high risk of developing cardiovascular complications need one or
more essential medicines to lower their blood pressure (JNC 8, 2014). As per
the recommendation of the JNC 7 (2003), the management of hypertension includes
pharmacological and non-pharmacological.
6.1 Pharmacological management
Pharmacological management by taking prescribed medication is of
immense importance for hypertensive individuals in controlling blood pressure
(JNC 7, 2003; WHO, 2013). Individuals need to take medications according to
the recommendations from the health care provider and must continue irrespective of
the blood pressure reading. All antihypertensive medications have their own
mechanism of actions which influences on blood pressure. Medications influence
blood pressure by increasing excretion of sodium and water and reducing cardiac
output. Regular medications are associated with blood pressure control and reduce
complications of hypertension (WHO, 2013). Pharmacological management includes
a number of drugs, which are currently available for hypertension treatment. There are
seven main groups of antihypertensive drugs use for the treatment of hypertension and
are classified below:
6.1.1 Thiazide diuretics are used as monotherapy, or they can be
administered adjunctively with other antihypertensive agents. Thiazide diuretics
inhibit reabsorption of sodium and chloride mostly in the distal tubules. Long-term
use of these drugs may result in hyponatremia. They also increase potassium and
bicarbonate excretion and decrease calcium excretion and uric acid retention.
Thiazides do not affect normal blood pressure (Leung, Wright, Pazo, Karson, &
Bates, 2011). Thiazide diuretics are cheap, easy to use and can be given once daily
and is more effective and are drug of choice for the elderly. However, most of
the drugs in this group possess a sulfonamide group and must be cautious to use in
individuals with allergies to sulfonamide.
6.1.2 Beta-blockers are use when patient has compelling cardiac
indications like heart failure, myocardial infarction, and patients with diabetes.
23
This group of drugs is generally not used as first line drugs for the treatment of
hypertension. This group of drugs must be use cautiously in patients with asthma or
severe Chronic Obstructive Pulmonary Disease (COPD). Dose must be reduce
gradually, as sudden withdrawal of drug results in exacerbations of angina and, in
some cases, myocardial infarction have been reported.
6.1.3 Calcium channel blockers binds to L-type calcium channels in
the vascular smooth muscle, which results in vasodilatation and a decrease in blood
pressure. They are effective as monotherapy in black patients and elderly patients.
Non-dihydropyridines calcium channel blockers, such as verapamil and diltiazem
bind to L-type calcium channels in the sinoatrial and atrioventricular node, as well as
exerting effects in the myocardium and vasculature. These agents constitute a more
effective class of medication for black patients (Cummings, Amadio, Nelson, &
Fitzgerald, 1991).
6.1.4 Angiotensin Converting Enzyme (ACE) inhibitors are
the treatment of choice in patients with hypertension, chronic kidney disease, and
proteinuria. ACE inhibitors reduce morbidity and mortality rates in patients with heart
failure, patients with recent myocardial infarctions, and patients with proteinuric renal
disease. ACE inhibitors appear to act primarily through suppression of the renin-
angiotensin-aldosterone system. ACE inhibitors prevent the conversion of angiotensin
I to angiotensin II and block the major pathway of bradykinin degradation by
inhibiting ACE. Accumulation of bradykinin has been proposed as an etiologic
mechanism for the side effects of cough and angioedema. It is important to note that
the blood-pressure-lowering effects of ACE inhibitors and thiazides are
approximately additive, and there is also the potential for hyperkalemia when ACE
inhibitors are co-administered with potassium supplements or potassium-sparing
diuretics. Careful monitoring of serum potassium levels is warranted when these
agents are used in combination (Cummings, et al., 1991).
6.1.5 Angiotensin II receptor antagonists or angiotensin receptor
blockers (ARBs) are used for patients who are unable to tolerate ACE inhibitors.
ARBs competitively block binding of angiotensin-II to angiotensin type I receptors,
thereby reducing effects of angiotensin II–induced vasoconstriction, sodium retention,
24
and aldosterone release. If monotherapy with an ARB is not sufficient, adding
a diuretic should be considered (Beevers et al., 2007).
6.1.6 Alpha-blockers are generally not recommended as initial
monotherapy. This group of drugs selectively blocks postsynaptic alpha 1-adrenergic
receptors and dilates arterioles and veins, thus lowering blood pressure. These drugs
can be combined with other anti-hypertensive. Common side effects seen in this drug
class include dizziness, headache, and drowsiness, in addition to orthostatic and first-
dose hypotension.
6.1.7 Vasodilators acts directly on the muscles in the walls of arteries,
preventing the muscles from narrowing. Vasodilators relax blood vessels to improve
blood flow, thus, decreasing blood pressure.
6.2 Non-pharmacological management
As the rates of hypertension continues to raise, health promoting
behaviors plays a crucial role in reversing the trend of increasing cases of
hypertension around the world. Research has indicated that persons with hypertension
can make multiple lifestyle changes that lower their blood pressure and reduce
the risk for cardiovascular complications. The Seventh Report of the Joint National
Committee of Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (JNC 7, 2003), AHA (2013), and the WHO (2013) recommends therapeutic
lifestyle modifications in lowering blood pressure and decrease cardiovascular risk.
The non-pharmacological interventions to reduce blood pressure include
the following.
6.2.1 Physical activity
According to Walker and Hill-Polerecky (1996), physical activity
consists of regular participation in activities at light, moderate, and vigorous intensity,
which may be planned or integrate as a part of daily life or leisure activities. Regular
physical activity has many health benefits including decreasing the risk of
cardiovascular diseases, obesity, and diabetes. Exercise aids in weight control and is
a key component of weight loss. It increases muscle and bone strength, decreases
body fat, and enhances psychological well-being. Exercise is also beneficial in
controlling and reducing hypertension. According to research and recommendation
from the Centers for Disease Control and Prevention (CDC), it is suggested that
25
people perform moderately intense exercise 30 minutes a day, most days of the week.
Some research has shown that 30 minutes of exercise a day can lower systolic blood
pressure 4-9 mm Hg (Chobanian et al., 2003). Regular aerobic exercise lasting 30-60
minutes and reduce consumption of salt in diet can lower systolic blood pressure on
an average of 5 mmHg and diastolic blood pressure on an average of 4 mmHg
(JNC-7, 2003; Whelton, Chin, & Xin, 2002). Similarly, in a randomized control trial
by Lee, Arthur, and Avis (2007) on people with hypertension showed that patients
who followed recommended physical activities decreased systolic blood pressure of
15.4 mmHg. Similarly, Fagard (2005), in the study of effects of exercise, found that
there was reduction in systolic blood pressure by 3.6 mmHg and diastolic blood
pressure of 2.7 mmHg. Patients with hypertension, who engaged in regular exercise,
can control their blood pressure (Fagard, 2005).
6.2.2 Nutrition
Nutrition involves selection and consumption of foods essential for
health and well-being in knowledgeable and appropriate way (Walker & Hill-
Polerecky, 1996). A healthy eating plan can both reduce the risk of developing high
blood pressure and lower a blood pressure that is already too high. Since blood
pressure is influenced by the amount of potassium and magnesium, a healthy diet with
potassium, magnesium and lipid intake are essential to help patients manage their
blood pressure and prevent complications. A land mark study, the Dietary Approaches
to Stop Hypertension [DASH] trials (Appel et al., 1997), demonstrated the effects of
diet on decreasing hypertension. The diet in this trial encouraged a high amount of
vegetables and fruits, which provide high levels of potassium, magnesium, and fiber.
The diet also consisted of low-fat dairy products, and foods low in total and saturated
fat, cholesterol, and approximately 2.4 grams of sodium or 6 grams of sodium
chloride per day. The DASH diet was most effective on people with prehypertension
to moderate hypertension. The following DASH diet plan is recommended to
the patients with hypertension (Chobanian et al., 2003).
Grains and grain products 6-12 servings per day includes 1 slice of bread,
1 cup of ready to eat cereal or half cup of cooked rice or any other cereals.
The servings is calculated based on the requirements of 2000 calories per day and
usually includes 3 whole grain foods.
26
Fruits 4-6 servings per day include 1 medium fruit, ¼ cup dried fruits and
6 ounces of fruit juice.
Vegetables 4-6 servings per day include 1 cup raw leafy vegetables, half cup
of cooked vegetables and 6 ounces vegetable juice.
Low fat or non-fat dairy foods 2-4 servings per day include 8 ounces milk,
1 cup yogurt and 1.5 ounces cheese.
Lean meat, fish and poultry 1.5-2.5 servings per day include 3 ounces
cooked lean meat, skinless poultry or fish.
Nuts, seeds and legumes 3-6 servings per week include one-third cup nuts
and half cup cooked dry beans.
Fats 2-3 servings and includes 1 teaspoon vegetable oil and 2 tablespoon
light salad dressing.
Diet low in sodium includes consuming not more than 2.4 grams of sodium
a day, which equals 6 grams (1 teaspoon) of salt a day.
Further the AHA recommends a diet that is low in sodium, is high in
potassium, and promotes the consumption of fruits, vegetables, and low-fat dairy
products for reducing BP and lowering the risk of complications. Study have shown
that DASH diet lowered blood pressures in hypertensive participants on average
11 mmHg systolic blood pressure and 5.5 mmHg diastolic blood pressure (Appel
et al., 1997, 2003, 2006; JNC 7, 2003). Similar, study on effect of diet on
hypertension found reduction of systolic blood pressure by 5.9 mmHg and diastolic
blood pressure by 4.2 mmHg (Fagard, 2005).
6.2.3 Weight management
One of the leading lifestyle modifications for all diseases is weight
reduction. The classification of overweight is a Body Mass Index (BMI) in excess of
25 and a BMI over 30 is considered obese (AHA 2005; Chobanian et al., 2003).
Research has provided strong evidence that being overweight or obese predisposes
individuals to many chronic diseases like type 2 diabetes, hypertension, high blood
cholesterol, cardiovascular diseases, stroke and many other illnesses and diseases.
The current recommendations are to maintain a normal body weight, a BMI between
18.5 and 24.9 to reduce the risk for cardiovascular and other diseases. Weight
reduction not only helps to normalize blood pressure by reducing strain on the heart,
27
it also lowers blood cholesterol. According to research, weight reduction of 5-10 kg
and maintaining a normal BMI under 25 can decrease systolic blood pressure 5-20
mmHg (AHA, 2005; Chobanian et al., 2003). A well balanced diet is also important in
aiding weight reduction and preventing obesity.
6.2.4 Smoking cessation
Chronic and heavy smoking is associated with hypertension and
patients must be strongly counseled to quit smoking (JNC 7). Blood pressure
increases acutely during smoking and has adverse effect on cardiovascular risk.
People who stop smoking rapidly reduce their risk of cardiovascular complications by
50 % after one year (Beevers et al., 2007). Smoking of tobacco causes several
immediate responses within the heart and its blood vessels within minutes after
inhaling smoke and increases heart rate. It is partially attributed to nicotine which
stimulates the body to produce adrenaline, thus increasing heart rate and blood
pressure (Beevers et al., 2007).
6.2.5 Limiting alcohol consumption
Limiting alcohol intake is another lifestyle modification. High dose of
alcohol ingestion have a dose related effect on blood pressure, both on hypertensive
and normotensive people. According to JNC 7 (2003), hypertensive patients should
limit alcohol consumption to not more than 30 mls, equivalent of 2 drinks per day for
men and not more than 15 mls for women. Hypertensive patients who are heavy
drinkers are more likely to have hypertension resistant to drugs treatment. High dose
of alcohol ingestion have a dose related effect on blood pressure, both on hypertensive
and normotensive people. Therefore, the only way to reduce blood pressure in this
group of people is to reduce or stop consuming alcohol. However, there still remains
conflicting research on alcohol consumption, in moderation, and its health benefits.
The majority of the research states that limiting consumption of alcohol to no more
than two drinks per day for men and 1 drink per day in women is acceptable. Systolic
blood pressure reductions of 2-4 mmHg have been shown as a result of limiting
alcohol consumption (Centers for Disease Control and Prevention, National Institutes
of Health, 2000; Chobanian et al., 2003).
28
6.2.6 Stress management
Although the precise mechanisms linking stress reactivity and
cardiovascular risk status are yet to be determined, it is evident that stress can
temporarily induce blood pressure. Stress is substantially connected to manifestation
of hypertension, cardiovascular disease, metabolic syndrome, obesity and emotional
overeating. Further it fuels 50 % of depression cases through disturbances of
hypothalamic–pituitary–adrenal axis and increased cortisol levels. It is important to
manage stress appropriately to avoid complications (Sharma et al., 2013). According
to Walker and Hill-Polerecky (1996), stress management is behaviors to identify and
utilize psychological and physical resources to effectively control and reduce tension.
Similarly, stress management refers to behaviors or activities that help individuals to
release stress with enough rest and sleep, and sharing emotional feelings appropriately
(Pender et al., 2011). Patients with hypertension face with physical, mental and social
changes about life when they get the disease and its complication. Therefore, to
manage stress among patients with hypertension, support and motivation from family
and friends is key to prevent complications. It is necessary to practice relaxation and
other ways to manage stress. Study by Kaushik and colleagues found that stress
management techniques like mental relaxation and slow breathing resulted in a fall in
systolic blood pressure and diastolic blood pressure (Kaushik, Kaushik, & Mahajan,
2006).
Pender’s health promotion model
Pender’s health promotion model is one of the most frequently used models
for health promotion which serves as a multivariate paradigm for explaining and
predicting health promoting component of lifestyle (Pender et al., 2011). The model is
used to assess an individual’s background and perceived perceptions of self among
other factors to predict health behaviors. Pender’s model serves as a guide for
exploration of the complex bio psychosocial processes that motivate individuals to
engage in behaviors directed toward the enhancement of health (Pender et al., 2011).
Within health promotion model, health promoting behavior is an expression of the
human tendency to actualize and is directed at elevating the individual’s level of well-
being, enhancing self-actualization, and maximizing personal fulfillment.
29
Two theories underlie Pender’s model which are important for understanding the
concepts she describes. These two theories are the expectancy-value theory and the
social cognitive theory. The expectancy-value theory is based on the idea that the
course of action will likely lead to the desired outcome, and that this outcome will be
of positive personal value. The social cognitive theory describes the concept of
perceived self-efficacy which is a judgment of one’s ability to carry out a particular
course of action (Pender et al., 2011). Pender predicts that a high confidence level will
lead to greater likelihood that the behavior will be performed. There are three major
concepts in Pender’s model which are further subdivided into narrower, more specific
concepts. The major concepts are individual characteristics and experiences,
behavior-specific cognitions and affect, and behavioral outcome.
Figure 2 Health promotion model
The model proposed that performing health behaviors can be achieved
through the direct and indirect effects of factors. The general individual characteristics
and experiences generally influence behavior indirectly and behavior-specific
30
cognitions and affects influence behavior directly. According to Pender et al. (2011),
individual characteristics are personal general such as age, health status, personality
structure, race, ethnicity, and socio economic status. Prior experiences are frequency
of the similar health behavior in the past. Behavioral-specific cognitions and affect
consists of following factors: perceived benefits of action are the positive perception
of individual to undertake or reinforce a health behavior; perceived barriers to action
are perceptions of blocks, hurdles, personal costs of undertaking a specific health
behavior; perceived self-efficacy is the judgment of personal capability to organize
and execute a particular health behavior; activity- related affect is the subjective
feeling states or emotions occurring before, during and after following a specific
health behavior; interpersonal influences includes norms, social support, role models
perceptions concerning the behaviors, beliefs, or attitudes of relevant others in regard
to engaging in a specific health behavior; situational influences are the perceptions of
the compatibility of life context or the environment with engaging in a specific health
behavior; commitment to a plan of action means the intention to carry out a particular
health behavior including the identifications of specific strategy to do successfully
and immediate competing demands and preferences. Health promoting behavior is
identified as the ultimate outcome of the model.
Factors related to health promotion behaviors of patients with
hypertension
Several studies on health promotion behaviors have used Pender’s Health
Promotion Model to examine and explore such behaviors (Ho et al., 2012;
Jaiyungyuen et al., 2008; Kwong & Kwan, 2007; Warren- Findlow et al., 2012).
Numbers of factors are related to health promotion behaviors. These factors may
impede or facilitate health promoting behaviors of hypertensive patients. These
factors include perceived self-efficacy, perceived benefits, perceived barriers and
perceived social support.
Perceived self-efficacy
Perceived self-efficacy refers to the confidence in performing a specific
behavior. Perceived self-efficacy affects one’s health promoting behaviors. People
31
with high perceived self-efficacy tends to involve in the health promoting behaviors
whereas, people with low perceived self-efficacy would surrendered when faced with
challenges and difficulties while performing such behaviors (Pender et al., 2011).
Individual who feels capable and efficacious in managing their health has a greater
chance of engaging in more frequent health promoting behaviors than an individual
who feels unskilled. Greater perceived self-efficacy leads to an increased probability
of commitment and action to a health promoting behavior (Pender et al., 2006).
Therefore, perceived self-efficacy is an important construct that enhances
the behavioral outcome associated with commitment to health promoting behavior.
Studies have investigated the role of self-efficacy on health promotion
behaviors in hypertensive patients. Jaiyungyuen et al. (2008) found that perceived
self-efficacy had positive relationship with health promotion behaviors in population
of people with hypertension (r = .59, p < .01). Similarly, in the study of 190 African-
American adults with hypertension, the result demonstrated that people with high
perceived self-efficacy had higher prevalence of engaging in physical activities and
eating low salt diet. Warren-Findlow et al. (2012) interviewed 190 hypertensive
patients and found that 59 % of participants reported to have high perceived self-
efficacy to manage hypertension. The result showed that individuals with high
perceived self-efficacy had 64 % higher prevalence ratio (PR) of eating low salt diet
(PR = 1.64, 95 % CI: 1.07-2.20), 27 % of individuals in engaging in physical
activities (PR = 1.27, 95 % CI: 1.08-1.39). Those with high perceived self-efficacy
also had higher prevalence of not smoking (PR = 1.10, 95 % CI: 1.01-1.15) and had
higher prevalence of following good weight management (PR = 1.63, 95 %
CI: 1.30-1.87). Similar study by Ho et al. (2012), of 107 patients with hypertension
found that perceived self-efficacy explained most variance in health promotion
behaviors (β = .31, p < .01). In a study of 234 elderly women with hypertension, Yang
et al. (2014), found that self-efficacy contributed most significantly and yielded the
largest standardized regression coefficient (β = .69).
The role of self-efficacy in health promotion behaviors has been widely
investigated and findings revealed that self-efficacy have a strong relationship with
health promotion behaviors in hypertensive patients. Therefore, to understand and
32
confirm relationship between self-efficacy and health promotion behavior in
Bhutanese population is necessary.
Perceived benefits of action
Perceived benefits of action are belief that a course of action will lead to
expected outcomes. Perceived benefits directly and indirectly motivate behavior
through determining the extent of commitment to a plan of action to engage in
behaviors (Pender et al., 2011). Individuals tend to invest time and resources in
activities that have a high likelihood of positive outcomes. Benefits may be intrinsic
or extrinsic. Intrinsic benefit includes increased alertness and energy and increased
perceived attractiveness. Extrinsic benefits include monetary rewards or social
interactions possible as a result of engaging in the behavior (Pender et al., 2011).
In a study of 198 hypertensive patients, the result indicated that perceived benefits
significantly related (r = .27, p < .01) to health promoting behavior (Nangyaem et al.,
2007). In similar study in women by Thanavaro and colleagues, they found that
perceived benefit was positively related to health promotion behavior (r = .38,
p < .01) (Thanavaro, Moore, Anthony, Narsavage, & Delicath, 2006).
Perceived barriers to action
Perceived barriers are perceptions (real or imagined) related to engaging in
action or inhibit commitment to a behavior. Barriers may include time, cost,
inconvenience, access, and actual performance. Many studies demonstrated that
perceiving either environmental or personal barriers was inversely associated with
health promotion behavior. A high barrier can constrain commitment to action and on
the other hand, when the barrier is low and the willingness is high, behavior is likely
to follow (Pender et al., 2006). Kwong and Kwan (2007) have identified several
barriers such as, fear of harming oneself, lack of self-motivation, lack of knowledge,
the cost and require effort of activities, and lack of support from family and
significant others as barriers in the domain of diet, physical activities and stress
management. A study by Murimi and Harpel (2010), in a population of low income
population found that fear of the unknown, and lack of companionship or support
were common barriers to health promotion. In similar study of 198 patients with
hypertension, it showed that perceived barriers was related to health promoting
behaviors (r = -.17, p < .01) (Nangyaem et al., 2007). Khatib et al. (2014) in their
33
systematic review of barriers to hypertension control found that, stress and anxiety
contributes to health promotion behaviors. Emotion includes lack of money and jobs,
single parenting, and living in unsafe neighborhoods. Barriers to following a healthy
diet included absence of nearby stores that sell healthy foods, limited healthy food
choices when eating out, and lack of guidance and dietary counseling from clinicians
are some of the barriers reflected in the literature.
Perceived social support
Individuals is likely to engage in health promoting behaviors when they
perceives the availability of social support, whereas, perception of lack of support can
interfere with successful engagement and maintenance of healthy behaviors (Pender
et al., 2011). Social support from family reinforced positive behavioral changes and
influenced healthy behaviors among people with hypertension. Interpersonal
influence are cognition concerning behaviors, beliefs, or attitudes of the others and
include norms (expectations of significant others) and social support. Primary sources
of interpersonal influences are families (Pender et al., 2006). Waite and Lehrer (2003)
found that those people receiving social support from their significant others were
more confident in engaging in healthy dietary practices than unmarried individuals.
The study by Ashida, Wilkison, and Koehly (2012), found that having at least one
network member who encourages one to eat more fruits and vegetables and to engage
in regular physical activity was associated with motivation to change the relevant
behavior. In Jaiyungyuen et al. (2008) study of older people with hypertension found
that social support was positively related to health promotion behavior in hypertensive
patients (r = .38, p <.01). Similar study, Ho et al. (2012) found that social support
was significant predictor of health promotion behaviors in adult patients with
hypertension (β = .27, p < .01). Further, similar study Yang et al. (2014) in low
income women with hypertension found that social support had positive relation with
health promoting behaviors(r = .48, p <.001).
Health promoting behaviors of Bhutanese patients with hypertension
In Bhutan, hypertension and its complications are on a consistent rise over
the years. The referral expenditure for the treatment of complications, outside Bhutan
has increased in recent years (Annual health report, 2013). Bhutan NHS (2012)
34
reported 16 % prevalence of hypertension among adults in Bhutan. Similarly, the
survey on prevalence of non-communicable disease in the capital city of Bhutan
revealed a 26 % prevalence of hypertension among adults (Cowan et al., 2009).
Hypertension is responsible for a large number of strokes, heart attacks and chronic
kidney diseases. In 2014, the National Referral Hospital treated 105 cases with
complication of hypertension. The data from the National Referral Hospital shows an
overwhelming number of strokes and acute myocardial infarction with 89 patients
diagnosed with stroke and 12 patients with acute myocardial infarction in the year
2012 (Wangdi, 2013). Cardiovascular and cerebrovascular diseases account for
14.9 % of total morbidity and non-communicable diseases account for 50 % of
inpatient mortality (Giri et al., 2013).
Although no studies are available regarding health promoting behaviors of
Bhutanese people, few studies revealed that traditional Bhutanese diet is high in fats,
is spicy and contains a lot of salt, although exact amount is not known. The traditional
national dishes of Bhutan are red rice, chilli pepper, cheese stew, and salted butter tea.
Chilli pickles called ezay are frequently served as appetizers and are consumed
in large quantities. Generally, large amounts of salt are added to both the curry and
the pickle or paste (Wangdi, 2013). According to the risk factors survey (Cowan et al.,
2009), two-third of the population (66.6 %) were not eating enough fruits and
vegetables. Prevalence of smoking was low, possibly due to strict regulation. It was
observed that 30.8 % respondents drank alcohol at least once in 30 day, males
drinking more than females. Majority of population (58.6 %) did not attain
a minimum requirement of health enhancing physical activity and the prevalence of
obesity (BMI > 30) was 12.1 % while 52.5 % population were overweight
(BMI > 25). The combination of a high carbohydrate intake in the form of thrice-daily
rice, salty butter tea and cheese curry, fat-rich meat and poultry dishes, together with
an increasingly sedentary lifestyle, especially among urban dwellers, contributes to
the high prevalence of overweight in adults leading to hypertension. Further, in recent
years rural urban migration of people is increasing, and there is possibility that people
must be living under constant stress contributing to hypertension.
Although, the studies focus on some of the behaviors of Bhutanese
population, no study has been undertaken in relation to health promotion behaviors of
35
hypertensive patients in Bhutan. Hence, further understanding of health promoting
behaviors is necessary to improve nursing knowledge and develop appropriate nursing
interventions.
In conclusion, the literature review suggests that, perceived self-efficacy,
perceived benefit, perceived barriers and perceived social support to have positive
relationship. Nursing professionals can help individuals to improve healthy behaviors
as these factors are modifiable by nurses. Although health promoting factors have
been widely discussed in the literature, little is known in relation to Bhutanese
population with hypertension. In fact, no study has been carried out till date in Bhutan
to understand the factors related to health promoting behaviors in hypertensive
patients. Further, with difference in culture, values, beliefs, physical and social
characteristics of Bhutanese population with hypertension, the findings from other
studies may not be same with Bhutanese population. This lack of information in
relation to hypertensive population suggests investigation, in order to develop
effective nursing intervention. Understanding the factors and their relationships to
health promoting behaviors will provide a deeper insight for the nursing professionals
and other health care providers to develop effective nursing strategies to help
individuals with hypertension to engage in health promotion to control hypertension
and prevent complications. Therefore, this research aimed to study whether perceived
self-efficacy, perceived benefits, perceived barriers, and perceived social support have
any relationship with health promoting behaviors among Bhutanese population with
hypertension.
36
CHAPTER 3
RESEARCH METHODOLOGY
This chapter presents the research methodology including research design,
setting, population, sample, instruments, protection of human subjects, data collection
procedures, and data analysis.
Research design
A descriptive correlational design was used in this study to examine
the relationships of perceived self-efficacy, perceived benefits, perceived barriers,
perceived social support, and health promoting behaviors of Bhutanese patients with
hypertension.
Research setting
Sample for the research was gathered from the general medical outpatient
department of Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), which
is an apex hospital catering, services to all Bhutanese population. It is a 350 bedded
hospital, where patients from all over the country visit for their health needs.
The hospital is located in the capital city of Bhutan, where people from all part of
country resides as employees of different organizations. For the convenience of
the relatives, their dependents with chronic illness lives together to get easy access to
health care facilities. The general outpatient department of the hospital sees
approximately 30 adult hypertensive patients per day and provides treatment and
other counseling services for the patients. The outpatient department working time is
from 8.30 am till 3.00 pm daily from Monday to Friday and 8.30 am to 1.00 pm on
Saturdays. The patients registers at 8.30 am, takes the registration number and wait
for the physician, while nurse conducts routine task of blood pressure monitoring and
provide information on healthy behaviors to patients.
37
Population and sample
Population
Population for this study was patients with primary hypertension as
diagnosed by the physician, visiting the outpatient department of Jigme Dorji
Wangchuck National Referral Hospital (JDWNRH) for follow up treatment. Sample
was selected based on the inclusion criteria as follows:
1. Adult patients age 18 years and above.
2. Have been diagnosed with primary hypertension for at least 1 month.
3. No serious complications of hypertension such as paralysis, and NYHA
(New York Heart Association) stage four heart failure.
4. Be able to read and write English language.
Sample size
The sample size was determined by using power analysis, a method to
reduce the risk of type II errors (wrongly accepting false null hypotheses). G* power
software was used to calculate the sample size. An effect size of 0.25, power of .80
with four variables and alpha level of .05 was used to calculate the sample size (Faul,
Erdfelder, & Lang, 2009). Effect was necessary to ensure that the phenomenon exists
and to determine that the samples were enough to prevent accepting false null
hypothesis. Therefore, the minimum number of samples in the study was 123.
Sampling techniques
In this study, a simple random sampling method was used. Patients who met
the inclusion criteria were randomly selected from the list of patients who came for
follow up treatment. Method of recruitment was as follow:
1. Participants were recruited in the study by using simple random
sampling technique. The sampling frame was attained by collecting the registration
numbers distributed during the period from 8.30 am to 9.30 am after screening those
meeting the inclusion criteria.
2. On the days of data collection, the list of patient’s registration numbers
who come for follow-up at outpatient department were obtained.
3. The registration numbers of patients who met the eligible criteria were
put in a container and mixed well.
38
4. The researcher then randomly drew out the registration numbers from
the container one at a time to obtain the study sample.
5. The selected participant’s number was immediately replaced in
the container before the next number was picked to provide exactly equal
opportunities for each subject to be selected.
6. On average approximately 10-12 participants were recruited each day.
Research instruments
There were six instruments and all instruments were self-administered
questionnaires and in English version.
1. Demographic Questionnaire
Demographic Data Questionnaire (DDQ) was developed by the researcher.
The questionnaire was used to collect patient’s demographic information.
Demographic characteristics included gender, age, education level, marital status,
occupation, income, co-morbidity, blood pressure, duration of hypertension, and body
mass index.
2. Health Promoting Behaviors Questionnaires (HPBQ)
Health promoting behaviors was measured by 26 items health promoting
behaviors questionnaires, developed by the researcher based on Pender’s Health
Promotion Model (Pender et al., 2011) and literature review. The instruments used
a 4 point Likert-type scale “1” = never, “2” = sometimes, “3” = often, “4” = routinely.
This 26 item include seven subscales to measure specific health promoting behaviors:
Taking medication (1-5), physical activity (6-7), nutrition (8-12), weight management
(13-17), smoking cessation (18-19), limiting alcohol (20-21) and stress management
(22-26). Total score range from 26-104. Score for sub scale for taking medication,
nutrition, weight management and stress management range from 5-20 while for
physical activity, smoking cessation and limiting alcohol, the score range from 2-8.
A higher score close to the highest score indicated greater health promoting behaviors
performance. Scores are transformed from the highest possible score minus the lowest
possible score and divided by 3 to get the range as low, moderate and high (Polit &
Beck, 2010). The interpretation of the total score is described as low (26-52),
moderate (53-78), and high (79-104). The interpretation of the score of subscales for
39
taking medication, nutrition, weight management and stress management is described
as low (5-10), moderate (11-15) and high (16-20), while for physical activity,
smoking cessation and limiting alcohol, it is described as low (2-3), moderate (4-5)
and high (6-8).
3. Self-Rated Abilities for Health Practices Scale (SRAHPS)
Self-Rated Abilities for Health Practices Scale, developed by Becker et al.
(1993) was used to measure perceived self-efficacy. This 28 item included four
subscales, with 7 items in each subscales specific to measure self-perceived ability to
perform the following health promoting behaviors: Nutrition (items 1-7),
Psychological well-being (items 8-14), exercise (items 15-21), and health
responsibility (items 22-28). Each item was rated on a 5-point scale score as follows:
“1” = not at all, “2” = a little, “3” = somewhat, “4” = mostly, “5” = completely.
A total score range from 28-140 and was calculated by totaling the responses. Score
for sub scale range from 7- 35. The score close to the highest score reflected a higher
level of perceived self-efficacy. The scale had been tested in health fair attendees and
has established reliability. The Cronbach’s alpha for the health fair attendees was .94
for the entire scale, .92 for the exercise subscale, .81 for the nutrition subscale, .90 for
psychological well-being subscale, and .86 for the responsible health practice subscale
(Becker et al., 1993). For validity, the scores on the general self-efficacy scale
(Sherer et al., 1982) were moderately correlated with total scores on the SRAHP (r =
.43). General self-efficacy scale scores were most highly correlated with the
responsible health practices and psychological well-being subscale of the SRAHP (r =
.44 and r = .43 respectively). All correlations were significant at the p < .01 level.
4. The Benefits Assessment Scale (BAS)
The Benefit Assessment Scale developed by Murdaugh and Verran (1987)
was used to measure perceived benefits of health promotion behaviors. The BAS is
a self-report questionnaire consisting of 12 statements describing benefits to
undertaking preventive health behaviors. Participants indicated the extent of their
agreement or disagreement with each statement in a 4-point Likert-type scale.
Reponses range from “1” = strongly disagree to “4” = strongly agree for each item on
the BAS. Items 2, 8 and 12 have negative score and responses range from “4”
40
(strongly disagree) to “1” (strongly agree). The total possible scores ranged from
12 to 48. The score near to the highest score, the participant has on the BES,
the greater the participant’s perceived benefits. The reported reliability coefficient of
the BAS was 0.72-0.79, and the 2-week-test-retest in a healthy population was
0.52-0.71, indicating the BES as a reliable tool for assessing perceived benefits to
undertaking preventative health behaviors (Murdaugh & Verran, 1987).
5. Barriers to Health Promoting Activities Scale (BHPAS)
The Barriers to Health Promoting Activities Scale developed by Stuifbergen
and Becker, (1994) was used to measure perceived barriers to health promotion
behaviors. It is an 18 item, 4-point Likert-type scale “1”= never, “2” = sometimes,
“3” = often, “4” = routinely, that requests individuals to indicate how often the listed
barriers kept them from taking responsibility for their health. The score range from
18-72. The higher the score an individual received on this summated rating scale,
the greater the perceived barriers. The scale has established validity and reliability
with internal consistency reliability of .82, with a 2 week test-retest reliability of .75.
Discriminate validity is supported by t-test analysis establishing significant
differences in scores between disabled persons and a comparison group of non-
disabled individuals (Stuifbergen & Becker, 1994).
6. Personal Resource Questionnaire (PRQ2000)
Personal Resource Questionnaire (PRQ2000) developed by Weinert (2003)
was used to measure perceived social support in performing health promoting
behaviors. This instrument consisted of 15 items and each item was rated on a 7-point
scale ranging from “1” = strongly disagree to “7” = strongly agree. A total score was
obtained by totaling responses ranging from 15-105. Higher score indicated higher
level of perceived social support. The scale has established reliability with Cronbach’s
alpha ranging from .87 to .93. Construct validity is also confirmed by factors analysis
and discriminant validity (Weinert, 2003).
Quality of the instruments
Validity
The researcher used the original version of the instruments with qualified
validity, for the four instruments; therefore, content validity was not tested. The health
41
promoting behaviors questionnaires was tested for validity by panel of five experts
with experience in cardiovascular nursing and expert in Pender’s health promotion
model. Experts were asked to rate each items on a four point likert scale “1” = not
relevant to “4” = very relevant. Their opinion on possible revision was taken into
consideration. To ascertain validity of the instrument, a content validity index was
used to calculate the validity using Content Validity Index formula. Content Validity
Index = Number of agreed items/ Total number of items (Burns & Grove, 2005).
The content validity of the instrument was .70.
Reliability
A pilot study was carried out at Jigme Dorji Wangchuck National Referral
Hospital on 30 hypertensive patients who met the same inclusion criteria with
the sample in the study to test for the internal consistency reliability of
the questionnaires. The results identified that the Cronbach’s alpha coefficient of
the HPBQ was .95. For subscales of this instrument, the Cronbach’s alpha were .83
for taking medication, .70 for physical activity, .88 for nutrition, .85 for weight
management, .70 for smoking cessation, .78 for limiting alcohol consumption, and .80
for stress management. The SRAHPS questionnaire presented the Cronbach’s alpha
of .97. The Cronbach’s alpha for BAS was .70. The Cronbach’s alpha for BHPAS and
the PRQ2000 were .91 and .89 respectively.
Protection of human subjects
The study was submitted for approval to the Institutional Review Board
(IRB), Faculty of Nursing, Burapha University. Upon availing approval from IRB,
Faculty of Nursing, Burapha University, the researcher approached the chairperson of
the Research Ethic Board of Health, Ministry of Health, Thimphu, Bhutan for
approval to collect data at Jigme Dorji Wangchuck National Referral Hospital.
The letter from Burapha University was presented to the Medical Director of
the hospital to seek permission for data collection. Participants were explained about
research purpose, procedures and benefits of the study. Informed consent was
reviewed and signed by each participant prior to data collection. The participants were
assured that they had the right to refuse to participate or withdraw from the study at
any time without any penalty. Anonymity and confidentiality of the participant were
42
assured and no personal information was disclosed to any other persons. All data was
stored in a secure place and only utilized for the purpose of the research. The data
would be destroyed after one year of publication of the study.
Data collection procedure
Data collection was conducted after the research proposal was approved
by the IRB of Faculty of Nursing, Burapha University. The researcher submitted
the proposal and the IRB approval letter to the chairperson, Research Ethic Board of
Health, Ministry of Health, for approval. Upon getting approval from the chairperson,
Research Ethic Board of Health, Ministry of Health, the researcher approached
the Medical Superintendent of Jigme Dorji Wangchuck National Referral Hospital
with the letter from Burapha University to seek permission for data collection. After
receiving the permission, the researcher met with the nursing superintendent, head
nurse, and the nurses of outpatient department to inform them about data collection
procedures. The procedures of data collection were as follow:
1. On the data collection days, the researcher was present at the outpatient
department of the hospital at 8.30 am.
2. The researcher screened the patients who came for follow-up treatment
as per the inclusion criteria and collected the registration numbers distributed during
the period between 8.30 am to 9.30 am of patients who met the inclusion criteria.
3. Registration numbers of patients who met the inclusion criteria were
written on a piece of paper and put in a container and mixed well.
4. The researcher then randomly drawn out the registration numbers to
obtain the study sample. The selected participant’s number was immediately replaced
in the container before the next number was picked to provide equal opportunities for
each subject to be selected.
5. The selected patient was approached by the researcher about
participation in the study. The researcher explained about human protection, purpose
and method of the research, their rights to withdraw from the study. Patients were also
ensured that they can see the doctor as soon as they finish answering the
questionnaires and also their medications would be collected by the nurse. If the
patient agreed to participate; a written consent form was obtained from the patient.
43
6. The data were collected, while the patients were waiting for
the physician check-up or after visiting the physician for follow-up treatment. Prior
answering the questionnaires, patient’s blood pressure, height and weight was taken
and recorded.
7. Data were collected by using self-reported questionnaires.
The researcher explained direction to respond to the questionnaires and then allow
the participants to fill out the questionnaires in the room adjacent to the doctor’s
chamber. Each participant took approximately 40-60 minutes in answering all
the questions.
8. The researcher continued the data collection until the required sample
size was obtained.
9. Finally, each filled questionnaire was checked for completeness by
the researcher before allowing the participant to leave.
10. Finally code number was put on each questionnaire and entered the data
into the statistical program for data analysis.
In order to maintain quality of data collection, 10-12 participants were
recruited each day.
Data analysis
All data was analyzed by the statistical software. An alpha level for
statistical significance was set at .05. Following statistical procedure was performed
to analyze the data:
1. Descriptive statistics including frequency, percentage, mean, and
standard deviation (SD) was used to describe the demographic characteristics of the
sample, the independent variables (perceived self-efficacy, perceived benefits,
perceived barriers and perceived social support) and the dependent variable (health
promoting behaviors).
2. Pearson’s product moment correlation coefficient was used to examine
the relationships of perceived self-efficacy, perceived benefits, perceived barriers,
perceived social support and health promoting behaviors.
44
CHAPTER 4
RESULTS
This chapter presents the findings of data analysis which describes
the demographic characteristics, medical information of the participants, health
promoting behaviors, and examined the relationships between perceived self-efficacy,
perceived benefits, perceived barriers, perceived social support, and health promoting
behaviors of Bhutanese patients with hypertension. The findings are presented based
on the objectives and the hypotheses of the study. The results of the study are
presented below.
Part 1 Description of demographic characteristics and medical information
of the participants.
Part 2 Description of perceived self-efficacy, perceived benefits, perceived
barriers and perceived social support.
Part 3 Description of health promoting behaviors of the participants
Part 4 Relationships between perceived self-efficacy, perceived benefits,
perceived barriers, perceived social support and health promoting behaviors.
Part 1 Description of demographic characteristics and medical
information of the participants
A total of 123 sets of questionnaires were distributed, all questionnaires
were completed and returned yielding a 100 % return rate. The demographic
characteristics and the medical information of the participants are described in
Table 1.
45
Table 1 Frequency, percentage, mean, standard deviation of demographic
characteristics of the participants (n = 123)
Variables Number (n) Percentage (%)
Gender
Male 59 48
Female 64 52
Age (M = 54.1, SD = 10.9, min = 23, max = 79)
20-40 16 13.1
41-60 78 63.4
61-80 29 23.5
Education
Primary 44 35.8
Secondary 25 20.3
High school 26 21.2
Undergraduate 11 8.9
Graduate 17 13.8
Occupation
Government service 51 41.5
Business 19 15.4
Agriculturist 6 4.9
Housewife 28 22.8
Retired 19 15.4
Marital status
Single 3 2.4
Married 107 87
Divorced 3 2.4
Widowed 10 8.2
46
Table 1 (Cont.)
Variables Number (n) Percentage (%)
Income
Less than Nu. 10,000 32 26
Nu.10,000-Nu. 20,000 32 26
More than Nu. 20,000 59 48
Table 1 showed that the numbers of male and female participants in the
study were almost equal with male representing 48 % and female 52 %. Age of
participants ranged from 23 to 79 years with mean age of 54.1 (SD = 10.9). Majority
of the participants were in the age group of 41-60 and consisted of 63.4 %. Most of
the participants had attended primary school and consisted of 35.8 %. Majority of
the participants in the study were government employees and consisted of 41.5 %,
followed by housewives with 22.8 %. 87 % of the participants were married. Majority
of the participants earn more than Nu. 20,000 ($ 320) and consisted of 48 % of
the total participants.
The description of medical information which includes co-morbidities,
current blood pressure, duration of hypertension, and body mass index of
the participants are described in Table 2.
Table 2 Frequency, percentage, mean, standard deviation of medical information of
the participants (n = 123)
Variables Number (n) Percentage (%)
Co-morbidity
No 74 60.2
Yes 49 39.8
Diabetes 40 32.5
Renal failure 5 4.1
Heart disease 4 3.3
47
Table 2 (Cont.)
Variables Number (n) Percentage (%)
Current systolic blood pressure (M = 144.2, SD = 20.8, min = 101, max = 200)
< 140 mmHg 50 40.6
≥ 140 mmHg 73 59.4
Current diastolic blood pressure (M = 86.9, SD = 13.2, min = 50, max = 123)
< 90 mmHg 63 51.2
≥ 90 mmHg 60 48.8
BMI (M = 26.9, SD = 4.1, min = 17.5, max = 38.8)
< 18.5 3 2.4
18.5-24.9 36 29.4
25-29.9 60 48.7
> 30 24 19.5
Duration of hypertension (M = 6.69, SD = 4.81, min = 1, max = 25)
< 1 year 2 1.6
1-5 years 62 50.4
6-10 years 43 35
> 10 years 16 13
Table 2 showed that 39.8 % of the participants had some forms of
co-morbidity, with 32.5 % of participants reported diabetes as the most frequent
diagnosis. The mean systolic and diastolic blood pressure was 144.2/ 86.9 mmHg and
showed that more than 50 % of the participants had uncontrolled blood pressure. The
mean of body mass index (BMI) was 26.9 (SD = 4.1) with majority of the participants
(48.7 %) were overweight and 19.5 % were obese. Majority of the participants
(50.4 %), were diagnosed with hypertension for 1-5 years with mean score of 6.7
(SD = 4.8).
48
Part 2 Description of perceived self-efficacy, perceived benefits,
perceived barriers and perceived social support
The descriptions of the independent variables are described in Table 3.
Table 3 Mean, standard deviation, range of perceived self-efficacy, perceived
benefits, perceived barriers, and perceived social support (n = 123)
Variables Range M SD
Possible Actual
Perceived self-efficacy 28-140 54-133 102.54 19.06
Perceived benefits 12-48 28-48 39.45 3.55
Perceived barriers 18-72 24-64 43.16 8.68
Perceived social support 15-105 66-103 89.41 7.99
Table 3 showed the possible score range from 28-140 and the mean score of
perceived self -efficacy of sample was 102.54 (SD = 19.06) in the mid margin
indicating that participants had moderate perceived self-efficacy. The mean score of
perceived benefits of participants was 39.54 (SD = 3.55) in the higher margin
indicating that participants overall had high level of perceived benefits of health
promoting behaviors. For perceived barriers, mean score was 47.04 (SD = 8.35)
in the mid margin indicating that participants perceived moderate barriers to perform
health promoting behaviors. Similarly, the mean score of perceived social support in
the study was 89.41 (SD = 7.99) in the higher margin indicating that participants had
high level of perceived social support.
Part 3 Description of health promoting behaviors of the participants
The health promoting behaviors consisting of seven dimension as taking
medication, physical activity, nutrition, weight management, smoking cessation,
limiting alcohol and stress management are describe in Table 4.
49
Table 4 Mean, standard deviation, range of health promoting behaviors (n = 123)
Variables Range M SD
Possible Actual
Health promoting Behaviors 26-104 53-103 81.07 11.85
Taking medication 5-20 11-20 16.03 2.65
Physical activity 2-8 3-8 6.0 1.28
Nutrition 5-20 8-20 14.49 2.78
Weight management 5-20 9-20 14.88 2.75
Smoking cessation 2-8 2-8 7.37 1.148
Limit alcohol 2-8 2-8 7.11 1.137
Stress management 5-20 6-20 15.24 2.68
The health promoting behaviors consisting of seven dimensions as taking
medication, physical activity, nutrition, weight management, smoking cessation,
limiting alcohol and stress management are described in Table 4. It showed that
the possible score range from 26-104 and the mean score of health promoting
behaviors of the participants was 81.07 (SD = 11.85) in the higher margin indicating
that sample had high level of health promoting behaviors. The subscales of health
promoting behaviors of taking medication (M = 16.03, SD = 2.65); physical activity
(M = 6.0, SD = 1.28); smoking cessation (M = 7.37, SD = 1.14); limiting alcohol
(M = 7.11, SD = 1.13); and stress management (M = 15.24, SD = 2.68) were at higher
margin indicating high level in these domains. However, nutrition (M = 14.49,
SD = 2.75) and weight management subscales (M = 14.88, SD = 2.75) were at
moderate level.
50
Part 4 Relationships between perceived self-efficacy, perceived
benefits, perceived barriers, perceived social support and health
promoting behaviors
To examine the relationships between perceived self-efficacy, perceived
benefits, perceived barriers, perceived social support and health promoting behaviors,
Pearson’s product moment correlation coefficient was used. Assumptions of
normality, linearity, homoscedasticity and randomization were initially explored to
test the assumption for using Pearson correlation. The assumptions for using
Pearson’s product moment correlation coefficient were met. Pearson’s product
moment correlation coefficient was used to test the relationships between perceived
self-efficacy, perceived benefits, perceived barriers, perceived social support and
health promoting behaviors. The relationships between dependent variable and
independent variables are shown in Table 5.
Table 5 Pearson’s product moment correlation coefficient between health promoting
behaviors and related factors (n = 123)
Independent Variables Correlation coefficient (r)
Perceived self-efficacy .55**
Perceived benefits .26**
Perceived barriers -.47**
Perceived social support .27*
* p < .05, ** p < .01
The results showed that there was high positive correlation between health
promoting behaviors and perceived self-efficacy (r = .55, p < .01); moderate negative
correlation between health promoting behaviors and perceived barriers (r = -.47,
p < .01), low positive correlation between health promoting behaviors and perceived
social support (r = .27, p < .05) and low positive correlation between health
promoting behaviors and perceived benefits (r = .26, p < .01).
51
CHAPTER 5
CONCLUSION AND DISCUSSION
This chapter presents the summary of the study and findings, discussion of
the findings, limitations, implication and recommendation for further research.
The results are discussed according to the objectives and hypotheses of the study.
Summary of the study
The objectives of the study were to (1) describe the health promoting
behaviors of patients with hypertension, and (2) to examine the relationships of
perceived self-efficacy, perceived benefits, perceived barriers, and perceived social
support on health promoting behaviors of Bhutanese patients with hypertension.
Pender’s health promotion model provided a conceptual framework for the study.
Simple random sampling was used to recruit the sample of 123 participants who
visited the outpatient department of Jigme Dorji Wangchuck National Referral
Hospital, Thimphu, Bhutan. Data were analyzed using descriptive statistics and
Pearson’s correlation.
Data were obtained by self- reported questionnaires and included
the demographic questionnaires and Health Promoting Behaviors Questionnaires
developed by the researcher; Self-rated Abilities for Health Practice Scale (Becker et
al., 1993), Benefits Assessment Scale (Murdaugh & Verran, 1987), Barriers to Health
Promoting Activities Scale (Becker et al., 1993), and the Personal Resource
Questionnaires (Weinert, 2003). The reliabilities of the questionnaires were:
Cronbach’s alpha coefficient of .95 for health promoting behaviors scale, .97 for Self-
rated Abilities for Health Practice Scale, .70 for Benefits Assessment Scale, .91 for
Barriers to Health Promoting Activities Scale, and .89 for Personal Resource
Questionnaires.
52
Results of the study
1. Description of demographic characteristics and medical information:
The findings of the present study showed that the mean age of the participants was
54.1 (SD = 10.9), ranging from 23 years to 79 years. 52 % of the participants were
female. 87 % of the participants were married. 63.4 % participants were in the age
group of 41-60 years and most of the participants had attended primary school
(35.8 %). 41.5 % of the participants in the study were government employees with
monthly income of more than Nu. 20,000 ($ 320).
The result also showed that 39.8 % of the participants had co-morbidity,
with 32.5 % of participants reported diabetes as the most frequent diagnosis.
The mean systolic and diastolic blood pressure was 144.2/ 86.9 mmHg. The mean
body mass index (BMI) was 26.9 (SD = 4.1) with majority of the participants
(48.7 %) Majority of the participants (50.4 %), were diagnosed with hypertension for
1-5 years with mean score of 6.7 (SD = 4.8).
2. Description of perceived self-efficacy, perceived benefits, perceived
barriers, and perceived social support: The mean score of perceived self-efficacy of
sample in the study was 102.54 (SD = 19.06) indicating that participants had moderate
level of perceived self-efficacy. The mean score of perceived benefits of participants
was 39.54 (SD = 3.55) indicating that participants overall had high level of perceived
benefits of health promoting behaviors. For perceived barriers, mean score was 47.04
(SD = 8.35) indicating that participants perceived moderate barriers to perform health
promoting behaviors. Similarly, the mean score of perceived social support in
the study was 89.41 (SD = 7.99) indicating that participants had high level of
perceived social support.
3. Description of health promoting behaviors: The mean score of health
promoting behaviors of the participants was 81.07 (SD = 11.85). The results revealed
that sample had high level of health promoting behaviors (M = 81.07, SD = 11.85).
The subscales of health promoting behaviors of taking medication (M = 16.03,
SD = 2.65); physical activity (M = 6.0, SD = 1.28); smoking cessation (M = 7.37,
SD = 1.14); limiting alcohol (M = 7.11, SD = 1.13); and stress management
(M = 15.24, SD = 2.68) were at higher level. While, nutrition (M = 14.49, SD = 2.75)
and weight management subscales (M = 14.88, SD = 2.75) were at moderate level.
53
4. Relationships between perceived self-efficacy, perceived benefits,
perceived barriers and perceived social support: The results from Pearson’s product
moment correlation coefficient analysis suggested that there were high positive
correlation between health promoting behaviors and perceived self-efficacy (r = .55,
p < .01); moderate negative correlation between health promoting behaviors and
perceived barriers (r = -.47, p < .01); low positive correlation between health
promoting behaviors and perceived benefits (r = .26, p < .01); and low positive
correlation between health promoting behaviors and perceived social support (r = .27,
p < .05).
Discussion
The discussions of the findings are based on the objectives and hypotheses
of the study. First objective was to describe the health promoting behaviors and
the second objective was to examine the relationships between perceived self-
efficacy, perceived benefits, perceived barriers, perceived social support and health
promoting behaviors of hypertensive patients in Bhutan.
1. Health promoting behaviors
The results revealed that participants had high level of health promoting
behaviors (M = 81.07, SD = 11.85). The subscales of health promoting behaviors of
taking medication, physical activity, smoking cessation, limiting alcohol and stress
management were at higher level while nutrition and weight management were at
moderate level. The possibility of moderate to high level of health promoting
behaviors in the present study could be explained by several reasons.
The high level of health promoting behaviors could be explained by the fact
that majority of the participants were married (87 %). Marital status could be
the reason for explaining the high level of health promoting behaviors. Spousal
assistance may be associated with high level of health promoting behaviors for
hypertensive patients through providing practical support like helping to follow
regular exercise, healthy diet and reminding to take medications (Shumaker & Hill,
1991). Trivedi, Ayotte, Edelman, and Bosworth (2008), found that being married was
associated with better compliance to healthy recommendations of taking medication
(r = .19, p < .001), exercise recommendations (r = .10, p < .001) and lower incidences
54
of smoking (r = -.18, p < .001). Further, study by Yang et al. (2014) also found that
marital status was related to health promoting behaviors in hypertensive patients
(r = -.25, p < .001).
Another reason for explaining high level of health promoting behaviors
might relate to duration of hypertension. The result showed that 50.4 % of participants
were diagnosed with hypertension for 1-5 years. High level of health promoting
behaviors could be explained by longer duration of hypertension because patients had
the opportunity to gain more experiences and knowledge which facilitate them to
engage in health promoting behaviors. Longer duration provides participants to get
more healthy recommendations and counseling from the health workers which help
them to change behaviors (Heyman, Gross, Tabenkin, Poter, & Porath, 2011). Similar
study by Kumar Elayaraja, Shailaja and Ramasamy on 100 hypertensive patients
found that longer duration of hypertension and individual who received healthy
recommendations and counseling from health workers improved their health
behaviors in the domain of taking medications, smoking cessation and reducing
alcohol consumption (Kumar, Elayaraja, Shailaja, & Ramasamy, 2011). The result of
the previous study also confirmed for this explanation. For example, study by Peters
and Templin (2008) on 306 hypertensive participants found that participants with
a longer history of hypertension had significantly higher level of health promoting
behaviors (r = .19, p < .01) (Peters & Templin, 2008).
Further, other possible reasons could be socioeconomic status, since most of
the participants at least had primary education, work as government employees
(41.5 %), and earn more than Nu. 20,000 ($ 320). They have better understanding
about the importance of eating healthy foods, taking medications, exercise and
avoidance of unhealthy behaviors like smoking and drinking alcohol. In addition, this
present study was conducted in the capital and the biggest city in the country. This
could have provided participants, an access to practice the recommended health
promoting behaviors because the city has access to availability of resources.
Although participants had high level of health promoting behaviors, more
than 54.1 % of participants had uncontrolled blood pressure. Uncontrolled blood
pressure is found in patients who did not follow health promoting recommendations
specifically nutrition and weight management in present study. This could be
55
explained by the reason that patients might have acquired knowledge on health
promoting behaviors from health care providers but they might not have real
behaviors. Another possible contributing factor for participant’s uncontrolled blood
pressure was most likely from the culture that Bhutanese consume three meals daily
consisting of huge portion of rice which cause overweight resulting in increased blood
pressure (Sasaki, 2011). Further, the traditional Bhutanese dishes are red rice, chilli
pepper, cheese stew, and salted butter tea. Chilli pickles called ezay are frequently
served as appetizers and are consumed in large quantities. Generally, large amounts
of salt are added to both the curry and the pickle or paste (Wangdi, 2013). It was
evident that cultural backgrounds served as important influences on health promoting
behaviors (Pender et al., 2006). In addition having cultural environment in which
the offer of food is practiced as a social norm restricted health promoting behaviors
specifically dietary restriction or adherence which most likely resulted in poor control
of blood pressure.
2. Factors related to health promoting behaviors
There was high positive correlation between health promoting behaviors and
perceived self-efficacy (r = .55, p < .01); low positive correlation between health
promoting behaviors and perceived benefits (r = .26, p < .01); moderate negative
correlation between health promoting behaviors and perceived barriers (r = -.47,
p < .01) and low positive correlation between health promoting behaviors and
perceived social support (r = .27, p < .05) of patients with hypertension. This finding
was supported by theoretical basis. According to Health promotion Model (Pender
et al., 2011), these factors are the motivational mechanisms for individual’s
acquisition and maintenance of health promoting behaviors. They can both directly or
indirectly impact on patient’s practice of such behaviors.
2.1 Perceived self-efficacy and health promoting behaviors
The present study points out that perceived self-efficacy had a significant
high positive correlation with participant’s health promoting behaviors. It is in line
with the hypotheses that the present study had positive correlation with health
promoting behaviors among Bhutanese patients with hypertension (r = .55).
Theoretically, individual demonstrating a high perceived self-efficacy tends to
practice health promoting behaviors. In contrast, low perceived self-efficacy may lead
56
to giving up such behaviors once challenging difficulties arises (Pender et al., 2011).
When a person highly believes in oneself, the perceived barriers will be lowered, thus
can overcome the challenges. Similarly, hypertensive patients have to change their
life style once they are diagnosed with hypertension. Therefore, high perceived self-
efficacy is the crucial factor, determining whether the patient can get over difficulties
in order to adhere to health promoting behaviors.
Findings from other studies also supported those of the present study.
Jaiyungyuen et al. (2008) found, that perceived self-efficacy had positive relationship
with health promotion behaviors in population of people with hypertension (r = .59,
p < .01). Similarly, Warren-Findlow et al. (2012) in the study of 190 African-
American adults with hypertension found that people with high perceived self-
efficacy had higher prevalence of engaging in physical activities and eating low salt
diet. Similar, study by Ho et al. (2012), of 107 patients with hypertension found that
perceived self-efficacy was positively related to health promoting behaviors of
hypertension patients and explained most variance in health promotion behaviors
(β = .31, p < .01). Furthermore, study of 234 elderly women with hypertension in
South Korea, Yang et al. (2014), also supported the finding of present study, that
perceived self-efficacy had positive relationship with health promoting behaviors
(r = .60, p < .001).
2.2 Perceived benefits and health promoting behaviors
There is positive relationship between perceived benefits and health
promoting behaviors among Bhutanese patients with hypertension. The results also
identified that perceived benefits had low positive relationship with health promoting
behaviors in hypertensive patients in this study (r = .26). According to Pender et al.
(2011), individuals tend to engage in health promoting behaviors if they perceived
positive outcomes. Likewise the participants demonstrated that they had a high level
of perceived benefits of health promotion behavior and hypertension control. All
agreed that regular exercise, eating low fat foods, maintain a normal weight, and
smoking cessation decreases the risk of complications and helps in preventing high
blood pressure. Similarly, all agreed that annual checkups were important for
detecting complications. These findings are similar to previous research. Thanavaro et
al. (2006), found that, perceived benefits was positively related to health promotion
57
behaviors (r = .38, p < .01). In their study, the participants identified improving
health, feeling better, and living longer as perceived benefits of health promotion
behaviors (Mosca et al., 2006; Thanavaro et al., 2006). Similarly, the study by
Nangyaem et al. (2007) among 198 hypertensive patients, the result supported the
finding that perceived benefits was significantly related to health promoting
behaviors among hypertensive patients (r = .27, p < .01).
2.3 Perceived barriers and health promoting behaviors
There is negative relationship between perceived barriers and health
promoting behaviors among Bhutanese patients with hypertension. The result
identified that there was moderate negative relationship between perceived barriers
and health promoting behaviors (r = -.47). According to Pender et al. (2011),
perceived barriers consists of perceptions about the unavailability, inconvenience,
expensive, difficulty, or time consuming nature of a particular action that affect health
promoting behavior directly by serving as blocks to action as well as indirectly
through decreasing commitment to a plan of action. Studies demonstrated that
perceiving either environmental or personal barriers was inversely associated with
health promotion behavior. In this study, maximum number of participants had at
least primary education, indicating that individuals with education perceived that they
experienced barriers less frequently than other participants. One reason for this is that
those with education have the means to seek care and know the value of health
promoting behavior, thus gaining the benefits that providers can contribute in
the form of education regarding health promotional behaviors (Lusk, Kerr, & Ronis,
1995). Further, in this study majority of participants were in between the age group
41-60 years which represented adult people who might have perceived minimal
barriers compared to elderly people (Wen, Parchman, & Shepherd, 2004).
The relationship between health promoting behaviors and perceived barriers in this
study is similar to the finding of Nangyaem et al. (2007), that perceived barriers was
related to health promoting behaviors (r = -.175, p < .01) (Nangyaem et al., 2007).
In contrast, the findings of present study were not consistent with Pierce (2005) which
found that there were no significant relationship between perceived barrier and health
promoting behaviors.
58
2.4 Perceived social support and health promoting behaviors
There is positive relationship between perceived social support and health
promoting behaviors among Bhutanese patients with hypertension. The results
revealed that there was low positive relationship between perceived social support and
health promoting behaviors (r = .27). This finding was supported by both theoretical
and studied basis. According to Pender et al. (2011), the support from others played
a crucial role to encourage patients in having health promoting behaviors. High level
of perceived social support leads to increased attachment, social integration,
nurturance, reassurance of worth, and perceived availability of assistance from others
in managing hypertension. Kanittha, Sukanya, Sutham, and Chokchai (2010) explored
341 hypertensive patients and reported that perceived social support was positively
related with health promoting behaviors (r = .40, p < .001). Jaiyungyuen et al. (2008),
in study of older people with hypertension also found that social support was
positively related to health promotion behavior in hypertensive patients (r =.38,
p < .01). Similar study by Ho et al. (2012), also found that social support was
significantly related to health promotion behaviors in adult patients with hypertension
which supports the findings of this study. The study found that better social support,
the better practice of health promoting behaviors. It can be explained that,
hypertension, as a chronic condition remains throughout in the lifetime. Therefore, the
disease requires the patients to change the lifestyle, habits and attitudes to their health.
Consequently, the patients need more support from significant others to deal with the
disease in their daily life.
In conclusion, for examining the health promoting behaviors of hypertensive
patients in Bhutan, it was apparent that sample in this study reported high level of
health promoting behaviors in order to manage hypertension. The study showed that
participants had high level of health promoting behaviors in the domain of taking
medications, physical activities, smoking cessation, limiting alcohol consumption and
stress management while nutrition and weight management had moderate level.
As expected, there were relationships between health promoting behaviors and
perceived self-efficacy, perceived benefits, perceived barriers and perceived social
support. Specifically, perceived self-efficacy found to have high correlation,
59
perceived barriers had moderate correlation and perceived benefits and perceived
social support had low correlation.
Implications
The findings of this study can be applied for clinical nursing practice,
nursing research and nursing education as follows:
For clinical nursing practice, the results of this study provided the nurses
an understanding about health promoting behaviors practices among hypertensive
patients in Bhutan. In addition, the confirmation of the relationships of health
promoting behaviors, perceived self-efficacy, perceived benefits, perceived barriers
and perceived social support provided the basis for clinical nurses to understand
the role of these factors while taking care for the patients with hypertension. Nurses
can provide information about benefits of health promoting behaviors and motivate
individuals to overcome barriers to practice health promoting behaviors. Enhancing
self-efficacy and support from other decreases barriers and helps in understanding
the benefits of health promoting behaviors. Further, nurses can also be confident in
developing nursing plans, for helping patients to have better behaviors in all domains
of health promoting behaviors, specifically in the domains of nutrition and weight
management that this study highlighted as moderate health promoting behaviors
among hypertensive patients.
For nursing education, the findings of this study identified factors including
perceived self-efficacy, perceived benefits, perceived barriers and perceived social
support can motivate the hypertensive patients in engaging and maintaining health
promoting behaviors. Thus, educating student nurses on these variables with focused
to Bhutanese culture may be needed.
For research, the findings identified the related factors of health promoting
behaviors among hypertensive patients in Bhutan. The results from this study may be
used for further research in health promoting behaviors of hypertensive patients and
explore the influences of these variables on health promoting behaviors as well as
develop nursing plan in order to modify health promoting behaviors of hypertensive
patients in Bhutan.
60
Recommendations for future research
Based on the results of the study, following are the recommendations for
future research:
1. Although this study was carried out in a national referral hospital, which
is an apex hospital in the country, it is acknowledged that the findings from a single
setting seem not to be strong enough to represent all the characteristics of Bhutanese
patients with hypertension. Thus, it is recommended that study should be replicated in
multiple settings in order to enhance the generalization of the findings. The results
from this study may also be used for further research to explore the influences of these
variables on health promoting behaviors as well as in order to modify health
promoting behaviors of hypertensive patients in Bhutan.
2. Future research should be predictive design aimed to enhancing patient’s
perceptions towards self-efficacy, perceived benefits, perceived barriers and perceived
social support for promoting and maintaining health promoting behaviors of patients
with hypertension.
Conclusion
With the hypotheses that perceived self-efficacy, perceived benefits,
perceived barriers, and perceived social support are associated with health promoting
behaviors of hypertensive patients; the present study was conducted with
123 participants. Data collected from the questionnaires proved the hypotheses. There
were relationships between perceived self-efficacy, perceived benefits, perceived
barriers, perceived social support and health promoting behaviors of hypertensive
patients. Thus, the findings of this study provided information to strengthen the roles
of perceived self-efficacy, perceived benefits, perceived barriers, and perceived social
support in determining hypertensive patient’s health promoting behaviors. The results
also highlighted a moderate score in nutrition and weight management domains of
health promoting behaviors. Thus, health care professionals, and nurses in particular
should motivate hypertensive patients to engage in proper nutrition and weight
management activities.
61
REFERENCES
Adeniyi, A. F., Idowu, O. A., Ogwumike, O. O., & Adeniyi, C. Y. (2012).
Comparative influence of self-efficacy, social support and perceived
barriers on low physical activity development in patients with type 2
diabetes, hypertension or stroke. Ethiopian Journal of Health Science,
22(2), 113-119.
American Heart Association [AHA]. (2013). In American Stroke Association (Ed.),
What about African Americans and high blood pressure? Retrieved from
http://www.American heart.org/statistics.
American Heart Association [AHA]. (2005). Heart disease and stroke statistics 2006.
Retrieved from http://www.americanheart.org/presenter.jhtml?identifier
Annual health report. (2013). Thimphu, Bhutan: Ministry of Health.
Appel, L. J., Moore, T. J., Obarzanek, E., Vollmer, W. M., Svetkey, L. P., Sacks, F.
M., Bray, G. A., Vogt, T. M., Culter, J. A., Windhauser, M. M., Lin, P.,
Karanja, N., Simons-Morton, D., McCullough, M., Swain, J-Steele, P.,
Evans, M. A., Miller, E. R., & Harsha, D. W. (1997). A clinical trial of
the effects of dietary patterns on blood pressure. The New England Journal
of Medicine, 336(16), 1117-1124.
Appel, L., Champagne, C., Harsha, D., Cooper, L., Obarzanek, E., & Elmer, P.
(2003). Writing group of the PREMIER collaborative research group.
Journal of American Medical Association, 289, 2083-2093.
Appel, L. J., Brands, M. W., Daniels, S. R., Karanja, N., Emler, P. J., & Sacks, F. M.
(2006). Dietary approach to prevent and treat hypertension. A scientific
statement from the American Heart Association. Journal of Hypertension,
47, 296-308.
Ashida, S., Wilkison, A. V., & Koehly, L. M. (2012). Social influence and motivation
to change health behaviors among Mexican origin adults: Implications for
diet and physical activity. American Journal of Health Promotion, 26(3),
176-179.
62
Bandura, A. (1997). Perceived self-efficacy: The exercise of control. New York:
W. H. Freeman.
Becker, H., Stuifbergen, A., Oh, H., & Hall, S. (1993). Self-rated abilities for health
practices: A health self-efficacy measure. Health Values, 17(5), 42-50.
Beevers, D., Lip, G., & O’ Brien, E. (2007). ABC of hypertension (5th
ed.).
Massachuesetts: Blackwell.
Burns, N., & Grove, S. K. (2005). The practice of nursing research: Conduct,
critique, and utilization (5th
ed.). St. Louis: Elsevier.
Catala- Lopez, F., Sanfelex-Gimeno, G., Garcia-Torris, C., Ridao, M., & Periso, S.
(2012). Control of arterial hypertension in Spain: A systemic review and
meta-analysis of 76 epidemiological studies on 341632 participants. Journal
of Hypertension, 30(1), 168-176.
Centers for Disease Control and Prevention, National Institutes of Health. (2000).
Healthy people 2010: Heart disease and stroke. Retrieved from
http://www.healthypeople.gov/Document/HTML/Volume1/12Heart.htm.
Centers for Disease Control and Prevention [CDC]. (2011). Vital signs: Awareness
and treatment of uncontrolled hypertension among adults. Morbidity and
Mortality Weekly Report, 61(35), 703-709.
Chobanian, A., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L.
J., Jones, D.W., Materson, B. J., Oparil, S.,Wright, J. T. J., & Roccella, E. J.
(2003). Seventh report of the joint national committee on prevention,
detection, evaluation, and treatment of high blood pressure: The JNC 7
report. Journal of the American Medical Association, 42, 1206-1252.
Collins, R., Peto, R., MacMahon, S., Hebert, P., Fiebach, N. H., Eberlein, K. A.,
Godwin, J., Qizilbash, N., Taylor, J. O., & Hennekens, C. H. (1990).
Blood pressure, stroke, and coronary heart disease: Part 2, Short-term
reductions in blood pressure: Overview of randomized drug trials in
their epidemiological context. Lancet, 335(8693), 827-838.
Cowan, M., Dorji, G., & Pelzom, D. (2009). Report of 2007 STEPs survey for risk
factors and prevalence of non-communicable diseases in Thimphu, Bhutan.
Thiphu: Ministry of Health.
63
Cummings, D. M., Amadio, P., Nelson, L., & Fitzgerald, J. M. (1991). The role of
calcium channel blockers in the treatment of essential hypertension. Arch
Intern Med, 151(2), 250-259.
Dominiczak, A. F., Negrin, D. C., Clark, J. S., Brosnan, M. J., & Alexander, Y.
(1999). Genes and hypertension: From gene mapping in models vascular
gene transfer strategies. Journal of Hypertension, 35, 164-172.
Eckman, M., & Kirk, K. (2013). Pathophysiology: Made incredibly easy (5th
ed.).
Philadelphia: Woltrrs Kluwer Health.
Fagard, R. H. (2005). Effects of exercise, diet and their combination on blood
pressure. Journal of Human Hypertension, 19, s20-s24
Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analyses
using G*Power 3.1: Tests for correlation and regression analyses. Behavior
Research Methods, 41, 1149-1160.
Fukuta, H., & Little, W. C. (2007). Diagnosis of diastolic heart failure. Current
Cardiology Reports, 9(3), 224-228.
Gandhi, S. K., Powers, J. C., Nomeir, A. M., Fowle, K., Kitzman, D. W., & Rankin,
K. M. (2001). The pathogenesis of acute pulmonary edema associated
with hypertension. New England Journal of Medicine, 344(1), 17-22.
Gaziano, T. A. (2008). Economic burden and the cost-effectiveness of treatment of
cardiovascular diseases in Africa. Heart, 94, 140-144.
Giri, B. R., Sharma, K. P., Chapagai, R. N., & Pelzom, D. (2013). Diabetes and
hypertension in Bhutanese men and women. Indian Journal of Medicine,
38(3), 138-143.
Hajjar, I., & Kotchen, T. A. (2003). Trends in prevalence, awareness, treatment, and
control of hypertension in the United States. Journal of the American
Medical Association, 290(2), 199-206.
Heidenreich, P. A., Trogdon, J. G., & Khavjou, O. A. (2011). Forecasting the future
of cardiovascular disease in the United States: A Policy Statement from
the American Heart Association. Circulation-Journal of the American
Heart Association, 123, 933-944.
64
Heyman, A., Gross, R., Tabenkin, H., Poter, B., & Porath, A. (2011). Factors
associated with hypertensive patients’ compliance with recommended
lifestyle behaviors. Isreal Medical Association Journal, 13, 553-557.
Ho, N. T., Pathumarak, N., & Hengudomsub, P. (2012). Factors influencing health
promoting behaviors of Vietnamese patients with hypertension. Journal of
Science, Technology, and Humanities, 10(1), 65-71.
Huang, N., Duggan, K., & Harman, J. (2008). Lifestyle management of hypertension.
Australian Prescribers, 31(6), 150-153.
Huether, S., & McCance, E. (2012). Understanding pathophysiology (5th
ed.).
St. Louis: Mosby.
Jaiyungyuen, U., Suwonnaroop, N., Priyatruk, P., & Moopayak, K. (2008). Factors
influencing health promotion behaviors of older people with hypertension.
Bangkok: Mahidol University.
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure [JNC 7]. (2003). American heart association.
Retrieved from http:// hyper.ahajournals.org
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure [JNC 8]. (2014). Evidence-based guidelines for
the management of high blood pressure in adults: Report from the panel
members appointed to the eighth joint national committee (JNC 8).
Retrieved from http://jama-jamanetwork.com
Kamppainea, J., Bomar, P. J., Kikuchi, K., Kanematsu, Y., Ambo, H., & Noguchi, K.
(2011). Health promotion behaviors of residents with hypertension in Iwate,
Japan and North Carolina, USA. Japan Journal of Nursing Science, 8,
20-32.
Kanittha, C., Sukanya, P., Sutham, N., & Chokchai, M. (2010). Factors influencing
health promoting behaviors among the elderly under the universal coverage
program, Buriram Province, Thailand. Asia Journal of Public Health, 1(1),
15-19.
Kaushik, R. M., Kaushik, R., & Mahajan, S. K. (2006). Effects of mental relaxation
and slow breathing in essential hypertension. Complementary Therapies in
Medicine, 14, 120-126.
65
Khatib, R., Schwalm, J. D., Yusuf, S., Haynes, R. B., McKee, M., & Nieuwallt, R.
(2014). Patient and healthcare provider barriers to hypertension awareness,
treatment and follow up: A systematic review and meta-analysis of
qualitative and quantitative studies. PLoS ONE, 9(1), 1-12.
Kumar, M. A., Elayaraja, J., Shailaja, K., & Ramasamy, C. (2011). Improving
medication adherence and clinical outcomes of hypertensive patients
through patient counseling. Pharmaceutical, Biological and Chemical
Sciences, 2(3), 231-241.
Kwong, E. W., & Kwan, A. Y. (2007). Participation in health- promotion behavior:
Influences on community-dwelling older Chinese people. Journal of
Advanced Nursing, 57(5), 522-534.
Lawes, C. M., Vander, S., & Rodgers, A. (2008). International society of
hypertension. Global burden of blood pressure related disease. The Lancet,
371(9623), 1513-1518.
Lee, J., Han, H., Song, H., Kim, J., Kim, K. B., Ryu, J. P., & Kim, M. T. (2010).
Correlates of self-care behaviors for managing hypertension among Korean
Americans: A questionnaire survey. International Journal of Nursing
Studies, 47, 411-418.
Lee, L., Arthur, A., & Avis, M. (2007). Evaluating a community-based walking
intervention for hypertensive older people in Taiwan: A randomized
controlled trial. Journal of Preventive Medicine, 44, 160-166.
Leung, A. A., Wright, A., Pazo, V., Karson, A., & Bates, D. W. (2011). Risk of
thiazide-induced hyponatremia in patients with hypertension. American
Journal of Medicine, 124(11), 1064-1072.
Lucas, J. A., Orshan, S. A., & Cook, F. (2000). Determinants of health promoting
behavior among women ages 65 and above living in the community.
Scholarly Inquiry for Nursing Practice, 14(1), 77-100.
Lusk, S. L., Kerr, M. J., & Ronis, D. L. (1995). Health-promoting lifestyles of
bluecollar, skilled trade, and white-collar workers. Nursing Research, 44(1),
20-24.
66
Marín, R., Gorostidi, M., Fernández-Vega, F., & AlvarezNavascués, R. (2005).
Systemic and glomerular hypertension and progression of chronic renal
disease: The dilemma of nephron sclerosis. Kidney International
Supplement, 68(99), S52-S56.
Martin, M. T., Person, S. D., Kratt, P., Prayor-Patterson, H., Kim, Y., Salas, M.,
& Pisu, M. (2012). Relationship of health behavior theories with self-
efficacy among insufficiently active African-American women. Journal of
Patient Education and Counseling, 72(1), 137-145.
Mosca, L., Mochari, H., Christian, A., Berra, K., Taubert, K., Mills, T., Burdick, A.
W., & Simpson, S. L. (2006). National study of women's awareness,
preventive action, and barriers to cardiovascular health. Circulation-Journal
of the American Heart Association, 113(4), 525-534.
Murdaugh, C. L., & Verran, J. A. (1987). Theoretical modeling to predict
physiological indicants of cardiac preventive behaviors. Nursing Research,
36(5), 284-291.
Murimi, M. W., & Harpel, T. (2010). Practicing preventive health: The underlying
culture among low-income rural populations. Journal of Rural Health,
26(3), 273-82.
Nangyaem, A., Deenan, A., & Chunlestskul, K. (2007). Determinants of eating
behavior of hypertensive patients. Journal of Nursing Science
Chulalongkorn University, 19(3), 84-96.
National Health Survey [NHS]. (2012). Thimphu, Bhutan: Ministry of Health.
O'Brien, E., Beevers, D. G., & Lip, G. Y. H. (2007). ABC of hypertension. London:
BMJ Books.
Pender, N. J., Barkauskas, V. H., & Hayman, L. (1992). Health promotion and disease
prevention: Toward excellence in nursing practice and education. Nursing
Outlook, 40,106-112.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health promotion in
nursing practice. Upper Saddle River, NJ: Prentice Hall.
Pender, N. J., Murdaugh, C., & Parsons, M. A. (2011). Health promotion in nursing
practice. (6th
ed.). New Jersey: Pearson Prentice Hall.
67
Pereira, M., Lunet, N., Azevedo, A., & Barros, H. (2009). Differences in
prevalence, awareness, treatment and control of hypertension between
developing and developed countries. Journal of Hypertension, 27(5), 963-
975.
Peters, R., & Templin, T. (2008). Measuring blood pressure knowledge and self-care
behaviors of African Americans. Research in Nursing and Health,
31(6), 543-552.
Philips, E. (2014). “The silent killer”: A review of psychological factors and systems-
level interventions that address hypertension in African American men.
Graduate Annual, 12(2), 54-58.
Pierce, C. (2005). Health promotion behaviors of rural women with heart failure.
Journal of Rural Nursing and Health Care, 5(2), 28-37.
Polit, D. F.,& Beck, C. T. (2010). Essentials of nursing research: Applying evidence
for nursing practice (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
Rana, B. K., Insel, P. A., Payne, S. H., Abel, K., Beutler, E., Zlegler, M. G., Schork, N.
J., & O’Connor, D. T. (2007). Population based sample reveals
gene-gender interactions in blood pressure in white Americans. Journal of
Hypertension, 49(1), 96-106.
Rigaud, A. S., Seux, M. L., Staessen, J. A., Birkenhager, W. H., & Forette, F.
(2000). Cerebral complications of hypertension. Journal of Human Hypertension, 14,
605-616.
Sasaki. (2011). Bhutan could be eating itself sick, Bhutan Observer. Retrieved
from http://www.bhutanobserver.bt/bhutaneating-sick
Sharma, S. B., Kulkarni, S., Mishra, K. P., & Srivastava, V. (2013). Stress: Effects on
human health and its management. Indo-American Journal of
Pharmacology Research, 3(10), 8297-8307.
Sherer, M., Maddux, J. E., Mercandante, B., Prentice-Dunn, S., Jacobs, B., & Rogers, R.
W. (1982). The Self-Efficacy Scale: Construction and validation.
Psychological Reports, 51, 663-671.
Shumaker, A., & Hill, R. (1991). Gender differences in social support and physical
health. Health Psychology, 10(2), 102-111.
Stuifbergen, A. K., & Becker, H. A. (1994). Predictors of health-promoting lifestyles
in persons with disabilities. Research in Nursing & Health, 17, 3-13.
68
Thanavaro, J. L., Moore, S. M., Anthony, M., Narsavage, G., & Delicath, T. (2006).
Predictors of health promotion behavior in women without prior history of
coronary heart disease. Applied Nursing Research, 19(3), 149-155.
Trivedi, D., Ayotte, B., Edelman, D., & Bosworth, H. (2008). The association of
emotional well-being and marital status with treatment adherence among
patients with hypertension. Journal of Behavioral Medicine, 31(6),
489-497.
Velagaleti, R., & Vasan, R. S. (2007). Heart failure in the 21st century: Is it a coronary
artery disease problem or hypertension problem? Cardiol Clin, 25(4),
487-500.
Verma, A., & Solomon, S. D. (2009). Diastolic dysfunction as a link between
hypertension and heart failure. The Medical Clinics of North America, 93(3),
647-664.
Viera, A. J., Kshisagar, A. V., & Hinderliter, A. L. (2008). Lifestyle modifications to
lower or control high blood pressure: Is Advice associated with action?
The behavioral risk factor surveillance survey. The Journal of Clinical
Hypertension, 10(2), 105-111.
Waite, L., & Lehrer, E. (2003). The benefits from marriage and religion in the
United States: A comparative analysis. Journal of Population
Development, 29(2), 255-276.
Wangdi, T. (2013). Burden, determinants and control of hypertension: A bhutanese
perspective. Regional Health Forum, 17(1), 20-25.
Walker, S. N., & Hill-Polerecky, D. M. (1996). Psychometric evaluation of the
health-promoting lifestyle profile II. Unpublished manuscript, University of
Nebraska Medical Center.
Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The health-promoting lifestyle
profile: Development and psychometric characteristics. Nursing Research,
36(2), 76-81.
Warren-Findlow, J., Seymour, R. B., & Huber, L. (2012). The association between
self-efficacy and hypertension self- care activities among African American
adults. Journal of Community Health, 37(1), 10-15.
69
Weinert, C. (2003). Measuring perceived social support: PRQ2000. In O. L.
Strickland, & C. DiIorio. (Eds.), Measurement of nursing outcomes
(pp. 161-172). New York: Springer.
Wen, L., Parchman, M., & Shepherd, M. (2004). Family support and diet barriers
among older hispanic adults with type 2 diabetes. Journal of Family
Medicine, 36(6), 423-430.
Whelton, S. P., Chin, A., & Xin, X. (2002). Effect of aerobic exercise on blood
pressure: A meta-analysis of randomized, controlled trials. Annal of
Internal Medicine, 136(7), 493-503.
White, W. B. (2009). Defining the problem of treating the patient with hypertension
and arthritis pain. The American Journal of Medicine, 122(5), S3-S9.
Whitworth, J. A. (2003). World Health Organization International Society of
Hypertension (ISH) statement on management of hypertension. Journal of
Hypertension, 21(11), 1983-1992.
Wong, T. Y., & Mitchell, P. (2004). Hypertensive retinopathy. The New England
Journal of Medicine, 351(22), 2310-2317.
World Health Organization [WHO]. (2011). Impact of out of pocket payments for
treatment of non-communicable diseases in developing countries: A review
of literature. WHO discussion paper. Geneva: World Health Organization.
World Health Organization [WHO]. (2013). A global brief on hypertension, Silent
killer, global public health crisis: World Health Day, 2013. Retrieve from
http://apps.who.int/iris/bitstream/10665/79059/1/WHO_DCO_WHD_2013.2
eng.pdf
Xin, X., He, J., Frotini, M., Ogden, L., Motsamai, O., & Whelton, P. (2001). Effects
of alcohol reduction on blood pressure: A meta-analysis of randomized
control trials. Journal of Hypertension, 38, 1112-1117.
Yang, S., Jeong, G., Kim, S., & Lee, S. H. (2014). Correlates of self-care behaviors
among low–income elderly women with hypertension in South Korea.
Journal of Obstetric Gynecology and Neonatal Nursing, 43, 97-106.
70
APPENDICES
71
APPENDIX A
Questionnaires (English version)
72
QUESTIONNAIRES
Date…………………
Code number……….
Questionnaire 1
The Demographic Questionnaire
Direction: Please read each question carefully and answer all questions by
tick mark (√) in the box for your correct response.
Please fill out your information in the space below.
1. Gender Female Male
2. Age…………….. years
3. Education level
Primary school Undergraduate
Secondary School Graduate
High School
4. Occupation
Unemployed Agriculturalist
Governmental office Housewife
Business Retired
5. Marital Status
Single Divorced
Married Widowed
6. Income
Less than Nu.10, 000 Nu. 10,000-20,000
More than Nu. 20,000
73
7. Comorbidity Yes No
Diabetes
Renal failure
Heart disease
Stroke
Others……………………..please specify.
This part of the questionnaires will be filled by the researcher
8. Current blood pressure………………………..
9. Duration of hypertension since diagnosis………………
10. Body mass index………………………(calculated from weight and height)
74
Questionnaire 2
Health Promoting Behaviors Questionnaires (HPBQ)
Direction: This questionnaire contains statements of activities you perform
to manage hypertension and control blood pressure. Please respond to each item by
indicating the frequency of activities you engage in each behaviors. Please fill the
statements by mark (√) in the column.
Never = Means you never perform these activities in a week.
Sometimes = Means you perform these activities 1-2 times per week.
Often = Means you perform these activities 3-4 time per week.
Routinely = Means you perform these activities every day in a week
No.
STATEMENTS
Nev
er
Som
etim
es
Oft
en
Rou
tin
ely
1
Taking Medication
Taking medications at assigned time.
2 …………………………………….
3 …………………………………….
4 …………………………………….
5 Monitor blood pressure.
6
Physical Activity
Perform 30 minutes physical activity like walking,
bicycling, and aerobic dancing.
7 …………………………………………………………
…………………………………………………………
…………………
8
Nutrition
Avoiding fatty foods like fried foods, cheese and butter.
75
No.
STATEMENTS
Nev
er
Som
etim
es
Oft
en
Rou
tin
ely
9 …………………………………………………………
…………………………………………………
10 ……………………………………………………
11 …………………………………………………………
………………………………………………………
12 Avoid using extra salt at meals.
13
Weight Management
Check body weight.
14 Eat meals in smaller portion.
15 …………………………………………………………
16 …………………………………………………………
…………..
17 Avoid sugary and fizzy drinks like coco-cola, Pepsi etc.
18
Smoking Cessation
Quitting smoking at all time.
19 …………………………………………
20 Limit Alcohol
Not drinking alcohol or limit drinking alcohol at all
time.
21 ……………………………………………….
22 Stress Management
Avoid stressful situations
23 ………………………………………………..
24 …………………………………………………..
25 ……………………………………………
26 Practice relaxation or meditation for 15-20 minutes
daily
76
Questionnaire 3
Self-Rated Abilities for Health Practices Scale (SRAHPS)
Direction: The following scale asks your confidence in performing various
health promoting behaviors. Read each statement and use the following scale to
indicate how well you are able to perform each of the activities. Please fill the
statements by mark (√) in the column.
No Statement
Not
at
all
A l
ittl
e
Som
ewh
at
Most
ly
Com
ple
tely
1 2 3 4 5
1 Find healthy foods that are within my budget
2 Eat a balanced diet
3 Figure out how much I should weight to be
healthy
4 …………………………………………
5 …………………………………………
6 ………………………………………...
7 …………………………………………
8 ………………………………………....
9 …………………………………………
10 …………………………………………
11 …………………………………………
13 …………………………………………
14 ……………………………………………..
15 …………………………………………
16 ………………………………………………
17 Find ways to exercise that I enjoy
18 Find accessible places for me to exercise in the
community
77
No Statement
Not
at
all
A l
ittl
e
Som
ewh
at
Most
ly
Com
ple
tely
1 2 3 4 5
19 ……………………………………
20 ……………………………………
21 ………………………………………….
22 ……………………………………………………
……………………………
23 ……………………………………………………
……………………………………………..
24 ……………………………………………………
…………………….
25 …………………………………….
26 Find a doctor or nurse who gives me good advice
about how to stay healthy
27 Know my rights and stand up for myself
effectively
28 Get help from others when I need it
78
Questionnaire 4
The Benefits Assessment Scale (BAS)
Directions: The following questions ask about your perception of performing
health promoting behaviors. Please indicate how strongly you agree or disagree to
each statement. There is no right or wrong answers as the statements measure
perception. Please fill the statements by mark (√) in the column.
No Statement
Str
on
gly
Dis
agre
e
Dis
agre
e
Agre
e
Str
on
gly
A
gre
e
1 2 3 4
1 Regular exercise may decrease my chances of a heart
attack.
2 Even if I eat a low fat diet I will not reduce my chance of
heart disease.
3 Regular exercise helps reduce tension and stress.
4 ……………………………………………………
..............................
5 ……………………………………………………………
……………………………..
6 ……………………………………………………………
…………………
7 ……………………………………………………………
………………….
8 ……………………………………………………………
…………………..
9 ……………………………………………………………
……………………
79
No Statement
Str
on
gly
Dis
agre
e
Dis
agre
e
Agre
e
Str
on
gly
A
gre
e
10 Regular exercise can make me feel I have more energy.
11 If I stopped smoking I will lower my chances of heart
disease
12 If I have smoked for many years it is too late to stop now
80
Questionnaire 5
Barriers to Health Promoting Activities Scale (BHPAS)
Direction: People sometimes perceive that they are not able to perform or
practice health promoting behaviors to manage hypertension. Please fill the
statements by mark (√) in the column which best indicates how much each of these
problems keeps you from taking care of your health.
No Statement
Nev
er
Som
etim
es
Oft
en
Rou
tin
ely
1 2 3 4
1 Lack of convenient facilities
2 Too tired
3 Lack of transportation
4 Feeling what I do doesn't help
5 …………………………………
6 …………………………………
7 ………………………………..
8 ……………………………….
9 …………………………………………
10 …………………………………………
11 …………………………………..
12 ………………………………………
13 …………………………………………….
14 …………………………………………
15 Feeling I can't do things correctly
16 Difficulty with communication
17 Bad weather
18 Lack of help from health care professionals
81
Questionnaire 6
Personal Resource Questionnaire (PRQ2000)
Direction: Below are some statements with which some people agree and
others disagree. Please indicate how you perceive that you have adequate support
from other people. Please read each statement and respond which is most appropriate
for you. There is no right or wrong answer. Please fill the statements by mark (√) in
the column.
No Statement
Str
on
gly
dis
agre
e
Dis
agre
e
Som
ewh
at
dis
agre
e N
eutr
al
Som
ewh
at
agre
e
Agre
e
Str
on
gly
agre
e
1 2 3 4 5 6 7
1 There is someone I feel close to who makes
me feel secure
2 I belong to a group in which I feel important
3 People let me know that I do well at my work
4 ………………………………………………
…………………………
5 ………………………………………………
……………………….
6 ………………………………………………
……………………………………….
7 ………………………………………………
…………………………………
8 ………………………………………………
………………..
9 ………………………………………………
………………………………..
82
No Statement
Str
on
gly
dis
agre
e
Dis
agre
e
Som
ewh
at
dis
agre
e N
eutr
al
Som
ewh
at
agre
e
Agre
e
Str
on
gly
agre
e
1 2 3 4 5 6 7
10 ………………………………………………
……………………………
11 ………………………………………………
……………………………..
12 ………………………………………………
13 ………………………………………………
……………
14 I have people to share social events and fun
activities with
15 I have a sense of being needed by another
person
83
APPENDIX B
Permission letter to use instruments
84
Permission letter to use Benefits Assessment Scale
To
cmurdaugh@nursing.arizona.edu
Dec 28 at 12:38 PM
Dear Dr. Murdaugh,
I am Hem Kumar Nepal, a master student at Faculty of Nursing, Burapha
University, Thailand. As a partial requirement of master degree, I am conducting a
study “Factors related to health promoting behaviors among hypertensive patients in
Bhutan.
Therefore, I would like to seek your permission to use your instrument "The
Benefits Assessment Scale".
I would look forward to hearing from you soon.
Thanking you,
Yours Sincerely
Hem Kumar Nepal
Murdaugh, Carolyn L - (carolyn5)
To
me
Dec 28 at 8:40 PM
I apologize for the delay in responding. I am out of town and will return on
Monday, December 29. You have permission to use the instrument, so I will send you
the scale and scoring key when I return. Happy New Year. Carolyn Murdaugh
Carolyn Murdaugh RN PhD FAAN
Professor Emerita & Adjunct Professor
College of Nursing
University of Arizona
85
Permission letter to use Self- Rated Abilities for Health Practices Scale
(SRAHPS) and Barriers to Health Promoting Activities Scale
To
astuifbergen@mail.utexas.edu
Dec 24 at 3:46 PM
Dear Dr. Stuifbergen,
I am Hem Kumar Nepal, a master student at Faculty of Nursing, Burapha
University, Thailand. As a partial requirement of master degree, I am conducting a
study “Factors related to health promotion behaviors among hypertensive patients in
Bhutan".
Therefore, I would like to seek your permission to use your two instruments
1. Self- Rated abilities for Health Practices Scale (SRAHPS)
2. Barriers to Health Promoting Activities Scale
I would look forward to hearing from you soon.
Thanking you,
Yours Sincerely
Hem Kumar Nepal
Dr. Becker and I are happy to allow you to use the instruments. You are free to adapt
or translate as needed for your research. We ask only that you cite the original source
and reference for the instruments.
Best wishes,
Alexa K. Stuifbergen, PhD, RN, FAAN
Dean
Laura Lee Blanton Chair in Nursing
James R Dougherty Jr., Centennial Professor in Nursing
The University of Texas at Austin
School of Nursing
1700 Red River, Austin, TX 78701
(512) 471-4100
86
Permission letter to use Personal Resource Questionnaires (PRQ2000).
November 24, 2015
Hem Kumar Nepal
Burapha University
Thailand
Ms. Nepal:
Please let this letter serve as your permission to use the PRQ85 or PRQ2000.
Any changes to question stems or answer sets must be approved in advance.
Translation of the PRQ into other languages is acceptable and encouraged. A copy of
the translated version of the PRQ should be sent to me. If you do, in fact, use the PRQ
for data collection in your study, I ask that you send me an abstract of your findings.
Should you have any questions or need clarification, kindly write or e-mail
cweinert@montana.edu. I will try to respond in a timely manner.
Thank you for your interest in the PRQ. I hope that this social support measure will
be helpful in your research.
Sincerely,
Clarann Weinert, SC,PhD,RN,FAAN
Professor Emerita
www.montana.edu/cweinert
87
APPENDIX C
Participants consent form
88
PARTICIPANTS INFORMATION SHEET
Dear …………
I am Hem Kumar Nepal a master student at the Faculty of Nursing, Burapha
University, Thailand. I am conducting a study “Factors Related to Health Promoting
Behaviors among Hypertensive Patients in Bhutan”. The objectives of this study are to
examine the perceived self-efficacy, perceived benefits, perceived barriers, and
perceived social support and their relationships to health promoting behaviors of
hypertensive patients in Bhutan. Therefore, I would like to invite you to participate in
this study.
This study is a survey design, and your participation is voluntary. If you agree to
participate in this study, you will be asked to answer some questions which may take
approximately one hour. There are no personal benefits from the study. The findings
will be presented as a group of participants and not individual. The result will be used
to improve nursing knowledge for the benefits of patients. You have the right to end
your participation in this study at any time without any penalty, and not necessary to
inform the researcher. Any information received from this study, including your
identity, will be kept confidential. A coding number will be assigned to you and your
name will not be use. All data will be destroyed completely within 1 year after
publishing or presenting the findings. You will receive a further and deeper
explanation of the nature of the study upon its completion, if you wish. The research
will be conducted by Hem Kumar Nepal, under supervision of my major advisor,
Assistant Professor Dr. Wanlapa Kunsongkeit. If you have any questions, please
contact me at telephone number 17976636 by or email: hemlotus2003@yahoo.co.in
and /or my advisor’s email address: jawanlapa@gmail.com. Your cooperation is
highly appreciated. You will be given a copy of this consent form to keep.
Name of Researcher: Hem Kumar Nepal
89
CONSENT TO PARTICIPATE IN A RESEARCH STUDY
Title: “Factors Related to Health Promoting Behaviors among Hypertensive
Patients in Bhutan”.
IRB approval number 11-01-2556
Date of data collection ……………Month……………..Year……………
Before I give signature in below, I am informed and explained about the
purposes, method, procedures, and benefits of the study by researcher, Mr. Hem
Kumar Nepal. I understood all of that explanation. I agree to be a participant of the
study and have received a copy of this form.
I Mr. Hem Kumar Nepal, as researcher had explained all details about
purposes, methods, procedures, and benefits of this study to the participant with
honesty. All of data/ information of the participants will only be used for the purpose
of this study.
Name and signature of participant Date…………..
(……………………………..)
Name and signature of witness…………………………
(………………………………)
Name and signature of researcher………………………..
(………………………………)
90
APPENDIX D
List of experts
91
LIST OF EXPERTS
1. Assistant Professor Dr. Kanitha
Hanprasitkam
Faculty of Medicine,
Ramathibodi Hospital,
Mahidol University, Thailand.
2. Dr. Varin Bihosen
School of Nursing,
Rangsit University,
Pathum Thani, Thailand
3 Assistant Professor Dr. Waree Kangchai
Faculty of Nursing,
Burapha University, Thailand.
4. Assistant Professor Dr. Supaporn
Duangpaeng
Faculty of Nursing,
Burapha University, Thailand.
5. Associate Lecturer Mrs. Kinga Pemo School of Nursing and Midwifery,
Deakin University, Melbourne,
Australia.
92
APPENDIX E
IRB approval and data collection letters
93
94
94
95
95
96
BIOGRAPHY
Name Hem Kumar Nepal
Date of Birth October 7, 1974
Place of Birth Beldara, Pemathang, Samdrupcholing,
Samdrupjongkhar
Present address Regional Referral Hospital, Mongar, Bhutan
Email address hemlotus2003@yahoo.co.in
Position held
1999 General Nurse Midwife (GNM),
Jigme Dorji Wangchuck National Referral
Hospital, Thimphu Bhutan
2000-present General Nurse Midwife,
Regional Referral Hospital, Mongar, Bhutan
Education
1998 Diploma in Nursing and Midwifery,
Royal Institute of Health Sciences (RIHS),
Thimphu, Bhutan
2003 Certificate in Critical Care Nursing,
Boromorajonani College of Nursing,
Bangkok, Thailand
2009 Bachelor of Nursing Science,
RIHS in collaboration with LaTrobe University,
Australia
2015 Master of Nursing Science
(International Program)
Burapha University, Chonburi, Thailand